MEDsurge FINaL
A client with Myasthenia Gravis is admitted to the medical surgical unit. Which of the following tests should the nurse expect to see ordered?
Tensilon test
The nurse teaching a support group of women with rheumatoid arthritis about how to manage activities of daily living suggests they should
Avoid activities requiring repetitive use of the same muscles and joints
A nurse cares for a client who has obstructive jaundice. The client asks, "Why is my skin so itchy?" How should the nurse respond?
Bile salt accumulate on the skin and cause the itching
Which outcome should receive priority in the care plan for a patient who has had a paracentesis to treat ascites?
The patient will have clear bilateral breath sounds
The nurse is preparing to administer a unit of PRBC to anemic client. After obtaining the blood from the blood bank, the nurse must administer it within which of the following periods?
30 minutes
A patient is being seen for comprehensive physical. Which of the following test would the nurse expect to be elevated if the patient is suspected of having acute viral hepatitis? Select all that apply.
ALT AST
A client is in emergency department with complaints of fever, severe pain in the left ear and hearing loss. The health care provider's otoscope exam revealed the ear drum is red and inflamed. What is suspected diagnosis for this patient?
Acute otitis media
A patient with end stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the patient's fluid volume excess?
Administering diuretics, Implementing fluid restrictions, enhancing patient positioning
A patient is admitted with acute pancreatitis. Which information for the health history should the nurse expect when assessing this patient?
Alcohol abuse
A patient has been diagnosed in out patient clinic with peptic ulcer disease. Which statement best describes the pathophysiology in peptic ulcer disease:
An erosion of lining of the stomach
A client with multiple myeloma has been started on filgrastim for treatment of neutropenia. The nurse identifies the drug is being effective when:
An increase int he white blood cell count occurs
Which of the following foods should the nurse instruct a client being discharged after an acute attack of gout to avoid to prevent future attacks?
Anchioves, liver, lentils
Which of the following foods should the nurse instruct a client being discharged after an acute attack of gout to avoid to prevent future attacks?
Anchovies, liver, lentils
Which information will the nurse teach a patient who has been newly diagnosed with Graves' disease?
Antithyroid medications may take several months for full effect
The nurse is seeing a patient in pre-op clinic before cataract surgery. Which of the following medications would the nurse want to bring to the attention of the surgeon? Select all that apply.
Aspirin Warfarin
The nurse reads on a client's chart that the client has exophthalmos. What assessment finding is consistent with this diagnosis?
Bulging eyes
A nurse receives report on a patient who surgical repair of an appendectomy. The patient also has a history of acute macular degeneration. Which one of the following would the nurse expect related this patient's vision?
Changes in central vision
An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000 during chemotherapy is to
Check all stool for occult blood
The nurse is caring for. a patient with severe liver disease. The nurse notes new ecchymotic areas on the patient's arms and legs. Which laboratory results will the nurse analyze regarding this finding? Select all that apply.
Complete blood count Coagulation studies
Which side effect may cause a client to stop taking a prescribed opioid analgesic medication?
Constipation
Which nursing action could the nurse delegate to PCT when caring for a patient who is using a fentanyl patch and a heating pad for treatment of chronic back pain?`
Count the respiratory rate every 2 hours
Which of the following conditions is caused by longterm exposure to high levels of cortisol?
Cushings syndromes
A client admitted with purpura and blood in the urine and stool. The nurse reviews the ordered blood work and suspects that the client might be experiencing :
Decreased platelet
an 82 yr old patient in a long term care facility is newly diagnosed with hypothyroidism. The nurse will need to consult with the health care provider before administering the prescribed.
Diazepam (Valium)
A student nurse is preparing a presentation about external otitis ("swimmer's ear"). What should be included in the presentation?
Earwax (cerumen) has an antibacterial effect
The physician suspects that a client is experiencing a disturbance of the lymphatic system. For what should the nurse assess this client?
Edema of the face
A client having exophthalmos from hyperthyroidism is upset because the eyes are dry, look funny, and wants to know when these symptoms will go away with treatment. What should the nurse respond?
Exophthalmos will recede in about 1 year
The client with anemia is in the emergency department. During the assessment and health history, what should the nurse ask the client?
Have you been experiencing bouts of energy
A patient presents to general medicine clinic with complaints of frequent upper respiratory infections, bruising, and bleeding gums noted for the past four months. Which question will the nurse ask during the nursing history?
Have you noticed bleeding from nose, or in stool and urine?
The nurse is teaching a community education class on prevention of eye injuries and care of someone with an eye injury. What should be included in this presentation? Select all that apply.
Eye protection devices should be worn when participating in high risk sports or occupations Use of seat belts and air bags prevents eye injuries in automobile crashes In case of injury immediately flush the eye with copious amounts of water if a chemical splash occurs
A client is suspected of having a detached retina. The nurse should assess the client for which finding that would support the diagnosis?
Flashes of light and floaters
A patient who is experiencing ten bloody, diarrhea stools a day dizziness, and diffuse abdominal pain related to an acute exacerbation of their UC is in the emergency room. The patient has vital signs: B/P: 94/60, heart rate 105, respirations 18, pulse oximetry, 95% on room air, weight 125 pounds, a 4 pound weight loss. Which one of the following diagnosis' would the nurse prioritize as the most important?
