MEDSURG III COMPREHENSIVE QUESTIONS (ATI & SAUNDER's)

The nurse is teaching a client who is beginning antiviral therapy for influenza. Which statement by the client indicates an understanding of the instructions?

"I must take the medication exactly as prescribed."

A nurse is teaching a client who is at 24 weeks of gestation and scheduled for an amniocentesis procedure. Which of the following client statements indicates an understanding of the teaching?

"I must urinate prior to the procedure."

A registered nurse is discussing evidence-based research with student nurses. Which of the following statements does not indicate understanding by a student nurse about reading a published journal article that explains the results of a study about a new nursing practice?

"I should determine who funded the study."

The nurse has just administered the first dose of omalizumab to a client. Which statement by the client alerts the nurse of a life-threatening effect?

"My lips and tongue are swollen."

The nurse is providing teaching to the parents of a school-age child who has ADHD and a new prescription for methylphenidate transdermal patches. Which of the following instructions should the nurse include in the teaching?

"Remove the patch from your child's skin after 9 hours."

Which of the following clients should not be considered to use anti-embolism stockings? Select all that apply

-A client with pulmonary edema due to heart failure -A client with necrotic limb tissue in the lower leg -A client with a deformity of the lower leg

A client is undergoing a cardiac catheterization to evaluate the amount of blockage present in the client's coronary arteries. Which of the following interventions would the nurse perform after the procedure? Select all that apply

-Apply pressure to the insertion site -Check the pedal pulses and document skin color -Administer analgesic for pain control

A nurse is reviewing a mental status examination (MSE) on a client who has Alzheimer's disease. The nurse should identify which of the following components are part of the MSE? Select all that apply

-Grooming -Short-term memory -Affect

A client with Crohn's disease has been treated with sulfasalazine but continues to report loose stools up to 10 times a day. She states she feels overwhelmed and has not had any outside support since her recent divorce. Which of the following nursing diagnoses should be included in this client's care plan? Select all that apply

-Hopelessness -Risk of deficient fluid volume -Ineffective coping -Imbalanced nutrition

A nurse is caring for a client with Parkinson's disease who has a prescription for selegiline (Eldepryl. Which of the following is true about this medication? Select all that apply

-It causes dizziness -It affects sleep patterns

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicates effective coping? Select all that apply

-Looking at old snapshots of family -Participating in a senior citizens program -Visiting the spouse's grave once a month -Decorating a wall with the spouse's pictures and awards received

The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops at list of high-fat foods to avoid and should include which food item on the list? Select all that apply

-Margarine -Cream cheese -Luncheon meats

The nurse is assigning tasks to unlicensed assistive personnel (UAP). Which of the following tasks is appropriate to assign to a UAP? Select all that apply

-Measuring and recording vital signs on a group of clients admitted to the floor -Checking bedside blood glucose levels for a group of clients -Ambulating a group of post-operative stable clients in the hallway

The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply

-Move beds away from windows -Close shades and curtains -Place blankets over client who are confined to bed

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mmHg. The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply

-Nausea -Confusion -Tachycardia -Lightheadedness

The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL. Which patterns would the nurse watch for on the electrocardiogram? Select all that apply

-Prolonged QT interval -Prolonged ST segment

The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2mg of hydromorphone was administered instead of the actual dose administered, which was 1mg. The nurse should take which action(s) to correct the error in the MAR? Select all that apply

-Right-click on the entry and modify it to reflect the correct information -Document the correct information and end with the nurse's signature and title -Obtain a cosignature from the RN who witnessed the waste of the remaining 1mg -Document in a nurse's note in the client's record detailing the corrected information

The nurse working a community outreach program for foster children plans care knowing that which health conditions are common in this condition? Select all that apply

-Sleep disorders -Bipolar disorder -Aggressive behavior -Attention-deficit hyperactivity disorder (ADHD)

A nurse is caring for a 36-year-old female client who has just been diagnosed with type 2 diabetes. The client has a BMI of 29.4 and a high waist circumference. In addition to these factors, which of the following is considered a risk factor for developing type 2 diabetes? Select all that apply

-Smoking -Previous history of gestational diabetes -Diagnosis of thyrotoxicosis

The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply

-The acuity level of the clients -Client needs and workers' needs and abilities

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mmol/L. Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply

-U waves -Inverted T waves -Depressed ST segment

The nurse is providing information to client entering perimenopause. Which of the following is true about this periodic change in the client? Select all that apply

-Vaginal pH increases -Vasomotor instability occurs -Vulvar tissue atrophies

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to contact the primary health care provider (PHCP) if the client is also taking which medications? Select all that apply

-Warfarin -Glimepiride -Amlodipine

A nurse is reviewing the laboratory results of a client who is suspected of having human immunodeficiency virus (HIV). The nurse should identify that which of the following tests are used to confirm HIV infection? Select all that apply

-Western blot -Enzyme-linked immunosorbent assay

A prescription reads Levothyroxine, 150 mcg orally daily. The medication label reads levothyroxine, 0.1 mg/tablet. The nurse administers how many tablet(s) to the client? Fill in the blank.

