Adult Medical Surgical

A nurse is caring for a client who reports shortness of breath and has an oxygen saturation of 90%. Which of the following actions should the nurse take?

Administer oxygen via nasal cannula.

A nurse is reinforcing discharge with a client who had a mechanical mitral valve replacement. Which of the following statements by the client indicates an understanding of the teaching?

I will notify my dentist about the procedure

A nurse is contributing to the plan of care for a client who had a stroke. For which of the following interprofessional team member should the nurse recommend a referral prior to initiating oral intake for the client?

Speech-language pathologist

A nurse is proving information regarding transmission-based precautions for a client who has Clostridium difficile to an assertive personnel (AP). Which of the following instructions should the nurse include? (Select all the apply.)

-Provide the client with disposable utensils and dishes for meals -Leave blood pressure equipment in the client's room -Clean contaminated surfaces with a bleach solution

A nurse is reinforcing dietary teaching with a client about increasing the intake of foods containing vitamin C to enhance absorption of oral iron supplements. Which of the following foos choices should the nurse include in the teaching?

1 cup of boiled broccoli

A nurse is reviewing the medication administration record of a client who has osteoarthritis. Which of the following analgesic prescriptions should the nurse expect to administer when the client reports pain?

Acetaminophen

A nurse is reinforcing teaching with a client who has coronary artery disease. Which of the following instructions should the nurse include in the teaching?

Add oily fish to your diet

A nurse is reinforcing instructions with a client who has a new hearing aid. Which of the following instructions should the nurse include?

Adjust the volume to a level where you can hear others speak a distance of 3 feet

A nurse contributing to the plan of care for a client who has just transferred to the medical-surgical unit from the PACU following right total knee arthroplasty Which of the following interventions should the nurse include in the plan

Assist the client to change positions at least every 2 hrs

A nurse is reinforcing teaching with a client who has osteoporosis and a new prescription of calcitonin. Which of the following statements should the nurse make to describe the effect of calcitonin in treating osteoporosis?

Calcitonin will slow the breakdown of the bone in your body.

A nurse is caring for a client who is 2hr postoperative following the amputation of a foot. Which of the following actions should the nurse take first?

Check the incisional dressing.

A nurse is caring for a client who is postoperative following an above the knee amputation of the right leg and reports pain in the absent portion of the limb. The client received an opioid analgesic 1 hr prior. Which of the following actions should the nurse take?

Collaborate with physical therapist to initiate alternative pain therapies

A nurse is caring for a client who is postoperative and has a portable wound bulb suction device. Which of the following actions should the nurse take ?

Compress the bulb reservoir and the close the drainage valve.

A nurse is caring for a client who has been taking enalapril. The nurse should monitor the client for which of the following adverse effects?

Cough

A nurse is caring for a client who has end-stage liver disease and just underwent an abdominal paracentesis. For which of the following manifestations should the nurse monitor as an adverse effect of the procedure?

Decreased blood pressure

A nurse is caring for four clients. Which of the following conditions should the nurse identify as a risk for developing vascular disease?

Diabetes mellitus

A nurse is collecting data from a client who is receiving sumatriptan. Which of the following is an expected outcome?

Diminished headache

A nurse is caring for a client who has age-related macular degeneration. Which of the following findings should the nurse expect?

Distorted central vision of the eyes

A nurse is reviewing the laboratory reports of a client who reports chest pain. Which of the following laboratory results indicate the client is experiencing a myocardial infarction?

Elevated troponin

A nurse in a clinic is assisting with the development of a pamphlet about STIs. Which of the following information should the nurse recommend including in the pamphlet?

Females have a higher risk for contracting STIs than males.

A nurse if reinforcing teaching with a client who has asthma and a new prescription for corticosteroid. Which of the following findings should the nurse include as an adverse effect of this medication?

Frequent colds

A nurse is assisting with the care of a client who had a stroke and is unable to speak. The nurse should identify that the clients injury occurred in which of the following lobes of the brain?

Frontal lobe

A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycosylate hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the teaching?

HbA1c results measure glucose control for the prior 3 months

A nurse is preparing to administer an influenza vaccine to a client. Which of the following statements by the client should cause the nurse to postpone administration of the vaccine

I had a low fever this morning.

A nurse is reinforcing teaching with a client prior to removal of a leg cast. Which of the following statements should indicate to the nurse that the client understands the teaching?

I will feel vibrations on my leg from the cast cutter.

A nurse is reinforcing teaching with a client who has chronic kidney disease about disease management. Which of the following statements by the client indicates an understanding of the teaching?

I will limit my daily intake of protein.

