Med Surg Test Bank for Exam 2
A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority? a. Auscultate for bowel sounds. b. Notify the provider immediately. c. Order an abdominal flat-plate x-ray. d. Palpate the mass and measure its size
B
A nurse cares for a client who is prescribed 4 mg of calcium gluconate to infuse over 5 hours. The pharmacy provides 2 premixed infusion bags with 2 mg of calcium gluconate in 100 mL of D5W. At what rate should the nurse administer this medication? (Record your answer using a whole number.) ____ mL/hr
40
A nurse cares for a client with acute pancreatitis who is prescribed gentamicin (Garamycin) 3 mg/kg/day in 3 divided doses. The client weighs 264 lb. How many milligrams should the nurse administer for each dose? (Record your answer using a whole number.) ____ mg/dose
120
A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next? a. Administer intravenous opioid medications. b. Position the client with knees to chest. c. Insert a nasogastric tube for decompression. d. Assess the clients bowel sounds.
D
A nurse is examining a client reporting right upper quadrant (RUQ) abdominal pain. What technique should the nurse use to assess this clients abdomen? a. Auscultate after palpating. b. Avoid any palpation. c. Palpate the RUQ first. d. Palpate the RUQ last.
D
A nurse cares for a client who is recovering from laparoscopic cholecystectomy surgery. The client reports pain in the shoulder blades. How should the nurse respond? a. Ambulating in the hallway twice a day will help. b. I will apply a cold compress to the painful area on your back. c. Drinking a warm beverage can relieve this referred pain. d. You should cough and deep breathe every hour.
a
A nurse cares for a client who states, My husband is repulsed by my colostomy and refuses to be intimate with me. How should the nurse respond? a. Lets talk to the ostomy nurse to help you and your husband work through this. b. You could try to wear longer lingerie that will better hide the ostomy appliance. c. You should empty the pouch first so it will be less noticeable for your husband. d. If you are not careful, you can hurt the stoma if you engage in sexual activity.
a
A nurse cares for a client with chronic hypercortisolism. Which action should the nurse take? a. Wash hands when entering the room. b. Keep the client in airborne isolation. c. Observe the client for signs of infection. d. Assess the clients daily chest x-ray.
a
A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is prescribed a 24-hour urine specimen collection. Which statement should the nurse include when delegating this activity to the UAP? a. Note the time of the clients first void and collect urine for 24 hours. b. Add the preservative to the container at the end of the test. c. Start the collection by saving the first urine of the morning. d. It is okay if one urine sample during the 24 hours is not collected.
a
A nurse assesses a client who is recovering from an ileostomy placement. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Pale and bluish stoma b. Liquid stool c. Ostomy pouch intact d. Blood-smeared output
a
A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, The stool in my pouch is still liquid. How should the nurse respond? a. The stool will always be liquid with this type of colostomy. b. Eating additional fiber will bulk up your stool and decrease diarrhea. c. Your stool will become firmer over the next couple of weeks. d. This is abnormal. I will contact your health care provider.
a
A nurse cares for a client who is prescribed a 24-hour urine collection. The unlicensed assistive personnel (UAP) reports that, while pouring urine into the collection container, some urine splashed his hand. Which action should the nurse take next? a. Ask the UAP if he washed his hands afterward. b. Have the UAP fill out an incident report. c. Ask the laboratory if the container has preservative in it. d. Send the UAP to Employee Health right away.
a
A nurse prepares to discharge a client with chronic pancreatitis. Which question should the nurse ask to ensure safety upon discharge? a. Do you have a one- or two-story home? b. Can you check your own pulse rate? c. Do you have any alcohol in your home? d. Can you prepare your own meals?
