PN Adult Med Surg

A nurse is planning care for a client who has a suspected myocardial infarction. Which of the following should the nurse administer first?

Oxygen

The nurse is contributing to the plan of care for a client who is 4 hr postoperative following a vaginal hysterectomy. Which of the following interventions should the nurse include in the plan of care?

Provide tub baths for perineal comfort.

A nurse is caring for a client who has COPD. Which of the following nursing actions is appropriate for this client?

Providing mouth care before meals

A nurse is preparing a client for a kidney biopsy. Which of the following actions should the nurse take?

A client who is short of breath.

A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture. Which of the following is a nurse's priority?

Airway management

A nurse is reinforcing teaching about preventing long-term complications of retinopathy and neuropathy with an older adult client who has diabetes mellitus. Which of the following actions is the most important for the nurse to include in the teaching?

"Maintain stable blood glucose levels."

A nurse is reinforcing teaching with a client who is scheduled for an exercise ECG stress test. Which of the following comments should indicate to the nurse that the client requires further instructions?

"I will expect to feel chest pain during this test."

A nurse is reinforcing discharge instructions with a client who has hepatitis A. The nurse determines that the teaching is effective when the client makes which of the following statements?

"I will not donate blood."

A nurse is reinforcing teaching for a client discharged from the hospital after treatment for poor circulation in the lower extremities. Which of the following statements by the client indicates a need for further teaching?

"I will wear stockings with elastic tops."

A nurse is reinforcing teaching to a female client who has acute cystitis and is to start therapy with phenazopyridine. Which of the following information should the nurse give to the client?

"Wear a protective pad under clothing to prevent staining."

A nurse is reviewing discharge instructions with a client who has pruritus following treatment for scabies. Which of the following instructions should the nurse include?

"Wear loose fitting clothing while you are experiencing itching."

A nurse is reinforcing discharge teaching for a client who has chronic pancreatitis. Which of the following statements by the nurse is appropriate?

"You should increase your daily intake of protein."

A nurse is reinforcing teaching with a client who has a skin lesion and is scheduled for an excision skin biopsy. Which of the following information should the nurse include in the teaching?

"You will need to change the dressing daily."

A nurse is assisting with the care of a client who was admitted to the emergency department with reports of chest pain and severe epigastric distress. The nurse should anticipate that the presence of an acute myocardial infarction the client's creatinine kinase-MB (CK-MB) is expected to break how many hours after the onset of chest pain?

24 hours

A nurse is evaluating a client who sustained severe burn injuries in a grease fire. The nurse shades the diagram indicating the burned surfaces areas. What percentage of body surface area does the nurse estimate the client has burned?

31.5%

A nurse has been assigned to care for four clients. The nurse should observe which of the following clients for indications of Vitamin B6 deficiency?

A client who has a chronic alcohol problem.

A nurse is planning possible interventions in the care for a client who may need for total parenteral nutrition (TPN). which of the following clients should benefit from TPN?

A client who has a complete bowel obstruction

A nurse is caring for a client who had a mastectomy and returns to the surgical unit immediately following surgery. Which of the following is the priority action by the nurse?

Access vital signs on the client's non-affected arm.

A nurse in the emergency department is assisting with the care of a client who is comatose. The provider suspects ketoacidosis. Which of the following findings should the nurse expect?

Acetone odor to breath

A nurse is caring for a client who enters an ambulatory clinic bleeding profusely from a deep laceration on his left lower forearm. After donning gloves, which of the following actions should the nurse take first?

Apply pressure directly over the wound.

A nurse in an emergency department is caring for a client who has a deep laceration on there left lower forearm and is bleeding heavily from the wound. Which of the following interventions should the nurse perform first?

Apply pressure directly to the wound.

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

Administer oxygen therapy.

A nurse is caring for a postthoracotomy client who has just returned from the operating room. Which of the following is the nurse's priority action?

Administer oxygen via nasal cannula

A client admitted to the hospital reports recurrent flank pain, nausea, and vomiting for 24 hrs. Which of the following would be a priority nursing action?

Administer pain medication.

A nurse in an emergency department is preparing to care for a client who is brought in with multiple system trauma following a motor vehicle crash. Which of the following is the priority focus of care?

Airway protection

A nurse is caring for a client who has end-stage renal disease and must limit protein intake. Which of the following foods should the nurse plan to include in the client's diet?

Eggs

A nurse is talking with a client who has gout. The nurse should remind the client to avoid the use of which of the following medications?

Aspirin

A nurse is planning care for a client who has a GI bleed. Which of the following actions should the nurse take first?

Assess orthostatic blood pressure.