1.5 Tablets

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first?

A client with a white blood cell count of 14,000 mm3 and a temperature of 38.4 C

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?

A client with asthma who requested breathing a treatment during the previous shift

The nurse employed in an emergency department is assigned to triage clients coming to the evening shift. The nurse should assign priority to which client?

A client with chest pain who states that he just ate pizza that was made with very spicy sauce

A nurse in an assisted living facility is assessing an older client who moved in 3 months ago following the death of his partner. The client reports awakening early in the morning and admits feeling very sad. The nurse should identify that the client is experiencing which of the following types of grief?

Acute grief

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

An increase in blood pressure and increased respirations

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client os hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?

An increased pH and an increased HCO3

A nurse is assisting with an amniotomy for a client who is in active labor. Which of the following actions should the nurse take?

Assess the fetal heart rate before and after the procedure

Your client has a deficiency of aldosterone. Which nursing diagnosis of risk is most appropriate for this client?

At risk for hyperkalemia related to an aldosterone deficiency

Which of the following psychiatric personality disorders places the client at greatest risk for suicide?

Borderline personality disorder

A nurse is planning to delegate tasks to a licensed practical nurse (LPN). Which of the following tasks should the nurse assign to the LPN?

Change the negative pressure wound therapy dressing on a client's chronic wound

The nurse is giving a bed bath to an assigned client when the assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action?

Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client

A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse should offer which full liquid item to the client?

Custard

A nurse is teaching a group of healthy older adult clients about expected age-related changes and sexual response. Which of the following changes should the nurse include as an age-related change?

Decreased vaginal lubrication

Terbutaline is prescribed for a client with bronchitis. Which disorder in the client's medical history requires caution by the nurse?

Diabetes mellitus

A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action?

Draw a sample for prothrombin time (PT) and international normalized ratio (INR)

A client admitted to the rehabilitation facility following a head injury has fallen out of bed twice. Which of the following restraints is indicated to prevent injury?

Enclosed bed

A nurse is caring for an 8-year-old child who has sickle cell anemia. Which of the following actions should the nurse take?

Give the child flavored popsicles

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?

Hyperactive bowel sounds

A nurse is assessing a client with pancreatitis who is admitted with abdominal pain, nausea, and vomiting for two days. The client's vital signs are T 100.8F, blood pressure 88/42 mmHg, heart rate 120/min, and respirations 30/min. The client's pulse oximeter shows an oxygen saturation of 87%. Which of the following does the nurse know may be affecting the accuracy of the pulse oximetry reading?

Hypotension

A nurse is caring for a client who just had coronary bypass graft surgery. The nurse knows not to rewarm the client too rapidly due to a risk of which of the following complications?

Hypotension

The nurse working in the emergency department (ED) is assessing a client who recently returned from Nigeria and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next?

Isolate the client in a private room

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed?

Leaving the rate of the heparin infusion as is

A nurse is assessing a male client who recently began taking haloperidol to treat schizophrenia. Which of the following adverse effects is the highest priority for the nurse to report to the provider?

Neck spasms

A nurse is caring for a client who is nulliparous and experiencing hypertonic uterine dysfunction. An assessment indicates 3 cm dilation. Which of the following actions should the nurse take?

Offer the client hydrotherapy

A nurse is assessing a child who has acute lymphocytic leukemia and is receiving vincristine sulfate. Which of the following findings is the nurse's priority?

Paresthesia

A nurse monitoring a client who is in the telemetry unit and notes the following on the rhythm strip (see image). This is an example of?

Premature Ventricular Contraction (PVC)

The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented?

Requires nasogastric suction

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mmHg (90 mmol/L), and HCO3 is 22 mEq/L (22 mmol/L). The nurse the results as indicating which condition?

Respiratory acidosis without compensation

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mmHg (30 mmol/L), and HCO3 of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition?

Respiratory alkalosis, compensated

A nurse caring for a client who has a hemoglobin of 6.7 g/dL and a prescription for transfusion. After retrieving the blood from the blood bank 30 minutes earlier, the nurse discovered that the client's IV was not patent and has been unable to insert a new IV successfully. Which of the following is the most appropriate nursing action?

Return the blood to the blood bank

A nurse is caring for a client immediately following extubation. Which of the following manifestations indicates that the nurse should call the rapid response team?

Stridor

A client has just returned to the nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position?

Supine with the residual limb supported with pillows

The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action?

Test the drainage for glucose

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm (72 mmol/L), and HCO3 = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make?

The client is hyperventilating

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)?

The client who has sustained a traumatic burn

A nurse is caring for a terminally ill client considering a Advanced Directive indicating Do Not Resuscitate status (DNR) who remains uncertain. When providing information to the client, the nurse knows that which of the following is legally and ethically equivalent to withholding life-sustaining treatment?

Withdrawal of life support