a
A nurse teaches a client who has been prescribed a 24-hour urine collection to measure excreted hormones. The client asks, Why do I need to collect urine for 24 hours instead of providing a random specimen? How should the nurse respond? a. This test will assess for a hormone secreted on a circadian rhythm. b. The hormone is diluted in urine; therefore, we need a large volume. c. We are assessing when the hormone is secreted in large amounts. d. To collect the correct hormone, you need to urinate multiple times.
a
An emergency nurse cares for a client who is experiencing an acute adrenal crisis. Which action should the nurse take first? a. Obtain intravenous access. b. Administer hydrocortisone succinate (Solu-Cortef). c. Assess blood glucose. d. Administer insulin and dextrose.
a
While assessing a client with Graves disease, the nurse notes that the clients temperature has risen 1 F. Which action should the nurse take first? a. Turn the lights down and shut the clients door. b. Call for an immediate electrocardiogram (ECG). c. Calculate the clients apical-radial pulse deficit. d. Administer a dose of acetaminophen (Tylenol).
a
A nurse assesses clients who have endocrine disorders. Which assessment findings are paired correctly with the endocrine disorder? (Select all that apply.) a. Excessive thyroid-stimulating hormone Increased bone formation b. Excessive melanocyte-stimulating hormone Darkening of the skin c. Excessive parathyroid hormone Synthesis and release of corticosteroids d. Excessive antidiuretic hormone Increased urinary output e. Excessive adrenocorticotropic hormone Increased bone resorption
a,b
A nurse assesses a client with hypothyroidism who is admitted with acute appendicitis. The nurse notes that the clients level of consciousness has decreased. Which actions should the nurse take? (Select all that apply.) a. Infuse intravenous fluids. b. Cover the client with warm blankets. c. Monitor blood pressure every 4 hours. d. Maintain a patent airway. e. Administer oral glucose as prescribed.
a,b,d
A nurse assesses clients with potential endocrine disorders. Which clients are at high risk for adrenal insufficiency? (Select all that apply.) a. A 22-year-old female with metastatic cancer b. A 43-year-old male with tuberculosis c. A 51-year-old female with asthma d. A 65-year-old male with gram-negative sepsis e. A 70-year-old female with hypertension
a,b,d
A nurse assesses a client with peritonitis. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Distended abdomen b. Inability to pass flatus c. Bradycardia d. Hyperactive bowel sounds e. Decreased urine output
a,b,e
A nurse assesses clients with potential endocrine disorders. Which clients are at high risk for hypopituitarism? (Select all that apply.) a. A 20-year-old female with benign pituitary tumors b. A 32-year-old male with diplopia c. A 41-year-old female with anorexia nervosa d. A 55-year-old male with hypertension e. A 60-year-old female who is experiencing shock f. A 68-year-old male who has gained weight recently
a,c,d,e
A nurse assesses a client with anterior pituitary hyperfunction. Which clinical manifestations should the nurse expect? (Select all that apply.) a. Protrusion of the lower jaw b. High-pitched voice c. Enlarged hands and feet d. Kyphosis e. Barrel-shaped chest f. Excessive sweating
a,c,d,e,f
A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which assessment findings should the nurse correlate with this diagnosis? (Select all that apply.) a. Serum potassium of 2.8 mEq/L b. Loss of 15 pounds without dieting c. Abdominal pain in upper quadrants d. Low-pitched bowel sounds e. Serum sodium of 121 mEq/L
a,c,e
A nurse cares for a client with a hypofunctioning anterior pituitary gland. Which hormones should the nurse expect to be affected by this condition? (Select all that apply.) a. Thyroid-stimulating hormone b. Vasopressin c. Follicle-stimulating hormone d. Calcitonin e. Growth hormone
a,c,e
A nurse inserts a nasogastric (NG) tube for an adult client who has a bowel obstruction. Which actions does the nurse perform correctly? (Select all that apply.) a. Performs hand hygiene and positions the client in high-Fowlers position, with pillows behind the head and shoulders b. Instructs the client to extend the neck against the pillow once the NG tube has reached the oropharynx c. Checks for correct placement by checking the pH of the fluid aspirated from the tube d. Secures the NG tube by taping it to the clients nose and pinning the end to the pillowcase e. Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent
