All Q’s MEDSURGE final
Dec. 3@1700 • Chest Xray • O2 titrate to keep saturation > 94% • Furosemide 40 mg IT times 1 now • Peripheral IV • Complete blood count, comprehensive metabolic panel Question 4: Place the prescriptions in order of the priority in which the nurse should complete them
1) Place O2 at 2L/nasal cannula 2) Place IV line 3) Deliver furosemide 40mg IV dose 4) Request chest x-ray and lab draw
What is a typical complication of inadequate chest tube dressing change? A) Infection B) Increased intra-abdominal pressure C) Activation of clotting factors D) Increased blood lactic acid
A) Infection
A client has sought care because of recent dark-colored stools. As a result, a fecal occult blood test has been ordered. The nurse should give what instructions to the client? A. "Take no NSAIDs within 72 hours of the test." B. "Take prescribed medications as usual." C. "Avoid over-the-counter (OTC) vitamin C supplements." D. "Do not use fiber supplements before the test."
A. "Take no NSAIDs within 72 hours of the test."
A client presents to the ED reporting severe substernal chest pain radiating down the left arm. The client is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU? A. Begin ECG monitoring. B. Obtain information about family history of heart disease. C. Auscultate lung fields. D. Determine if the client smokes.
A. Begin ECG monitoring
A client with advanced venous insufficiency is confined to bed rest following orthopedic surgery. How can the nurse best prevent skin breakdown in the client's lower extremities? A. Ensure that the client's heels are protected and supported. B. Closely monitor the client's serum albumin and prealbumin levels. C. Perform gentle massage of the client's lower legs, as tolerated. D. Perform passive range-of-motion exercises once per shift.
A. Ensure that the client's heels are protected and supported.
A community health nurse is preparing for an initial home visit to a client discharged following a total gastrectomy for treatment of gastric cancer. What would the nurse anticipate that the plan of care is most likely to include? A. Enteral feeding via gastrostomy tube (G tube) B. Gastrointestinal decompression by nasogastric tube C. Periodic assessment for esophageal distension D. Administration of injections of vitamin B12
A. Enteral feeding via gastrostomy tube (G tube)
The nurse has just admitted a client for cardiac surgery. The client tearfully describes feeling afraid of dying while undergoing the surgery. What is the nurse's best response? A. Explore the factors underlying the client's anxiety. B. Teach the client guided imagery techniques. C. Obtain an order for a PRN benzodiazepine. D. Describe the procedure in greater detail.
A. Explore the factors underlying the client's anxiety.
The nurse is administering medications to a client through a feeding tube. Which action should the nurse take? A. Flush the tube with 5 mL of water before administering medication. B. Turn the tube feeding off for 1 hour before administering the medication. C. Administer each medication separately. D. Flush with 50 mL of water between each medication.
A. Flush the tube with 5 mL of water before administering medication.
The nurse is assessing a client suspected of having developed acute glomerulonephritis. The nurse should expect to address what clinical manifestation that is characteristic of this health problem? A. Hematuria B. Precipitous decrease in serum creatinine levels C. Hypotension unresolved by fluid administration D. Glucosuria
A. Hematuria
Which classification of clients would be at greatest risk for hospital- acquired endocarditis? A. Hemodialysis clients B. Clients on immunoglobulins C. Clients who undergo intermittent urinary catheterization D. Children under the age of 12
A. Hemodialysis clients
The nurse is planning the care of a client with heart failure. The nurse should identify what overall goals of this client's care? Select all that apply. A. Improve functional status B. Prevent endocarditis. C. Extend survival. D. Limit physical activity. E. Relieve client symptoms.
A. Improve functional status B. Prevent endocarditis. E. Relieve client symptoms.
A client admitted to the medical unit with heart failure is exhibiting signs and symptoms of pulmonary edema. How should the nurse best position the client? A. In a high Fowler position B. On the left side-lying position C. In a flat, supine position D. In the Trendelenburg position
A. In a high Fowler position
A nurse is preparing to place a client's prescribed nasogastric tube. What anticipatory guidance should the nurse provide to the client? A. Insertion is likely to cause some gagging. B. Insertion will cause some short-term pain. C. A narrow-gauge tube will be inserted before being replaced with a larger-gauge tube. D. Topical anesthetics will be used to reduce discomfort during insertion.
