Medical Surgical Nursing III Final Questions

A nurse is administering a unit of RBC 350 mL over 3 hours to a client who has anemia. The nurse set the IV pump to deliver how many mL/hr?

117 mL/hr

A nurse is planning discharge teaching for a client who is receiving chemotherapy and has bone marrow suppression. Which of the following instructions should the nurse plan to include in the teaching?

"Bathe with an antimicrobial soap twice per day."

A nurse is teaching a client who has Parkinson's disease and is prescribed carbidopa-levodopa. Which of the following client statements indicates an understanding of the teaching?

"I should expect this medication to make me drowsy"

A nurse is providing teaching to a client who has systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching?

"I should wear gloves when it is cold outside."

A nurse is providing teaching to a client who has rheumatoid arthritis and a new prescription for methotrexate. Which of the following client statements indicates an understanding of the teaching?

"I will avoid being in large crowds while taking this medication."

A nurse is preparing to administer 0.9% sodium chloride 1,200 mL IV to infuse over 24 hours. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

13 gtt/min

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect?

Intention tremors

A nurse is preparing to transfuse one unit of packed RBC to a client experiencing a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine before the transfusion for which of the following allergic responses?

Urticaria

A nurse is teaching a client who has osteoporosis and has a new prescription for alendronate. Which of the following information should the nurse include in the teaching?

Remain upright for 30 minutes after taking the medication

A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt to the hemianopsia, the nurse should take which of the following actions?

Remind the client to look consciously at both sides of their meal tray

A nurse is teaching a client who has multiple sclerosis and has a new prescription for glatiramer acetate. Which of the following statements indicates that the client understands the teaching?

" I will avoid going to the store when it is crowded."

A nurse is reviewing the daily laboratory results for a female client who has acute leukemia. Which of the following values is an expected finding?

WBC 21,000

A nurse is planning to perform a blood transfusion for a client. Which of the following actions should the nurse plan to take?

check vital signs before transfusion insert an IV with a 19-gauge needle check the expiration date of the blood product with a second nurse

A nurse is providing teaching to a client who has rheumatoid arthritis and reports persistent pain. Which of the following responses should the nurse make?

"Ask a friend or family to help you with household chores."

A nurse is providing teaching to a client who takes oral contraceptives and has a new prescription for amoxicillin. Which of the following statements by the client indicates an understanding of the teaching?

"I will use a backup method of birth control while I am taking this medication."

A nurse is developing a teaching plan for a client who has Meniere's disease. Which of the following instructions should the nurse include?

"Move your head slowly to decrease vertigo."

A nurse is teaching a client and her family about the diagnosis and treatment of Alzheimer's disease. Which of the following statements should the nurse identify as an indication that the family understands the teaching?

"The medications that treat Alzheimer's disease can help delay cognitive changes."

A nurse is caring for a client who is to receive a unit of packed RBCs. The nurse should prime the blood administration tubing using which of the following IV solutions?

0.9% sodium chloride

A nurse is caring for a client who had an anaphylactic reaction after a blood transfusion. The nurse reviews the literature to further understand antibody-mediated immunity. Which of the following should the nurse confirm about AMI?

AMI is mediated by antibodies produced by B-lymphocytes

A nurse is caring for a 73-year-old client in the emergency department (ED). It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications.

Administer broad-spectrum antibiotics Measure lactate level Rapidly administer 30 mL/kg of normal saline Obtain blood cultures

A nurse is preparing to administer 2 units of packed RBCs to an older adult client. Which of the following actions should the nurse take?

Administer each unit over 3 hours

A nurse is preparing to administer blood to a client. The unit of blood is type B, and the client has AB blood. Which of the following actions should the nurse take?

Administer the blood as ordered

A nurse is preparing to administer blood to a client. The unit of blood on hand is O negative, and the client has type A positive blood. Which of the following actions should the nurse take?

Administer the blood as ordered

A nurse is caring for a client who reports a skin change. Which of the following findings should the nurse report to the provider?

An asymmetrical papule that is pigmented

A nurse is caring for four clients. Which of the following clients is at greater risk for pneumonia?

An older adult client who has dysphagia

A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first?

Auscultate for wheezing

A nurse is performing a breast examination on a female client who is pregnant. Which of the following findings should the nurse report to the provider?

Breast tissue with an orange peel appearance

A nurse is providing teaching to a client who has an allergy to peanuts. Which of the following instructions is the priority to include in the teaching?

Carry an emergency anaphylaxis kit

A nurse is reviewing a client's laboratory results and finds the hemoglobin is 10 g/dL and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following?

Cellular hypoxia

A nurse is assessing a client who has systemic lupus erythematosus. Which of the following findings should the nurse expect?

Decreased urine output Butterfly rash Joint inflammation

A nurse is caring for a client who has HIV. Which of the following laboratory findings should suggest to the nurse that medication therapy is effective?

Decreased viral load

A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload?

Dyspnea

A nurse is planning an education program about testicular cancer for a group of male adolescents. Which of the following information should the nurse include?

Examine the testicles immediately after showering

A nurse is assessing a client who has disseminated intravascular coagulation. Which of the following should the nurse expect?