a,c,e
A nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members should the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.) a. Registered dietitian b. Nursing assistant c. Clinical pharmacist d. Certified herbalist e. Health care provider
a,c,e
A nurse teaches a client with hyperthyroidism. Which dietary modifications should the nurse include in this clients teaching? (Select all that apply.) a. Increased carbohydrates b. Decreased fats c. Increased calorie intake d. Supplemental vitamins e. Increased proteins
a,c,e
nurse assesses a client with Cushings disease. Which assessment findings should the nurse correlate with this disorder? (Select all that apply.) a. Moon face b. Weight loss c. Hypotension d. Petechiae e. Muscle atrophy
a,d,e
A nurse cares for a client who is prescribed vasopressin (DDAVP) for diabetes insipidus. Which assessment findings indicate a therapeutic response to this therapy? (Select all that apply.) a. Urine output is increased. b. Urine output is decreased. c. Specific gravity is increased. d. Specific gravity is decreased. e. Urine osmolality is increased. f. Urine osmolality is decreased.
a,d,f
nurse assesses a client with cholelithiasis. Which assessment findings should the nurse identify as contributors to this clients condition? (Select all that apply.) a. Body mass index of 46 b. Vegetarian diet c. Drinking 4 ounces of red wine nightly d. Pregnant with twins e. History of metabolic syndrome f. Glycosylated hemoglobin level of 15%
a,d,f
A nurse cares for a client with acute pancreatitis. The client states, I am hungry. How should the nurse reply? a. Is your stomach rumbling or do you have bowel sounds? b. I need to check your gag reflex before you can eat. c. Have you passed any flatus or moved your bowels? d. You will not be able to eat until the pain subsides.
c
A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this clients plan of care to reduce discomfort? a. Administer morphine sulfate intravenously every 4 hours as needed. b. Maintain nothing by mouth (NPO) and administer intravenous fluids. c. Provide small, frequent feedings with no concentrated sweets. d. Place the client in semi-Fowlers position with the head of bed elevated.
b
A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best? a. Allow the client cool liquids only. b. Assess the clients gag reflex. c. Remind the client to remain NPO. d. Tell the client to wait 4 hours.
b
A nurse assesses a client with hyperthyroidism who is prescribed lithium carbonate. Which assessment finding should alert the nurse to a side effect of this therapy? a. Blurred and double vision b. Increased thirst and urination c. Profuse nausea and diarrhea d. Decreased attention and insomnia
b
A nurse assesses a female client who presents with hirsutism. Which question should the nurse ask when assessing this client? a. How do you plan to pay for your treatments? b. How do you feel about yourself? c. What medications are you prescribed? d. What are you doing to prevent this from happening?
b
A nurse assesses clients for potential endocrine disorders. Which client is at greatest risk for hyperparathyroidism? a. A 29-year-old female with pregnancy-induced hypertension b. A 41-year-old male receiving dialysis for end-stage kidney disease c. A 66-year-old female with moderate heart failure d. A 72-year-old male who is prescribed home oxygen therapy
b
A nurse assesses clients for potential endocrine dysfunction. Which client is at greatest risk for a deficiency of gonadotropin and growth hormone? a. A 36-year-old female who has used oral contraceptives for 5 years b. A 42-year-old male who experienced head trauma 3 years ago c. A 55-year-old female with a severe allergy to shellfish and iodine d. A 64-year-old male with adult-onset diabetes mellitus
b
A nurse cares for a client newly diagnosed with Graves disease. The clients mother asks, I have diabetes mellitus. Am I responsible for my daughters disease? How should the nurse respond? a. The fact that you have diabetes did not cause your daughter to have Graves disease. No connection is known between Graves disease and diabetes. b. An association has been noted between Graves disease and diabetes, but the fact that you have diabetes did not cause your daughter to have Graves disease. c. Graves disease is associated with autoimmune diseases such as rheumatoid arthritis, but not with a disease such as diabetes mellitus. d. Unfortunately, Graves disease is associated with diabetes, and your diabetes could have led to your daughter having Graves disease.