A. Insertion is likely to cause some gagging.
The nurse is preparing to perform a client's abdominal assessment. What examination sequence should the nurse follow? A. Inspection, auscultation, percussion, and palpation B. Inspection, palpation, auscultation, and percussion C. Inspection, percussion, palpation, and auscultation D. Inspection, palpation, percussion, and auscultation
A. Inspection, auscultation, percussion, and palpation
Diagnostic imaging and physical assessment have revealed that a client with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? A. Peritonitis B. Gastritis C. Gastroesophageal reflux D. Acute pancreatitis
A. Peritonitis
The nurse is caring for a client who is seeking care for signs and symptoms of lymphedema. The nurse's plan of care should prioritize which nursing diagnosis? A. Risk for infection related to lower extremity swelling secondary to lymphedema B. Disturbed body image related to lower extremity swelling secondary to lymphedema C. Ineffective health maintenance related to lower extremity swelling secondary to lymphedema D. Risk for deficient fluid volume related to lower extremity swelling secondary to lymphedema
A. Risk for infection related to lower extremity swelling secondary to lymphedema
Regarding chest tubes, which finding in the suction system indicates a significant air leak? A) Hypoxemia B) Excessive bubbling C) Chest pain D) Shortness of breath (SOB)
B) Excessive bubbling
Using the interpreter for the dialysis instructions, the nurse identifies that Alfredo is concerned about complying with the renal and diabetic diet with his preference of traditional Hispanic foods. Which action should the nurse take? a) Plan to have hospital prepare his meals b) Identify a Spanish-speaking dietitian in the community that Alfredo can consult c) Teach his family about the dietary restrictions, encouraging him to stay compliant d) Arrange for meals-on-wheels to deliver his meals
B) Identify a Spanish-speaking dietitian in the community that Alfredo can consult
Which finding should prompt urgent re-evaluation of a patient with a chest tube? A) Malar rash B) Shortness of breath (SOB) C) Dry mouth D) Constipation
B) Shortness of breath (SOB)
A nurse is caring for a client with impaired renal function. A creatinine clearance measurement has been ordered. The nurse should facilitate collection of what samples? A. A fasting serum potassium level and a random urine sample B. A 24-hour urine specimen and a serum creatinine level midway through the urine collection process C. A BUN and serum creatinine level on three consecutive mornings D. A sterile urine specimen and an electrolyte panel, including sodium, potassium, calcium, and phosphorus values
B. A 24-hour urine specimen and a serum creatinine level midway through the urine collection process
A nurse on a busy medical unit provides care for many clients who require indwelling urinary catheters at some point during their hospital care. The nurse should recognize a heightened risk of injury associated with indwelling catheter use in which client? A. A client whose diagnosis of chronic kidney disease requires a fluid restriction B. A client who has Alzheimer disease and who is acutely agitated C. A client who is on bed rest following a recent episode of venous thromboembolism D. A client who has decreased mobility following a transmetatarsal amputation
B. A client who has Alzheimer disease and who is acutely agitated
The nurse is preparing to check for tube placement in the client's stomach as well as measure the residual volume. What are these nursing actions attempting to prevent? A. Gastric ulcers B. Aspiration C. Abdominal distention D. Diarrhea
B. Aspiration
A client's NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next? A. Withdraw the NG tube 2 inches (5 cm) and reattempt aspiration. B. Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating. C. Withdraw the NG tube slightly and attempt to dislodge by flicking the tube with the fingers. D. Remove the NG tube promptly and obtain an order for reinsertion from the primary care provider.
B. Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating.
The nurse is assessing a client who is known to have right-sided heart failure. What assessment finding is most consistent with this client's diagnosis? A. Pulmonary edema B. Distended neck veins C. Dry cough D. Orthopnea
B. Distended neck veins
A nurse has written a plan of care for a client diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. Which intervention is the most appropriate for this diagnosis? A. Elevate the legs and arms above the heart when resting. B. Encourage the client to engage in a moderate amount of exercise. C. Encourage extended periods of sitting or standing. D. Discourage walking in order to limit pain.
B. Encourage the client to engage in a moderate amount of exercise.
While assessing a client, the nurse notes that the client's ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best follow up this assessment finding? A. Assess the client's use of over-the-counter dietary supplements. B. Implement interventions relevant to arterial narrowing. C. Encourage the client to increase intake of foods high in vitamin K. D. Adjust the client's activity level to accommodate decreased coronary output.