Excessive thrombosis and bleeding

A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?

Febrile

A nurse is reviewing the laboratory values of a client who is a risk for disseminated intravascular coagulopathy. Which of the following values should the nurse report to the provider?

Fibrinogen 85 mg/dL

A nurse is caring for a client who has a retinal detachment. Which of the following findings should the nurse expect?

Flashes of bright lights

A nurse in an emergency department is caring for a client who has sustained a fracture of the femur following a motor vehicle crash. Which of the following images should the nurse recognize as a comminuted fracture?

Fragments into several pieces

A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?

Generalized urticaria

A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting a headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?

Hemolytic

A nurse is preparing to administer a unit of red blood cells. The nurse's responsibility is to compare and verify the information on the blood label with the client's information. The nurse should use which of the following as the priority source of verification?

Identification wristband

A nurse is planning an education program for a group of high school teachers who will be taking students on a hike. Which of the following information should the nurse include regarding Lyme disease?

If you develop pain and stiffness in your joints, you should see a doctor

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect?

Impulsive behavior

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

Increase in the heart rate from 88 to 110

A nurse is caring for a client who has viral pneumonia. Which of the following findings should the nurse report to the provider immediately?

Left shift in WBC differential

A nurse is providing teaching to a group of clients regarding skin cancer prevention. Which of the following risk factors should the nurse include in the teaching?

Light skinned pigmentation

A nurse is planning care for a client who has a closed traumatic brain injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurse's priority?

Maintain a PaCO2 of approximately 35

A nurse in an emergency department is assessing a client who reports sudden, severe eye pain with blurry vision. The provider determines that the client has primary angle-closure glaucoma. Which of the following medications should the nurse expect to administer?

Osmotic diuretics via IV bolus

A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority?

Monitor pulse oximetry findings

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?

Mottled skin

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

Narrowing pulse pressure

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Oliguria

A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings is a manifestation of a hemolytic transfusion reaction?

Report of low back pain

A nurse is caring for a client who is 72 hours postoperative following an above-the-knee amputation and reports phantom limb pain. Which of the following actions should the nurse take?

Request a prescription for gabapentin for the client

A nurse is assessing a client who has a head injury following a motor vehicle crash. The nurse should identify which of the following indicates increasing intracranial pressure.

Restlessness

A nurse is reviewing a client's CBC findings and discovers that the client's platelet count is 9,000. The nurse should monitor the client for which of the following conditions?

Spontaneous bleeding

A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64. Which of the following actions should the nurse take first?

Stop the infusion of blood

A nurse is assessing a client who is receiving a unit of packed RBCs. The client appears flushed and reports low back pain. Which of the following actions is the nurse's priority?

Stop the transfusion

A nurse is caring for a client who is receiving a transfusion of packed red blood cells and suspects that the client is experiencing a hemolytic reaction. Which of the following interventions is the priority?

Stop the transfusion

A nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to stimulate micturition?

Stroke the client's inner thigh

A nurse is planning to teach a client who has epilepsy and a new prescription for phenytoin. Which of the following instructions should the nurse plan to include?

Take medications at a consistent time each day to maintain therapeutic blood levels

A nurse is planning care for a client who has leukemia and a platelet count of 48,000. Which of the following interventions should the nurse include in the plan?

Test the client's urine and stool for occult blood

A nurse is assessing a client who is receiving a unit of packed red blood cells. Which of the following is a manifestation of acute hemolytic reaction?

The client reports low back pain

A nurse is caring for a client who has neutropenia. Which of the following findings indicates a need for intervention?

The client's grandchild is visiting and telling the client about the first day of kindergarten

A nurse is educating a client who is scheduled for a kidney transplant. Which of the following information about hyperacute rejection should the nurse include in the teaching?

The organ will need to be removed if hyperacute rejection occurs

A nurse is teaching the parent of a child about administration guidelines for the human papillomavirus vaccine. Which of the following information should the nurse include?

Three doses are administered to adolescents who start the series after age 15

A nurse is preparing to administer blood to a client. Which of the following actions should the nurse take to identify the client?

Verify the provider's prescription with another RN Scan the barcode on the client's identification band Compare the client identification number to the blood component bag

A nurse is assessing a client who has a new prescription for clindamycin to treat acute pelvic inflammatory disease. The nurse should report which of the following findings to the provider immediately?

Watery diarrhea

A nurse is reviewing postoperative instructions with a client following a cataract surgery. Which of the following client statements indicates an understanding of the teaching?

"I should call my doctor if my vision gets worse."

A nurse is providing discharge teaching to a client who has HIV. Which of the following statements by the client indicates an understanding of the teaching?

"I should discard open beverages that have been refrigerated for 1 hour."

a nurse is preparing to administer an IV fluid bolus of 200 mL dextrose 5% in water over 30 minutes. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

100 gtt/min

A nurse is preparing to administer clindamycin 300 mg by intermittent IV bolus over 30 minutes to a client with a staphylococci infection. Available is clindamycin premixed in 50mL 0.9% sodium chloride. The nurse should set the IV pump to deliver how many mL/hr?