A nurse is assisting with the development of a plan of care to manage pain for a client who has herpes zoster with lesions on the lower extremities. Which of the following interventions should the nurse include in the plan of care?

Keep bed linens off the affected areas.

A nurse is reinforcing discharge teaching with a client who has Crohn's disease. Which of the following statements should the nurse include in the teaching?

Maintain a low-residue diet

A nurse is reinforcing teaching with a client who is postoperative following a cemented total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?

Maintain hip flexion at 90 or less when sitting.

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

Muscle spasticity

A nurse is caring for a client following a thyroidectomy. Which of the following findings should alert the nurse to the possibility of parathyroid gland injury?

Muscle twitching

A nurse is collecting data from an older adult client who has several concerns. Which of the following concerns should the nurse recognize as an expected change associated with aging?

My food tastes bland even after I add seasoning.

A nurse is contributing to the plane of care to promote a restful nights sleep for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan of care?

Offer a small snack at bedtime

A nurse is assisting with an educational program for clients who have been newly diagnosed with a diabetes mellitus. Which of the following instructions should the nurse include in the program regarding insulin?

Opened insulin can be stored on a cool countertop away from light.

A nurse is reinforcing teaching with a client about testicular self-examination. Which of the following instructions should the nurse include in the teaching?

Perform testicular self-examination after taking a warm shower.

A nurse is reviewing the chart of a client who's is experiencing an adrenal crisis, which was precipitated by the client not taking their medication for several days. The nurse should identify that withdrawal from which of the following medications potentiated adrenal crisis?

Prednisone

A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client?

Rephrase client instructions when not understood.

A nurse is caring for a client who is in Buck's traction for a fractured hip. The client reports increased pain at the site of the fracture. Which of the following actions should the nurse take?

Reposition the client

A nurse is caring for a client who is receiving a continuous tube feeding of 60mL/hr at 1.2 cal.mL. How many calories will the client receive in 12 hr?

Step 1: What is the unit of measurement the nurse should calculate? cal Step 2: What is the volume the nurse should infuse? X mL = 60 mL/hr x 12 hr = 720 mL Step 3: What is the total infusion time? 12 hr Step 4: Should the nurse convert the units of measurement? No Step 5: Set up an equation and solve for X. X cal = Volume x Calories X cal = 720 mL x 1.2 cal/mL X cal = 864 cal Step 6: Round if necessary. Step 7: Determine if the amount to administer makes sense. If the provider prescribed 60 mL/hr to infuse over 12 hr, it makes sense to administer 720 mL over 12 hr. If there are 1.2 cal/mL, it makes sense that the total number of calories the nurse will deliver in 12 hr is 864 cal. Follow these steps to calculate the infusion rate using the Dimensional Analysis method of calculation: Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) X cal = Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) 1.2 calX cal = 1 min Step 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 1.2 cal60 min12 hrX cal = × × 1 min1 hr1 Step 4: Solve for X. X cal = 864 cal Step 5: Round if necessary. Step 6: Determine if the amount to administer makes sense. If the provider prescribed 60 mL/hr to infuse over 12 hr, it makes sense to administer 720 mL over 12 hr. If there are 1.2 cal/mL, it makes sense that the total number of calories the nurse will deliver in 12 hr is 864 cal.

A nurse is reinforcing teaching with a client who has osteoporosis. Which of the following instructions should the nurse include in the teaching?

Take calcium supplements with meals.

A nurse is caring for a client who has prostate cancer. The client ask the nurse why they are having a difficulty with urination. Which of the following responses should the nurse make?

The tumor causes obstruction of the urine from the urethra

A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes. Which of the following information should the nurse include?

The virus can be transmitted without lesions being present.

A home health nurse is caring for a client who has COPD. The client reports shortness of breath while eating, despite the use of home oxygen. Which of the following recommendations should the nurse make?

Use a bronchodilator 30 minutes before your meal.

A nurse is contributing to the plane of care for a client who has a head injury and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse include in the plan?

Use a turn sheet to reposition the client.

A nurse is reviewing the medical records of a client who is postoperative. Which of the following findings should the nurse identify as a complication of surgery?

WBC count of 15,000/mm3

A nurse is collecting data from a client who has an obstructive pulmonary disorder. The nurse should document the sound as which of the following?

Wheezes

A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for regular and NPH insulin. Which of the following instructions on preparing the insulins should the nurse include?

Withdraw the regular insulin before withdrawing the NPH insulin

A nurse is reinforcing discharge teaching with a client who has leukemia and is receiving chemotherapy. Which of the following statements should the nurse include in the teaching?

You should place your toothbrush in hydrogen peroxide