B. Implement interventions relevant to arterial narrowing.
A client has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurse's priority intervention? A. Administration of antiemetics B. Insertion of an NG tube for decompression C. Infusion of hypotonic IV solution D. Administration of proton pump inhibitors as prescribed
B. Insertion of an NG tube for decompression
The nurse is taking a health history of a new client who reports pain in the left lower leg and foot when walking. This pain is relieved with rest, and the nurse observes that the left lower leg is slightly edematous and is hairless. When planning this client's care, the nurse should most likely address which health problem? A. Coronary artery disease (CAD) B. Intermittent claudication C. Arterial embolus D. Raynaud disease
B. Intermittent claudication
An adult client is admitted to the ED with chest pain. The client states that there was unrelieved chest pain for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions? A. Thrombolytics (fibrinolytics), oxygen administration, and nonsteroidal anti-inflammatories B. Morphine sulphate, oxygen, and bed rest C. Oxygen and beta-adrenergic blockers D. Bed rest, albuterol nebulizer treatments, and oxygen
B. Morphine sulphate, oxygen, and bed rest
A 52-year-old client is scheduled for diagnostic testing to address prolonged signs and symptoms of genitourinary dysfunction. What signs and symptoms are particularly suggestive of urinary tract disease? Select all that apply. A. Petechiae B. Pain C. Gastrointestinal symptoms D. Changes in voiding E. Jaundice
B. Pain C. Gastrointestinal symptoms D. Changes in voiding
A client with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly, and that the client's abdomen is increasing in girth. What is the nurse's most appropriate action? A. Advance the catheter 2 to 4 cm further into the peritoneal cavity. B. Reposition the client to facilitate drainage. C. Aspirate from the catheter using a 60-mL syringe. D. Infuse 50 mL of additional dialysate.
B. Reposition the client to facilitate drainage.
A client with a sacral pressure ulcer has had a urinary catheter inserted. As a result of this new intervention, the nurse should prioritize what nursing diagnosis in the client's plan of care? A. Impaired physical mobility related to presence of an indwelling urinary catheter B. Risk for infection related to presence of an indwelling urinary catheter C. Deficient knowledge regarding indwelling urinary catheter care D. Disturbed body image related to urinary catheterization
B. Risk for infection related to presence of an indwelling urinary catheter
A client who experienced a large upper gastrointestinal (GI) bleed due to gastritis has had the bleeding controlled and is now stable. For the next several hours, the nurse caring for this client should assess for what signs and symptoms of recurrence? A. Tachycardia, hypotension, and tachypnea B. Tarry, foul-smelling stools C. Diaphoresis and sudden onset of abdominal pain D. Sudden thirst, unrelieved by oral fluid administration
B. Tarry, foul-smelling stools
A nurse is caring for a newly admitted client with a suspected GI bleed. The nurse assesses the client's stool after a bowel movement and notes it to be a tarry-black color. This finding is suggestive of bleeding from what location? A. Sigmoid colon B. Upper GI tract C. Large intestine D. Anus or rectum
B. Upper GI tract
Alfredo is placed in a fluid restriction of 1 liter per 24 hours. He is asking fir something to drink at 2245. Based on the intake and output record, what the nurse's best action? a) " No, I'm sorry, but you've had allotment of fluid for the day. I can bring you some oral swabs." b) "You have almost met your allotment of fluid for the day. Let me listen to your lungs to see if I can give you something more." c) "You have almost met your restriction for the day; I'll bring you some ice chips." d) "You can have a glass of juice, water or milk. Which would you prefer
C) "You have almost met your restriction for the day; I'll bring you some ice chips."
Regarding chest tube management and care, what is the physical exam finding associated with subcutaneous emphysema? A) Coughing B) Respiratory depression C) Crepitus D) Dyspnea and respiratory distress
C) Crepitus
The nurse reassess the SpO2 reading after 15 minutes, and it is 94%. What should the nurse do next? a) Nothing, this is acceptable b) Notify the HCP c) Increase the Oxygen to 3L/nasal cannula d) Place Alfredo on a simple mask
C) Increase the O2 to 3 L/nasal cannula
The nurse is caring for a patient who is post-op day 1 aortic valve repair. The patient has not ambulated and reports felling too fatigued to walk in the hallway. Upon assessment, the nurse notes that there are diminished breath sounds in the bases, oxygen saturation is 93% on room air, low-grade fever 99.2 F degree and shallow breathing. What is the nurse's next action? A) Call hospital code B) Inform the physician C) Instruct the patient to use spirometer incentive spirometer (ICS) at least 10 times per hour D) Apply compression wrap to the lower extremities
C) Instruct the patient to use spirometer incentive spirometer (ICS) at least 10 times per hour
You are monitoring care for a patient diagnosed with active pulmonary tuberculosis who has been taking the prescribed dosses of isoniazid, rifampin, pyrazinamide, and ethambutol. Which finding best indicates the antibiotic therapy is effective A) Patient can breathe better B) No more fever C) Sputum cultures converts to negative D) Non- productive cough only
C) Sputum cultures converts to negative
The management of the client's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the client is managing the tube correctly? A. "I clean my stoma twice a day with alcohol." B. "The only time I flush my tube is when I'm putting in medications." C. "I flush my tube with water before and after each of my medications." D. "I try to stay still most of the time to avoid dislodging my tube."