b
A nurse cares for a client who is prescribed patient-controlled analgesia (PCA) after a cholecystectomy. The client states, When I wake up I am in pain. Which action should the nurse take? a. Administer intravenous morphine while the client sleeps. b. Encourage the client to use the PCA pump upon awakening. c. Contact the provider and request a different analgesic. d. Ask a family member to initiate the PCA pump for the client.
b
A nurse cares for a client who possibly has syndrome of inappropriate antidiuretic hormone (SIADH). The clients serum sodium level is 114 mEq/L. Which action should the nurse take first? a. Consult with the dietitian about increased dietary sodium. b. Restrict the clients fluid intake to 600 mL/day. c. Handle the client gently by using turn sheets for re-positioning. d. Instruct unlicensed assistive personnel to measure intake and output.
b
A nurse cares for a client who presents with bradycardia secondary to hypothyroidism. Which medication should the nurse anticipate being prescribed to the client? a. Atropine sulfate b. Levothyroxine sodium (Synthroid) c. Propranolol (Inderal) d. Epinephrine (Adrenalin)
b
A nurse cares for a client with a new ileostomy. The client states, I dont think my friends will accept me with this ostomy. How should the nurse respond? a. Your friends will be happy that you are alive. b. Tell me more about your concerns. c. A therapist can help you resolve your concerns. d. With time you will accept your new body.
b
A nurse cares for a client with adrenal hyperfunction. The client screams at her husband, bursts into tears, and throws her water pitcher against the wall. She then tells the nurse, I feel like I am going crazy. How should the nurse respond? a. I will ask your doctor to order a psychiatric consult for you. b. You feel this way because of your hormone levels. c. Can I bring you information about support groups? d. I will close the door to your room and restrict visitors.
b
A nurse is caring for a client who was prescribed high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The clients symptoms have now resolved and the client asks, When can I stop taking these medications? How should the nurse respond? a. It is possible for the inflammation to recur if you stop the medication. b. Once you start corticosteroids, you have to be weaned off them. c. You must decrease the dose slowly so your hormones will work again. d. The drug suppresses your immune system, which must be built back up.
b
A nurse obtains a clients health history at a community health clinic. Which statement alerts the nurse to provide health teaching to this client? a. I drink two glasses of red wine each week. b. I take a lot of Tylenol for my arthritis pain. c. I have a cousin who died of liver cancer. d. I got a hepatitis vaccine before traveling.
b
A nurse plans care for a client with hyperparathyroidism. Which intervention should the nurse include in this clients plan of care? a. Ask the client to ambulate in the hallway twice a day. b. Use a lift sheet to assist the client with position changes. c. Provide the client with a soft-bristled toothbrush for oral care. d. Instruct the unlicensed assistive personnel to strain the clients urine for stones.
b
A nurse teaches a client with a cortisol deficiency who is prescribed prednisone (Deltasone). Which statement should the nurse include in this clients instructions? a. You will need to learn how to rotate the injection sites. b. If you work outside in the heat, you may need another drug. c. You need to follow a diet with strict sodium restrictions. d. Take one tablet in the morning and two tablets at night
b
After teaching a client who has a new colostomy, the nurse provides feedback based on the clients ability to complete self-care activities. Which statement should the nurse include in this feedback? a. I realize that you had a tough time today, but it will get easier with practice. b. You cleaned the stoma well. Now you need to practice putting on the appliance. c. You seem to understand what I taught you today. What else can I help you with? d. You seem uncomfortable. Do you want your daughter to care for your ostomy?