A nurse is caring for a client in a body cast. Which of the following is the priority action the nurse should recommend for inclusion in the plan of care?

Assess the abdomen

A nurse is caring for a client who has unilateral leg edema with associated pain and low-grade temperature. Which of the following actions should the nurse take?

Elevate the affected leg.

A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching?

Breathing in through her nose and out through pursed lips

A nurse is reviewing the lab report of a client who is receiving treatment for a high fever and a viral infection. Which of the following findings should the nurse expect?

Elevated T-cell count

A nurse is caring for a client who has been prescribed a potassium wasting diuretic medication. Which recommendation should the nurse make for change in the diet?

Encourage oranges, bananas, and whole grain breads.

A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse perform first?

Check the client's temperature.

A nurse is caring for a client in skeletal traction who reports pain at the pin insertion site. Which of the following should be the initial nursing action?

Check the pin site for signs of drainage or inflammation.

A nurse is teaching a client who is at risk for iron-deficiency anemia about optimizing her dietary intake of iron. The nurse should explain that which of the following sources of iron is easiest for the body to absorb?

Chicken

A nurse is reviewing a client's admission lab findings, which indicate the client is hyponatremic. Which of the following lab findings should the nurse anticipate will also be below the expected reference range?

Chloride

A nurse is preparing a client for discharge following a bronchoscopy. Which of the following is the nurse's monitoring priority?

Confirming gag reflex

A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following is the priority intervention?

Count respiratory rate.

A nurse is collecting date from a client who has Paget's disease. Which of the following findings should the nurse expect?

Cranial enlargement, skeletal pain, wadding gait.

A nurse is collecting data from a client who has a respiratory disorder and displays manifestations of hypoxia. Which of the following findings should the nurse expect?

Cyanosis

A nurse is caring for a client diagnosed with myasthenia graves. Which of the following findings indicates the client is experiencing an advanced symptom of this disease?

Incontinence

A nurse is collecting data on a client who has renal failure for fluid volume increase. Which of the following assessment methods is most reliable?

Daily weight

A nurse is reinforcing teaching with a class about preventing DVT. The nurse should include in the teaching that which of the following is a risk factor for this disorder?

Dehydration, oral contraceptives, immobility.

A nurse is collecting data from a client who has diabetes and is overweight. The client tells the nurse that she wants to start an exercise program. Which of the following actions should the nurse take first?

Determine the client's usual pattern of activity.

A nurse is collecting data for a client who has early manifestations of renal impairment. Which of the following findings should the nurse expect?

Diluted urine

A nurse is caring for a client following the application of an aquathermia pad. Which of the following is the first indication that the client is experiencing a thermal injury to the application site?

Erythema

A nurse is caring for a client who has widespread psoriasis. The nurse should prepare the client for which of the following treatments?

Exposure to photo chemotherapy

A nurse is checking the lab results of a client who is at risk for diabetes mellitus. Which of the following lab results indicates to the nurse that the client is at risk for diabetes mellitus?

Fasting blood glucose 155 mg/dL

A nurse is assisting with the care of a client who is at risk for disseminated intravascular coagulopathy (DIC). The nurse should plan to report which of the following lab values that indicates DIC?

Fibrinogen 85 mg/dL

A nurse finds radioactive pellets on the surgical suite floor. Which of the following should the nurse's priority action?

Follow material safety data sheet (MSDS) instructions.

A nurse is caring for a client who just had an endoscopic procedure. Which of the following is the monitoring priority for this client?

Gag reflex

A nurse is caring for a client who has a large wound that has a vacuum-assisted closure device placed over it. Which of the following findings by the nurse indicates healing of the wound?

Granulation tissue on the surface of the wound.

A nurse is caring for an older adult client diagnosed with colon cancer. The client asks he nurse several questions about his treatment plan. Which of the flooring nursing actions is appropriate?

Help the client write down questions to ask his provider

A nurse is caring for a client who has Addison's disease. For which of the following manifestations should the nurse observe?

Hyperpigmentation

A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations?

Hypotension

A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative period?

Ineffective airway clearance related to thick, copious secretions.

A nurse is reinforcing teaching for a client about using a metered-dose inhaler (MDI). Identify the sequence the client should follow.

Inhale deeply and exhale Place lips around mouth piece Breathe in over 2 to 3 seconds while pushing down on the canister Hold breath for 10 seconds Exhale through pursed lips Wait 30-60 seconds between each puff

A nurse is planning care for a client who has acute dysphagia. Which of the following is appropriate to include in the plan of care?