C. "I flush my tube with water before and after each of my medications."
The triage nurse in the emergency department is assessing a client with chronic heart failure who has presented with worsening symptoms. In reviewing the client's medical history, which condition is a potential primary cause of the client's heart failure? A. Endocarditis B. Pleural effusion C. Atherosclerosis D. Atrial septal defect
C. Atherosclerosis
The nurse is caring for an acutely ill client. What assessment finding should prompt the nurse to inform the health care provider that the client may be exhibiting signs of acute kidney injury (AKI)? A. An inability to initiate voiding for 2 days. B. The urine is cloudy and has visible sediment with a foul odor. C. Average urine output has been 10 mL/hr for several hours. D. Client reports left-sided flank pain.
C. Average urine output has been 10 mL/hr for several hours.
The nurse is participating in the care conference for a client with acute coronary syndrome (ACS). What goal should guide the care team's selection of assessments, interventions, and treatments? A. Maximizing cardiac output while minimizing heart rate B. Decreasing energy expenditure of the myocardium C. Balancing myocardial oxygen supply with demand D. Increasing the size of the myocardial muscle
C. Balancing myocardial oxygen supply with demand
A client is admitted to the ICU after a motor vehicle accident. On the second day of the hospital admission, the client develops acute kidney injury. The client is hemodynamically unstable, and renal replacement therapy is needed to manage the client's hypervolemia and hyperkalemia. Which of the following therapies will the client's hemodynamic status best tolerate? A. Hemodialysis B. Peritoneal dialysis C. Continuous venovenous hemodialysis (CVVHD) D. Plasmapheresis
C. Continuous venovenous hemodialysis (CVVHD)
A client is receiving education about an upcoming Billroth I procedure (gastroduodenostomy). This client should be informed that the client may experience which of the following adverse effects associated with this procedure? A. Persistent feelings of hunger and thirst B. Constipation or bowel incontinence C. Diarrhea and feelings of fullness D. Gastric reflux and belching
C. Diarrhea and feelings of fullness
A nurse is providing anticipatory guidance to a client who is preparing for a total gastrectomy. The nurse learns that the client is anxious about numerous aspects of the surgery. What intervention is most appropriate to alleviate the client's anxiety? A. Emphasize the fact that gastric surgery has a low risk of complications. B. Encourage the client to focus on the benefits of the surgery. C. Facilitate the client's contact with support services. D. Obtain an order for a PRN benzodiazepine.
C. Facilitate the client's contact with support services.
The nurse is caring for a client with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The client has an elevated phosphorus level and has been prescribed calcium acetate to bind the phosphorus. The nurse should teach the client to take the prescribed medication at what time? A. Only when needed B. Daily at bedtime C. First thing in the morning D. With each meal
C. First thing in the morning
The nurse is caring for a client suspected of having renal dysfunction. When reviewing laboratory results for this client, the nurse interprets the presence of which substances in the urine as most suggestive of pathology? A. Potassium and sodium B. Bicarbonate and urea C. Glucose and protein D. Creatinine and chloride
C. Glucose and protein
A client asks the nursing assistant for a bedpan. When the client is finished, the nursing assistant notifies the nurse that the client has bright red streaking of blood in the stool. The nurse's assessment should focus on what potential cause? A. Diet high in red meat B. Upper GI bleed C. Hemorrhoids D. Use of iron supplements
C. Hemorrhoids
A clinic client has described recent dark-colored stools, and the nurse recognizes the need for fecal occult blood testing (FOBT). What aspect of the client's current health status would contraindicate FOBT? A. Gastroesophageal reflux disease (GERD) B. Peptic ulcers C. Hemorrhoids D. Recurrent nausea and vomiting
C. Hemorrhoids
A client who has been experiencing changes in his bowel function is scheduled for a barium enema. What instruction should the nurse provide for postprocedure recovery? A. Remain NPO for 6 hours postprocedure. B. Administer a Fleet enema to cleanse the bowel of the barium. C. Increase fluid intake to evacuate the barium. D. Avoid dairy products for 24 hours' postprocedure.