b
After teaching a client who is recovering from a complete thyroidectomy, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional instruction? a. I may need calcium replacement after surgery. b. After surgery, I wont need to take thyroid medication. c. Ill need to take thyroid hormones for the rest of my life. d. I can receive pain medication if I feel that I need it.
b
After teaching a client who is recovering from laparoscopic cholecystectomy surgery, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. Drinking at least 2 liters of water each day is suggested. b. I will decrease the amount of fatty foods in my diet. c. Drinking fluids with my meals will increase bloating. d. I will avoid concentrated sweets and simple carbohydrates.
b
An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the clients lower abdomen. Which action should the nurse take first? a. Measure the clients abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the clients hemoglobin and hematocrit. d. Obtain the clients complete health history.
b
A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is in the healing phase of acute pancreatitis. Which statements focused on nutritional requirements should the nurse include when delegating care for this client? (Select all that apply.) a. Do not allow the client to eat between meals. b. Make sure the client receives a protein shake. c. Do not allow caffeine-containing beverages. d. Make sure the foods are bland with little spice. e. Do not allow high-carbohydrate food items.
b,c,d
A nurse evaluates the following laboratory results for a client who has hypoparathyroidism: Calcium 7.2 mg/dL Sodium 144 mEq/L Magnesium 1.2 mEq/L Potassium 5.7 mEq/L Based on these results, which medications should the nurse anticipate administering? (Select all that apply.) a. Oral potassium chloride b. Intravenous calcium chloride c. 3% normal saline IV solution d. 50% magnesium sulfate e. Oral calcitriol (Rocaltrol
b,d
A nurse teaches a client with Cushings disease. Which dietary requirements should the nurse include in this clients teaching? (Select all that apply.) a. Low calcium b. Low carbohydrate c. Low protein d. Low calories e. Low sodium
b,d,e
A nurse teaches a client who is recovering from acute pancreatitis. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Take a 20-minute walk at least 5 days each week. b. Attend local Alcoholics Anonymous (AA) meetings weekly. c. Choose whole grains rather than foods with simple sugars. d. Use cooking spray when you cook rather than margarine or butter. e. Stay away from milk and dairy products that contain lactose. f. We can talk to your doctor about a prescription for nicotine patches
b,d,f
A nurse cares for a client who has hypothyroidism as a result of Hashimotos thyroiditis. The client asks, How long will I need to take this thyroid medication? How should the nurse respond? a. You will need to take the thyroid medication until the goiter is completely gone. b. Thyroiditis is cured with antibiotics. Then you wont need thyroid medication. c. Youll need thyroid pills for life because your thyroid wont start working again. d. When blood tests indicate normal thyroid function, you can stop the medication.
c
A nurse assesses a client who has cholecystitis. Which clinical manifestation indicates that the condition is chronic rather than acute? a. Temperature of 100.1 F (37.8 C) b. Positive Murphys sign c. Light-colored stools d. Upper abdominal pain after eating
c
A nurse assesses a client who is recovering from a subtotal thyroidectomy. On the second postoperative day the client states, I feel numbness and tingling around my mouth. What action should the nurse take? a. Offer mouth care. b. Loosen the dressing. c. Assess for Chvosteks sign. d. Ask the client orientation questions.
c
A nurse cares for a teenage girl with a new ileostomy. The client states, I cannot go to prom with an ostomy. How should the nurse respond? a. Sure you can. Purchase a prom dress one size larger to hide the ostomy appliance. b. The pouch wont be as noticeable if you avoid broccoli and carbonated drinks prior to the prom. c. Lets talk to the enterostomal therapist about options for ostomy supplies and dress styles. d. You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable.
c
A nurse plans care for a client who has hypothyroidism and is admitted for pneumonia. Which priority intervention should the nurse include in this clients plan of care? a. Monitor the clients intravenous site every shift. b. Administer acetaminophen (Tylenol) for fever. c. Ensure that working suction equipment is in the room. d. Assess the clients vital signs every 4 hours.
