Capstone: Adult Medical Surgical Preassessment

A nurse is providing teaching to a client who has nephrotic syndrome. The nurse should recognize that which of the following client statements indicates a need for further teaching?

"I should increase my sodium intake."

A nurse is providing teaching to a client about the manifestations of uterine prolapse. Which of the following statements by the client should indicate to the nurse a need for further teaching?

"Feces can be present in the vagina"

A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority Intervention?

Withhold oral fluids and food

A nurse is assessing a client who is post op and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?

fatigue

The nurse is selecting a qualified staff member to double check a blood label with a client ID bracelet prior to infusing unit of blood. The nurse should identify that which of the following persons is qualified?

Oncology nurse

A nurse in a medical clinic is providing teaching to an older adult client who has osteoarthritis that is affecting her knees. Which of the following statements indicates and understanding of the teaching?

"I can use either heat or ice to help relieve the discomfort."

A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect

A dry, red rash across the bridge of the nose and cheeks

A nurse in a provider's office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions?

Heart Failure

A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder?

smoking cessation

A nurse is caring for a client who has heart failure and a history of asthma the nurse reviews the providers orders and recognizes that clarification is needed for which of the following medications

Carvedilol

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse preform first?

Administer IV fluids

NGN Question The nurse is caring for a disoriented client experiencing nausea and vomiting Client has no significant past medical history of heart, lung, or stroke issues who presents to the emergency room (ER) with partner post marathon fur. The client voices nausea and episodes of vomiting, dizziness, headache, weakness, and disorientation. Client states they felt fine during most of the rate, but around the final 10 miles, they felt ill. At the end of the race, they vomited, became disoriented, and complained of a headache, and collapsed. The client states they trained for the race and has run three other marathons in the last two years and has never had this issue before. Client has an allergy to amoxicillin

Anticipated: Monitor Serum Sodium, I&O Nonessential: Blood Type and screen Contraindicated: Oral intake of 2500 mL/ day

A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?

Atropine

A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include?

Basal cell carcinoma has a low incidence of metastasis.

A nurse is caring for a client who has suspected cholecystitis. The nurse should expect the client's urine to appear which of the following colors?

Dark and foamy

A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases?

TB

A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?

Auscultate bowel sounds.

A nurse is caring for a client following an esophagogastroduodenoscopy (EGD) procedure. Which of the following assessments is the nurse's priority?

Gag Reflex

A nurse is teaching about disease management for a client who has type 1 diabetes mellitus. Which statement made by the client indicates an understanding of the teaching?

I give the insulin injections in my abdominal area

A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse take?

It helps eliminate the barium.

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?

Keep the drainage system below the level of the client's chest at all times.

NGN Question The nurse is caring for a client who is 24 hours post abdominal aortic aneurysm repair. 6 months ago Client is being seen for a chief complaint of abdominal pain, dizziness. and pulsating sensation to belly button, CT of abdomen ordered to determine structural integrity, Client has a history of uncontrolled hypertension, sedentary lifestyle and 1 pack per day smoker. Pre-operative Day 1 0700 Client presents with history of uncontrolled hypertension, sedentary lifestyle and 1 pack per day smoker admitted for surgical repair of abdominal aortic aneurysm (AAA). Client has received yearly CT scans to monitor but AAA grew 0.5 cm within the past six months and now measures at 5.5 cm. Admitted for surgical repair of AAA via endovascular graft stents.

The nurse should address the client's Select. Pain.. the client's Select followed by Dressing

A nurse is reviewing risk factors for osteoporosis with a group of nursing students. The nurse should include that which of the following types of medication therapy is a risk factor for osteoporosis?

Thyroid hormones

A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client?

Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart

a nurse is providing education for a client who has glaucoma. which of the following statements should the nurse include in the teaching?

without treatment, glaucoma can cause blindness

After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions?

Apply hydrating lotions.

A nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's extension traction. The nurse should include which of the following information in the teaching?

Buck's extension traction will relieve muscle spasms.

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

Plantar flexion of the legs

A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?

Resp Status

NGN Question Medical History Admission Note: The client is being transferred from the trauma unit to the medical- surgical telemetry unit after a motor vehicle accident. CT with contrast confirmed a T4-T5 fracture with primary, complete spinal cord injury. The client is non-ambulatory with paraplegia. The client reports pain of 4 on a 0 to 10 pain scale near fracture. Turning required every two hours. Sensations of touch, position, and vibration are intact. Glasgow Coma Scale is 15. The client expresses feelings of hopelessness and anxiety. Nurses Notes Day 2 1730 The client is lying supine in bed, exhibiting facial flushing, sweating to the upper extremities and pallor and goosebumps noted below the level of injury. The client reports pain of 4 on a 0 to 10 pain scale, a headache, and blurred vision. Bladder position is noted above the symphysis pubis Vital Signs Day 2 1730 Temperature: 37.2°C (99.1°F) Heart rate: 60/min Respiratory rate: 22/min Blood pressure: 170/98 mung Oxygen saturation: 95% on room air Pain: 4 on a 0 to 10 pain scale Diagnostic Results Laboratory Test Arterial blood gas (ABG) pH 7.41 Pco2 37 mm Hg po² 95 mm Hg HCO3 25 mmol/L Lactate 1.2 mmol/l (arterial) Sodium 14

The nurse should first address the client's Select: Position followed by the client's Select : Distended bladder