C. Increase fluid intake to evacuate the barium.
The nurse is caring for an adult client who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina? A. Ineffective breathing pattern related to decreased cardiac output B. Anxiety related to fear of death C. Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD) D. Impaired skin integrity related to CAD
C. Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)
A client presents to the clinic reporting intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the client that angina is most often attributable to what cause? A. Decreased cardiac output B. Decreased cardiac contractility C. Infarction of the myocardium D. Coronary arteriosclerosis
C. Infarction of the myocardium
A client has had a indwelling urinary catheter removed after having it in place for 10 days during recovery from an acute illness. Two hours after removal of the catheter, the client informs the nurse that the client is experiencing urinary urgency resulting in several small-volume voids. What is the nurse's best response? A. Inform the client that urgency and occasional incontinence are expected for the first few weeks post-removal. B. Obtain an order for a loop diuretic in order to enhance urine output and bladder function. C. Inform the client that this is not unexpected in the short term and scan the client's bladder following each void. D. Obtain an order to reinsert the client's urinary catheter and attempt removal in 24 to 48 hours.
C. Inform the client that this is not unexpected in the short term and scan the client's bladder following each void.
A client who underwent a gastric resection 3 weeks ago is having their diet progressed on a daily basis. Following the latest meal, the client reports dizziness and palpitations. Inspection reveals that the client is diaphoretic. What is the nurse's best action? syndrome. A. Insert a nasogastric tube promptly. B. Reposition the client supine. C. Monitor the client closely for further signs of dumping D. Assess the client for signs and symptoms of aspiration.
C. Monitor the client closely for further signs of dumping
The nurse is providing discharge education to a client diagnosed with heart failure. What should the nurse teach this client to do to assess fluid balance in the home setting? A. Monitor and record blood pressure daily. B. Monitor and record radial pulses daily. C. Monitor weight daily. D. Monitor bowel movements
C. Monitor weight daily.
The nurse notes that a client has developed dyspnea; a productive, mucus cough; peripheral cyanosis; and noisy, moist-sounding, rapid breathing. These signs and symptoms suggest which health problem? 37 A. Pericarditis B. Cardiomyopathy C. Pulmonary edema D. Right ventricular hypertrophy
C. Pulmonary edema
A nurse educator is conducting an in-service for nursing students about how tobacco use impacts coronary artery disease (CAD)? What are the primary ways that tobacco use impacts CAD? Select all that apply. A. Decreases the supply of oxygen to the myocardium B. Increases platelet adhesion C. Raises the heart rate and blood pressure D. Causes the coronary arteries to dilate E. Increases the blood carbon monoxide level
C. Raises the heart rate and blood pressure E. Increases the blood carbon monoxide level
Cardiac client's resistance to left ventricular filling has caused blood to back up into the client's circulatory system. Which health problem is likely to result? A. Acute pulmonary edema B. Right-sided heart failure C. Right ventricular hypertrophy D. Left-sided heart failure
C. Right ventricular hypertrophy
Results of a client's 24-hour urine sample indicate osmolality of 510 mOsm/kg (510 mmol/kg), which is within reference range. What conclusion can the nurse draw from this assessment finding? A. The client's kidneys are capable of maintaining acid-base balance. B. The client's kidneys reabsorb most of the potassium that the client ingests. C. The client's kidneys can produce sufficiently concentrated urine. D. The client's kidneys are producing sufficient erythropoietin
C. The client's kidneys can produce sufficiently concentrated urine.
Family members bring a client to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data? A. The symptoms indicate angina and should be treated as such. B. The symptoms indicate a pulmonary etiology rather than a cardiac etiology. C. The symptoms indicate an acute coronary episode and should be treated as such. D. Treatment should be determined pending the results of an exercise stress test.