c
A nurse plans care for a client with Cushings disease. Which action should the nurse include in this clients plan of care to prevent injury? a. Pad the siderails of the clients bed. b. Assist the client to change positions slowly. c. Use a lift sheet to change the clients position. d. Keep suctioning equipment at the clients bedside.
c
A nurse plans care for a client with hypothyroidism. Which priority problem should the nurse plan to address first for this client? a. Heat intolerance b. Body image problems c. Depression and withdrawal d. Obesity and water retention
c
After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. The capsules can be opened and the powder sprinkled on applesauce if needed. b. I will wipe my lips carefully after I drink the enzyme preparation. c. The best time to take the enzymes is immediately after I have a meal or a snack. d. I will not mix the enzyme powder with food or liquids that contain protein.
c
A nurse cares for a client with elevated triiodothyronine and thyroxine, and normal thyroid-stimulating hormone levels. Which actions should the nurse take? (Select all that apply.) a. Administer levothyroxine (Synthroid). b. Administer propranolol (Inderal). c. Monitor the apical pulse. d. Assess for Trousseaus sign. e. Initiate telemetry monitoring.
c,e
A nurse assesses a client on the medical-surgical unit. Which statement made by the client should alert the nurse to the possibility of hypothyroidism? a. My sister has thyroid problems. b. I seem to feel the heat more than other people. c. Food just doesnt taste good without a lot of salt. d. I am always tired, even with 12 hours of sleep.
d
A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should alert the nurse to a serious adverse effect? a. Nausea and vomiting b. Frontal headache c. Vertigo and syncope d. Mid-sternal chest pain
d
A nurse assesses a client who is prescribed levothyroxine (Synthroid) for hypothyroidism. Which assessment finding should alert the nurse that the medication therapy is effective? a. Thirst is recognized and fluid intake is appropriate. b. Weight has been the same for 3 weeks. c. Total white blood cell count is 6000 cells/mm3. d. Heart rate is 70 beats/min and regular.
d
A nurse assesses a client who is recovering from a total thyroidectomy and notes the development of stridor. Which action should the nurse take first? a. Reassure the client that the voice change is temporary. b. Document the finding and assess the client hourly. c. Place the client in high-Fowlers position and apply oxygen. d. Contact the provider and prepare for intubation.
d
A nurse cares for a client after a pituitary gland stimulation test using insulin. The clients post-stimulation laboratory results indicate elevated levels of growth hormone (GH) and adrenocorticotropic hormone (ACTH).How should the nurse interpret these results? a. Pituitary hypofunction b. Pituitary hyperfunction c. Pituitary-induced diabetes mellitus d. Normal pituitary response to insulin
d
A nurse cares for a client who is recovering from a parathyroidectomy. When taking the clients blood pressure, the nurse notes that the clients hand has gone into flexion contractions. Which laboratory result does the nurse correlate with this condition? a. Serum potassium: 2.9 mEq/L b. Serum magnesium: 1.7 mEq/L c. Serum sodium: 122 mEq/L d. Serum calcium: 6.9 mg/dL
d
A nurse prepares to palpate a clients thyroid gland. Which action should the nurse take when performing this assessment? a. Stand in front of the client instead of behind the client. b. Ask the client to swallow after palpating the thyroid. c. Palpate the right lobe with the nurses left hand. d. Place the client in a sitting position with the chin tucked down
d
After teaching a client who has a history of cholelithiasis, the nurse assesses the clients understanding. Which menu selection made by the client indicates the client clearly understands the dietary teaching? a. Lasagna, tossed salad with Italian dressing, and low-fat milk b. Grilled cheese sandwich, tomato soup, and coffee with cream c. Cream of potato soup, Caesar salad with chicken, and a diet cola d. Roasted chicken breast, baked potato with chives, and orange juice
d