100 mL/hr

A nurse is preparing to administer lactated ringers by continuous IV infusion at 120 mL/hr. The drop factor of the manual IV tubing is 60 gtt/mL. the nurse should set the manual IV infusion to deliver how many gtt/min?

120 gtt/min

A nurse is caring for a client who has sepsis and a prescription for vancomycin 1 g in 250 mL dextrose 5% over 2 hours by IV intermittent bolus. The nurse should use the pump to deliver how many mL/hr.?

125 mL/hr

A nurse is preparing to administer 40 mEq of potassium chloride in 0.45% sodium chloride 500 mL IV to infuse 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr?

125 ml/hr

A nurse is providing teaching to a client who has Hodgkin's lymphoma and is undergoing external radiation treatment. Which of the following instructions should the nurse include?

Avoid direct sun exposure to the skin

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?

Epinephrine

A nurse is providing teaching to a client who is scheduled for a Papanicolaou test. The nurse should inform the client that the Pap test is to screen for which of the following?

Cervical cancer

A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take?

Check the capillary refill every 4 hours

A nurse is caring for a client who is in balanced suspension skeletal traction and reports intermittent muscle spasms. Which of the following actions should the nurse take first?

Check the position of the weights and ropes

A nurse is assessing a client who is receiving a platelet transfusion. Which of the following findings is an adverse effect of the transfusion?

Chills

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider?

Clear drainage from the nose

A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings supports this conclusion?

Confusion

A nurse is caring for a client who has non-Hodgkin's lymphoma and is receiving chemotherapy. Which of the following is the priority assessment finding?

Erythema at the IV site

A nurse is assessing a client who has a new diagnosis of osteoarthritis. Which of the following findings should the nurse expect?

Crepitus with joint movement Decreased range of motion of the affected joint Joint pain that resolves with rest

A nurse is assessing a client who is quadriplegic following a cervical spine fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110. Which of the following actions should the nurse take first?

Elevate the head of the client's bed

A nurse in an emergency department is assessing a newly admitted client. Which of the following actions places the client at an increased risk of contracting hepatitis B?

Engaging in unprotected sexual intercourse

A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to take?

Ensure that the client lies flat for up to 12 hours

A nurse is caring for a client who has an elevated prostate-specific antigen level. The nurse should anticipate that the client will undergo which of the following diagnostic tests?

Digital rectal exam

A nurse is caring for a client who has a history of status epilepticus and requires seizure precautions. Which of the following actions should the nurse take?

Establish iv access

A nurse is performing a pain assessment for a postoperative client. Which of the following findings should the nurse use to determine the severity of the client's pain?

The client's report of pain on a pain scale

A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation. Which of the following laboratory results should the nurse expect?

The laboratory values are prolonged

A nurse is caring for a client who is admitted with enlarged lymph nodes and a fever. To confirm a diagnosis of bacterial pharyngitis, the nurse should anticipate which of the following diagnostic tests?

Throat culture

A nurse in the emergency department is caring for a client who suddenly lost consciousness and fell while at home. The provider determines that the client had an embolic stroke. Which of the following medications should the nurse expect to administer?

Tissue plasminogen activator

A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?

Ulnar deviation

A nurse is preparing to administer ringers' lactate 400 mL bolus to infuse over 3 hours. The drop factor of the manual IV tubing is 20 gtt/mLs. The nurse should set the manual IV infusion to deliver how many gtt/min?

44 gtt/min

A nurse is preparing to administer cefazolin 1 g by intermittent IV bolus over 30 minutes. Available is cefazolin 1 g in 100 mL dextrose 5% in water. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

33 gtt/min

A nurse is preparing to administer ringers' lactate 500 mL bolus to infuse over 3 hours. The drop factor of the manual IV tubing is 20 gtt/mLs. The nurse should set the manual IV infusion to deliver how many gtt/min?

56 gtt/min

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?

Packed RBCs

A nurse is teaching an assistive personnel about providing care to a client following a total hip arthroplasty. Which of the following instructions should the nurse include?

Place the abductor pillow between the client's legs when turning the client

A nurse is reviewing the laboratory report for a client who has Hodgkin's lymphoma. Which of the following findings should the nurse expect?

Reed-Sternberg cells

A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitor for fluid volume overload?

Dyspnea Jugular vein distention Confusion

A nurse is reviewing the laboratory results of a postoperative client. Which of the following laboratory findings should the nurse identify as an indication of postoperative infection?

Increased band neutrophils Elevated erythrocyte sedimentation rate

A nurse in the emergency department is assessing a client who had internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings is an indication of hypovolemic shock.

Increased heart rate

A nurse is completing a physical examination of a client and notes that laboratory values indicate leukocytosis. The nurse should recognize which of the following manifestations is associated with leukocytosis.

Inflammation

A nurse is teaching a client who is postoperative following a right hip arthroplasty. Which of the following images indicates the position the nurse should teach the client to take when sitting in a chair?

Sit with hips at a 90-degree angle

A nurse is assessing a client who has HIV. Which of the following findings should cause the nurse to suspect that the client's diagnosis has progressed to AIDS?

Small, purple-colored skin lesions