C. The symptoms indicate an acute coronary episode and should be treated as such.
The cardiac nurse is caring for a client who has been diagnosed with dilated cardiomyopathy (DCM). Echocardiography is likely to reveal what pathophysiological finding? A. Decreased ejection fraction B. Decreased heart rate C. Ventricular hypertrophy D. Mitral valve regurgitation
C. Ventricular hypertrophy
A nurse in the rehabilitation unit is caring for an older adult client who is in cardiac rehabilitation following an MI. The nurse's plan of care calls for the client to walk for 10 minutes 3 times a day. The client questions the relationship between walking and heart function. How should the nurse best reply? A. "The arteries in your legs constrict when you walk and allow the blood to move faster and with more pressure on the tissue." B. "Walking increases your heart rate and blood pressure. Therefore, your heart is under less stress." C. "Walking helps your heart adjust to your new arteries and helps build your self-esteem." D. "When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart."
D. "When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart."
A geriatric nurse is performing an assessment of body systems on an older adult client. The nurse should be aware of what age-related change affecting the renal and urinary systems? A. Increased ability to concentrate urine B. Increased bladder capacity C. Urinary incontinence D. Decreased glomerular filtration rate
D. Decreased glomerular filtration rate
A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid-base balance? A. Sequestering free hydrogen ions in the nephrons B. Returning bicarbonate to the body's circulation C. Retaining ammonium chloride D. Excreting bicarbonate in the urine
D. Excreting bicarbonate in the urine
The nurse is caring for a client who has a fluid volume deficit. When evaluating this client's urinalysis results, what should the nurse normally anticipate? A. Decrease in blood urea nitrogen (BUN) B. Less antidiuretic hormone (ADH) released C. Decreased urine osmolality D. Increased urine specific gravity
D. Increased urine specific gravity
A client is recovering in the hospital following gastrectomy. The nurse notes that the client has become increasingly difficult to engage and has had several angry outbursts at staff members in recent days. The nurse's attempts at therapeutic dialogue have been rebuffed. What is the nurse's most appropriate action? A. Ask the client's primary provider to liaise between the nurse and the client. B. Delegate care of the client to a colleague. C. Limit contact with the client in order to provide privacy. D. Make appropriate referrals to services that provide psychosocial support.
D. Make appropriate referrals to services that provide psychosocial support.
A nurse working in a long-term care facility is performing the admission assessment of a newly admitted 85-year-old resident. During inspection of the resident's feet, the nurse notes early evidence of gangrene on one of the resident's great toes. The nurse should assess for further evidence of which health problem? A. Chronic venous insufficiency B. Raynaud phenomenon C. Venous thromboembolism (VTE) D. Peripheral artery disease (PAD)
D. Peripheral artery disease (PAD)
A client is being assessed for a suspected deficit in intrinsic factor synthesis. What diagnostic or assessment finding is the most likely rationale for this examination of intrinsic factor production? A. Muscle wasting B. Chronic jaundice in the absence of liver disease C. The presence of fat in the client's stool D. Persistently low hemoglobin and hematocrit
D. Persistently low hemoglobin and hematocrit
A client has experienced excessive losses of bicarbonate and has subsequently developed an acid-base imbalance. How will this lost bicarbonate be replaced? A. The kidneys will excrete increased quantities of acid. B. Bicarbonate will be released from the adrenal medulla. C. Alveoli in the lungs will synthesize new bicarbonate. D. Renal tubular cells will generate new bicarbonate.
D. Renal tubular cells will generate new bicarbonate.
A nurse is assessing a new client who is diagnosed with peripheral artery disease. The nurse cannot feel the pulse in the client's left foot. How should the nurse proceed with assessment? A. Have the primary care provider prescribe a computed tomography (CT) scan. B. Apply a tourniquet for 3 to 5 minutes and then reassess. C. Elevate the extremity and attempt to palpate the pulses. D. Use Doppler ultrasound to identify the pulses.
D. Use Doppler ultrasound to identify the pulses.
A nasogastric tube is being inserted in a client with the COVID virus. Which action should the nurse take? A. Place the client in a prone position. B. Administer bolus feedings. C. Place a mask over the client's nose. D. Wear personal protective equipment.