Instruct the client to tilt the head forward when swallowing

A nurse is collecting data from a client who has atrial fibrillation. When documenting the quality of the client's pulse, which of the following terms should the nurse use?

Irregular

A nurse notes the catheter of a client who is 24 hr post transurethral resection of the prostate (TRUP) has drained no using during the last hour. Which of the following actions should the nurse perform first?

Irrigate the catheter as prescribed.

A nurse is collecting data from a client who has AIDS. The nurse notes that the client has multiple, widespread purplish-brown skin lesions. The nurse should suspect that the client has developed which of the following types of skin lesions?

Kaposi's sarcoma

The nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?

Maintain the drainage container below the level of the client's chest.

A nurse is caring for a client who has an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following is the most important nursing action for this client?

Maintaining fluid and electrolyte balance.

A nurse is caring for client who throat culture is positive for group A streptococcus 24 hr after the rapid strep test (RST) was negative. Which of he following is the priority nursing action?

Notify the client to return to the clinic for initiation of antibiotic therapy.

While admitting a client for cardiac cauterization, the nurse asks the client about allergies. Te client states, "I always get a rash when I eat shellfish." Which of the following is the priority nursing intervention?

Notify the provider of the client's allergy.

A nurse is monitoring a client who has a spinal cord injury and suspects autonomic dysreflexia. Which of the following actions should the nurse implement first?

Place the client in a sitting position

A nurse is caring for a client who is 1 day postoperative following an open thoracotomy. The client is receiving oxygen mist at 40% by face tent. The client's SiO2 is 89%. ABG results are: pH 7.31, PaO2 93mm Hg, PCO2 50 mm Hg, HCO3 25 meq/L. Which of the following is an appropriate action by the nurse?

Place the client in high-Fowler's position and encourage the use of incentive spirometer and coughing.

A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrated decorticate posturing. Which of the following findings should the nurse expect to observe?

Plantar flexion of the legs

A nurse is caring for a toddler admitted to the hospital with acute gastroenteritis. Which of the following findings has the highest priority?

Potassium 2.5 mEq/L

A nurse is contributing to the plan of care for a client who has a pressure ulcer on his heel. Which of the following should the nurse include in the planning?

Provide the client a diet high in vitamin C.

A nurse is reinforcing teaching with a client who has herpes zoster. The nurse should include which of the following statements in the teaching?

Recurrence of infection can be triggered by stress or trauma.

A nurse is caring for a client who has a respiratory rate of 7/min. Which of the following is an appropriate interpretation of the client's arterial blood gasses (ABGs)?

Respiratory acidosis

A nurse is reviewing the readmission lab test results of a client who is scheduled for a carotid endarterectomy in 3 days. Which of the following results should the nurse report to the provider?

Sodium 151 mEq/L

A nurse is reinforcing teaching to a client who wants to increase daily intake of omega-3 type fatty acids. Which of the following foods should the nurse suggest the client increase?

Soybean oil

A nurse is caring for a client following a CT scan with dye who has an anaphylaxis reaction. Which of the following conditions requires a priority nursing response?

Strider

A nurse is reinforcing health teaching regarding skin cancer to a group of clients. Which of the following should the nurse identify as the leading cause of skin cancer?

Sun exposure

A nurse in a health clinic is assisting in the planning of an educational program on skin cancer. Which of the following statements should be included in the presentation?

Sun exposure as a child is a significant risk factor for skin cancer.

A nurse is reinforcing teaching for a middle-age client who is at high risk for osteoporosis and is taking a calcium supplement. Which of the following instructions should the nurse include?

Take vitamin D supplements.

A nurse is reinforcing teaching about self-care techniques with a client who has rheumatoid arthritis. Which of the following strategies should the nurse include to illustrate the concept of doing protection?

Turn doorknobs in a counterclockwise motion to open them

A nurse is reinforcing teaching to a client who has a new diagnosis of a Grade II ankle sprain. Which of the following instructions should the nurse include in the teaching?

Wrap the ankle snugly with an elastic bandage

A nurse is caring for a client who is postoperative following a below-the-knee amputation and will soon undergo a fitting for a leg prosthesis. Which of the following is an appropriate nursing intervention for the client at this time?

Wrap the stump with an elastic bandage in a figure-eight configuration.

A community health nurse is assisting with planning an immunization clinic for older adult clients. The nurse should advise the clients to receive an influenza vaccine

annually.

A nurse is assigned to care for a client suspected of having diabetes insidious. The nurse should frequently check the client for the development of

hypotension.

A nurse is caring for a client who has primary open-angle glaucoma. The client questions the nurse about the purpose of the tonometry examination. The nurse should explain that this test is used to

measure intraocular pressure.