Fluid volume deficit related to bloody diarrhea
The nurse is caring for a patient with cobalamin (Vit. B12) deficiency. What gastrointestinal (GI) symptom does the nurse observe during assessment?
Glossitis
A patient with gastrointestinal dysfunction says, "I was having chest pain so bad last week I thought I was having a heart attack! What should the nurse suspect the patient was experiencing?
Hiatal hernia
When checking laboratory values, the nurse notes the client's platelet count is 100,000 mm3. The nurse should include which action in the client's plan of care?
Hold pressure over the injection sites to ensure that clotting has occurred.
The nurse is preparing the monitoring medications for a patient with GERD. Which nursing intervention would be appropriate for this patient's medications?
Hold the antacids for at least 2 hours after oral medications are taken
A clinical instructor is preparing a lecture on ulcerative colitis and medications that reduce the symptoms of the disease. Which of the following classes of drugs would be included during that lecture? Select all the apply.
Immunmodulating drugs, corticosteroids
A 30 year-old male construction worker was recently diagnosed with sensorineural hearing loss. The client asked the nurse to explain sensorineural hearing loss. What is the best response by the nurse?
Loud noise or music damaged the cochlea
The nurse assesses a reduction in a patient's peripheral vision. Which additional measure would be a priority during the assessment of this patient?
Intraocular pressure assessment
A client is diagnosed with pernicious anemia. What should the nurse instruct is needed to absorb vitamin B12?
Intrinsic Factor
A patient with chronic gastritis says, "I've stopped taking the medication because I feel so much better now that I drink ginger tea." The nurse realizes that this patient:
Is using a complementary therapy for the symptoms
The nurse is caring for a patient with GERD. What should the nurse include when teaching the patient about this health problem?
Limit last food intake to 3 hours before bedtime
A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this client's plan of care to reduce discomfort?
Maintain nothing by mouth (NPO) ad administer intravenous fluids
An example of secondary prevention in eye and ear health would be? Select all that apply.
Measure intraocular pressure at annual eye visit Audiometry screening at senior center
The nurse is assigned to care for a client with cirrhosis of the liver. The nurse recognizes that the client's impaired liver function will affect:
Metabolism of drugs
Which menu choice indicates that the patient understands the nurse's teaching about best dietary choices for iron-deficiency anemia?
Omelet and whole wheat toast
The lab result for a patient reveal the presence of H. pylori. The patient is diagnosed with PUD. Based on this diagnosis, what should the nurse teach this patient is the priority of treatment?
Pain management
Which clients would be most at risk for developing megaloblastic anemia from cobalamin (Vit. B 12) deficiency? Select all that apply.
Pernicious anemia, strict vegetarians, non dairy diet
The nurse is preparing to discharge a client who is being treated for Addison's disease. What should the ensure the client understands?
Relationship between stress and hormone levels
The nurse is preparing to discharge a client who is being treated for Addison's disease. What should the nurse ensure the client understands?
Relationship between stress and hormone levels
During an emergency code, the physician verbally orders a medication for client. Which of the following should the nurse do?
Repeat the order back to the physician for confirmation then administer it
The nurse is providing care to a patient admitted with hematemesis, melon, an abdominal pain. Which nursing diagnosis is the highest priority for this patient?
Risk for Aspiration related to potential changes in level of consciousness
A patient with symptoms consistent with pancreatitis reports feeling ill for the past week. Which diagnostic test will provide the most definitive diagnosis of pancreatitis?
Serum amylase
Which discharge instructions should the nurse include for a patient with sickle cell anemia to avoid future crises?
Take pain medication as ordered
The nurse should assess for which side effect when clients are receiving NSAIDs for pain?
Tarry black stools and epigastric pain
A client is scheduled for cataract surgery. What teaching should the nurse provide prior to surgery?
Teaching that helps the client reduce intraocular pressure
Which of the following task would be appropriate for the nurse on a surgical unit to delegate to unlicensed assistive personnel?
Set up the client's lunch tray
An older patient who is being admitted to the hospital repeatedly asks the nurse to "speak up so that I can hear you." Which action should the nurse take?
Speak normally but more slowly
A lidocaine patch is being used on a patient with musculoskeletal pain in the back. Which one of the following would be used by the nurse when administering this drug?
The patch is placed over the painful site for 12 hours and removed
A patient in the acute care unit has developed neutropenia. A nurse would identify which history as a possible etiology of this condition?
The patient has been receiving chemotherapy treatment for lung cancer
Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis?
The patient is alert and oriented
Which of the following statements is true regarding the use of placebos in management?
They are appropriate in clinical trials
A patient with a traumatic brain injury is being treated for diabetes insidious. Which finding would the nurse evaluate as indicating treatment is effective?
Urine output has decreased
A client's red blood cell transfusion was discontinued due to an acute hemolytic transfusion reaction. Which of the following strategies should the nurse use to best minimize the risk of such a reaction?
Verify all client identifying information according to policy prior to hanging unit of blood
A female patient recently diagnosed with polycythemia vera informs the nurse that she does not understand what is happening with her blood and why she gets so short of breath. What is the most appropriate response by the nurse?
You blood is very thick and does not carry enough oxygen