D. Wear personal protective equipment.
The public health nurse is participating in a health fair and interviews a client with a history of hypertension, who is currently smoking one pack of cigarettes per day. The client denies any of the most common manifestations of CAD. The nurse should expect the focuses of CAD treatment to be: A. drug therapy and smoking cessation. B. diet and drug therapy. C. diet therapy only. D. diet therapy and smoking cessation
D. diet therapy and smoking cessation
What hypothesis can the nurse make from the lab and chest Xray report? a) Alfredo has renal insufficiency causing fluid overload. b) Alfredo has signs of liver failure causing fluid shifting c) Alfredo has an infection that is likely pneumonia d) Alfredo has poor myocardial contractility causing fluid excess
a) Alfredo has renal insufficiency causing fluid overload
Alfredo us admitted to the medical unit with dyspnea and renal insufficiency. A nephrologist is consulted and prescribes a 24-hour urine collection for creatinine clearance. The nurse requests a translator to instruct Alfredo about the process of collection. What should the nurse include in the teaching? Select all that apply a) All urine must go into the container over the next 24 hours b) The container with urine must be kept at room temperature c) Only this dark container can be used to collect the urine d) Empty your bladder now, before we begin the test e) There will be signs in the bathroom alerting the staff of this test
a) All urine must go into the container over the next 24 hours c) Only this dark container can be used to collect the urine d) Empty your bladder now, before we begin the test e) There will be signs in the bathroom alerting the staff of this test
Knowing that Alfredo's condition is worsening, what potential complication (s) should the nurse be monitoring for? Select all that apply. a) Cardiac dysthymias b) Pulmonary edema c) Sepsis d) Liver failure e) Deep vein thrombosis
a) Cardiac dysthymias b) Pulmonary edema d) Liver failure e) Deep vein thrombosis
What should the nurse include in Alfredo's plan of care? Select all that apply. a) Daily weights b) Strick intake and output c) Monitor pulse for irregularity d) Restrict dietary sodium and potassium
a) Daily weights b) Strick intake and output c) Monitor pulse for irregularity d) Restrict dietary sodium and potassium
A client is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what event? a) Hemodynamic instability b) Decreased urine output c) Refeeding syndrome d) Breakthrough pain
a) Hemodynamic instability
What action should the nurse take in response to the post-dialysis assessment? Select all that apply. a) Lower the head of the bed b) Deliver fluid-wide open c) Have Alfredo drink juice d) Apply a cooling blanket e) Apply oxygen
a) Lower the head of the bed c) Have Alfredo drink juice
The first symptom of deep vein thrombosis ( DVT) may be a) Pain of cramp in the calf b) Fever c) Hypotension d) Numbness of the toes
a) Pain of cramp in the calf
Aspirin, a common over-the counter (OTC) medication that inhibits platelet aggregation should be discontinued 7 days to 10 days before surgery or the patient may be at risk for bleeding. a) True b) False
a) True
A major of nursing diagnosis in the post-op period may include decreased ____________ related to shock or hemorrhage a) Respiratory rate b) Cardiac output c) Liver function d) Nothing
b) Cardiac output
The nurse is evaluating the client's response to the furesemide. Which finding determines the dose was effective? a) Urine output of 200 mL over 4 hours b) Crackles bilaterally in the lower bases c) Jugular venous distension evident d) Potassium level decreases
b) Crackles bilaterally in the lower bases
An elderly patient was admitted 2 days ago with a seriously fractured femur. During today's assessment you note the patient is confused, restless, and tachypnea. You hear diminished breath sounds and note petechiae on the patient chest and neck. You consider these symptoms represent what cause? a) Cardiac arrest syndrome b) Fat embolism syndrome c) Cushing syndrome d) Panicking syndrome
b) Fat embolism syndrome
Which of the following statement is true about orthostatic hypotension a) Heart rate decreases and blood pressure increases at the same time b) Heart rate increases first before blood pressure drops c) Blood pressure drops first then heart rate increases d) Heart rate and blood pressure increase
b) Heart rate increases first before blood pressure drops
Which of the following condition is a result of blood loss, hypoventilation, position changes, pooling of blood in the extremities, or side effects of medication and anesthesia? a) Hypertension b) Hypotension c) Hyperglycemia d) Hypoglycemia
b) Hypotension
The nurse learn that Alfredo is going to dialysis in 3 hours. He has several medications due, which ones should the nurse hold before dialysis? Select all that apply. a) Regular insulin, 5 units subcutaneously b) Metoprolol 25 mg orally c) Furosemide 80 mg orally d) Calcium acetate 667 mg orally e) Amoxicillin 250 mg orally
b) Metoprolol 25 mg orally c) Furosemide 80 mg orally
Temp 97.2 F, HR 110, BP 122/75, RR 24, SpO2 91% on room air. Blood glucose monitor reading is 240 g/dL. AOx3. Lungs with bilateral fine crackles ½ way up the lung fields, moist cough, respirations labored. Bowel sounds active. Denies pain. Stated " Me cuesta mucho respirar." He has 3+ pedal edema and 1+ dorsalis pedis pulses, bilaterally. Question: List top 3 priority assessment concerns that indicates fluid volume excess What should be the nurse's priority nursing action? a) Obtain an order for insulin b) Raise the head of the bed c) Place oxygen at 2L/ nasal cannula d) Obtain a translator
b) Raise the head of the bed
The purpose of withholding food and fluid before surgery is to prevent a) Infection b) Hypotension c) Aspiration d) Loosing weight
c) Aspiration
The nurse observes tall, peaked T-waves on EKG of a patient end-stage renal disease. What action should the nurse take next? a) Call the MD b) Document the findings c) Check the serum electrolyte panel d) Prepare to administer an ampoule of sodium bicarbonate to prevent acidosis-induced ventricle tachycardia
c) Check the serum electrolyte panel
The nurse is providing an educational workshop about coronary artery disease (CAD). The nurse explains to participants that CAD has many risk factors some that can be controlled, and some cannot. Which risk factors should the nurse list that can be controlled or modified? a) Gender, obesity, family history, and smoking b) Inactivity, stress, gender, and smoking c) Cholesterol level, HTN, and smoking d) Stress, family history, and obesity
c) Cholesterol level, HTN, and smoking
It is determined that Alfredo will be started on hemodialysis. A temporary dialysis catheter is placed into his right internal jugular. What should the nurse assess with this type of catheter? a) Bruit and thrill b) Circulation to the extremity c) Dressing intactness d) Radial pulse
c) Dressing intactness
The primary goal in treatment cardiomyopathy: a) Absence of complications b) Adherence to the self-care program c) Improve cardiac output d) Increase activity
c) Improve cardiac output
The nurse is caring for a patient who is post-op day 5. During each client assessment, the nurse evaluates the client for infection. Which of the following would be the most indication of infection? a) Sutures intact and dry b) Patient complaints of pain 3 on the scale of 10 c) Incision site is red, warm, tender d) Dressing is wet
c) Incision site is red, warm, tender
Any nutritional deficiency prior to surgery should be corrected before surgery to provide adequate ____________ for tissue repair and collagen synthesis a) Lipid b) Carbohydrate c) Protein d) Vitamin D
c) Protein
Alfredo Hernandez is a 38-year-old male who lives in southern Texas. He and his family migrated to the United States from Guatemala a few years ago and live together in a small house. His primary language is Spanish, but he acquired the ability to understand and speak some English in his three years here. Like his mother, father, sisters, and cousins, he has Type II diabetes. His diabetes is loorly controlled, and he is now insulin dependent. He has hypertension, decreased vision and his feet are often " cold and numb". His family brings him to the community hospital today because he's having a hard time breathing. What should be the nurse's first action after placing Alfredo in a hospital gown? a) Obtain a glucose monitor reading b) Assess the blood pressure c) Take an SpO2 reading d) Place Alfredo on an EKG monitor
c) Take an SpO2 reading
The chest X-Ray is completed. The radiologist calls the nurse to say " The lungs have fluffy consolidation bilaterally." How sould the nurse interpret this report? a) There is pneumonia in both lungs b) Atelectasis is present c) There is fluid accumulation on both lungs d) A pneumothorax is present
c) There is fluid accumulation on both lungs
The nurse is changing the dressing for a patient 2 days post-op abdominal surgery. Upon inspection of the incision line, the nurse notes a 2 cm separation of the wound edges and a small amount of the serous drainage on the dressing. What is the accurate interpretation of this observation? a) Infection b) Healing by secondary intervention c) Wound dehiscence d) Chronic wound
c) Wound dehiscence
The nurse is mentoring a second-semester nursing student who is studying fluid assessment findings. Help the student match each finding with its appropriate fluid status a) Fluid overload b) Fluid Deficit c) Either overload or deficit • Hepatomegaly • Cerebral edema • Orthostatic hypotension • Tachycardia • Thready pulse • Thirst • Weight gain • Puff eyes • Cool skin • Edema • Distended jugular veins
• Hepatomegaly - Fluid overload • Cerebral edema - Fluid overload • Orthostatic hypotension - Fluid Deficit • Tachycardia - Either overload or deficit • Thready pulse - Fluid Deficit • Thirst - Fluid Deficit • Weight gain - Fluid overload • Puff eyes - Fluid overload • Cool skin - Fluid Deficit • Edema - Fluid overload • Distended jugular veins- Fluid overload
