Final med sur
Assessing confused pt for pain w/limited verbal ability. Which of the following findings may indicate increase of pain? A ) increased blood pressure B) Increased bowel sounds C) Not able to read from the picture D) Urinary retention
A ) increased blood pressure
The nurse has just received change-of shift report. Which patient should the nurse assess first A) A 23-year-old pt with type 1 diabetes who has a blood glucose of 40 mg/dL B) A 19-year-old pt with type 2 diabetes who has a hemoglobin A1C of 12% C) A 40 year old pt who is pregnant and whose oral glucose tolerance test is 202 mg/dL D) A 50 year old pt who uses glyburide and is complaining of acute abdominal pain 4/10
A) A 23-year-old pt with type 1 diabetes who has a blood glucose of 40 mg/dL
3. A nurse is teaching a client about the seven warning signs of cancer. Which of the following signs should the nurse include as manifestations of cancer? (Select all that apply.) A) A nonhealing sore B) Bloating C) Change in bowel pattern D) Change in moles E) Nagging cough
A) A nonhealing sore C) Change in bowel pattern D) Change in moles E) Nagging cough
2. A home health nurse is reinforcing coping strategies with the family caregiver of a client who has Alzheimer's disease. Which of the following information should the nurse include in the teaching? (Select all that apply.) A) Actions to reduce stress B) Identification of a support system C) Referral to community resources D) Instruction on client medication administration
A) Actions to reduce stress B) Identification of a support system C) Referral to community resources
7. A client presents to the clinic with complaints of continued pain and paresthesia on the face and neck after a shingles infection (herpes zoster). What nursing actions should be taken next? (Select all that apply.) A) Assess the nature, quality/intensity, and location of the pain. B) Determine what exacerbates or alleviates the pain. C) Gently massage the painful area to see if that will alleviate it. D) Administer the prescribed antiviral agent. E) Tell the client that the infection is healed so the pain should be gone.
A) Assess the nature, quality/intensity, and location of the pain. B) Determine what exacerbates or alleviates the pain. D) Administer the prescribed antiviral agent.
5. The nurse is caring for a client with diabetic peripheral neuropathy. The client reports that sometimes there's an inability to determine the position of his feet when standing from a sitting position. What would be the priority nursing actions? (Select all that apply.) A) Be sure the client's feet are securely planted on the floor before helping the client to stand. B) Help the client sit on side of bed with the feet on a stool. C) Place client on fall precautions and caution the other staff. D) When making the bed, be sure to give the client's toes room under the sheet and blanket. E) Ensuring that the client understands the need for assistance with standing and ambulation.
A) Be sure the client's feet are securely planted on the floor before helping the client to stand. D) When making the bed, be sure to give the client's toes room under the sheet and blanket. E) Ensuring that the client understands the need for assistance with standing and ambulation.
20. The health care provider diagnoses impetigo in a patient who has impetigo on the lower face. Which instructions should the nurse include in the teaching plan A) Clean the infected areas with soap and water B) Apply alcohol-based cleansers on the lesions C) Avoid use of antibiotic ointments on the lesions D) Use petroleum jelly to soften crusty areas
A) Clean the infected areas with soap and water
4. A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan (select all that apply)? A) Cool, wet cloths or compresses applied to the skin to reduce itching. B) Vigorously rub yourself dry with a towel after bathing to scratch the area. C) Add oil to your bath water to aid in moisturizing the affected skin. D) Use of diphenhydramine can reduce itching. E) Take cool or tepid oatmeal baths several times daily to decrease itching.
A) Cool, wet cloths or compresses applied to the skin to reduce itching. D) Use of diphenhydramine can reduce itching. E) Take cool or tepid oatmeal baths several times daily to decrease itching.
6. A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? (Select all that apply.) A) Loosen restrictive clothing. B) Insert a bite stick into the client's mouth. C) Place the client into a prone position. D) Place a pillow under the client's head. E) Apply restraints.
A) Loosen restrictive clothing. D) Place a pillow under the client's head.
Process by which degenerative manifestations of Alzheimer's reverse the order of acquisition is normal development is A) Retrogenesis B) Retrograde development
A) Retrogenesis
8. A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan (select all that apply)? A) Talk to the oncologist before having any dental cleaning or procedures. B) Make sure your food is thoroughly cooked before eating. C) Use rectal suppositories as needed for constipation. D) Avoid public transportation. E) Include more fresh fruits and vegetables in your diet.
A) Talk to the oncologist before having any dental cleaning or procedures. B) Make sure your food is thoroughly cooked before eating. D) Avoid public transportation.
1. The nurse is caring for a client who is experiencing fatigue from iron-deficiency anemia. The client has an oral iron supplement ordered. What actions does the nurse implement at this time? (Select all that apply.) A) Teach the client to eat eggs, nuts, beef, and whole-grain rice. B) Explain the normal values of hemoglobin and hematocrit. C) Teach the client ways to prevent constipation. D) Tell the client to report black stools immediately. E) Instruct the client on daily temperature checks.
A) Teach the client to eat eggs, nuts, beef, and whole-grain rice. B) Explain the normal values of hemoglobin and hematocrit. C) Teach the client ways to prevent constipation.
The nurse should recognize that which of the following measures is the most reliable indicator of pain A) Vital signs B) Self-report of pain C) Type of condition/surgery D) Non-verbal, objective indicators
B) Self-report of pain
You are an Emergency Department nurse. Which patient requires the most rapid assessment and care A) The pt with excess iron (hemochromatosis) who reports abdominal pain B) The pt with neutropenia who has a temperature of 101.8 C) Not able to read from the picture D) The pt with sickle cell anemia who has had nausea for 24 hours
B) The pt with neutropenia who has a temperature of 101.8
A pt with an open leg wound has a white blood cell count of 14,500/uL. What prescribed action should the nurse take first? A) Administer antibiotic IV B) Collect cultures of the wound C) Document wound drainage D) Increase frequency of dressing changes
B) Collect cultures of the wound
15. A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear sunscreen. Which statement by the patient indicates that the need for further teaching A) I wear a hat and sit under the umbrella when not in the water B) I don't bother with sunscreen on overcast days C) I use a sunscreen with the highest SPF number D) I wear a UV shirt and limit exposure to the sun by covering up
B) I don't bother with sunscreen on overcast days
. A nurse is assessing a client with Parkinson's disease. Which of the following manifestations would be expected? A) Pruritis B) Hypertension C) Bradykinesia D) Xerostomia
C) Bradykinesia
What should the priority focus be in treating the stage 3 pressure ulcer for a hospitalized pt with paraplegia? A) Change the wet-to-dry dressings twice daily B) Eat a diet with many fruits, vegetables, and high protein C) Change positions Q1H and use a pressure reduction mattress or gel pad D) Admin vitamin supplement to promote healing
C) Change positions Q1H and use a pressure reduction mattress or gel pad
17. A nurse is developing a plan of are for a client who has cellulitis of the leg. Which of the following interventions should the nurse include in the plan A) Enforce strict bedrest for 3 days B) Apply fresh ice packs every 4 hrs C) Elevate the affected leg on two pillows D) Apply antibiotic ointment to the wound with dressing changes
C) Elevate the affected leg on two pillows
Order: 4 mg Morphine IV. Available 10 mg/1 mL. Which of the following will the nurse want to do in this situation? A) Dispose the extra medication in a sharps container B) Save the extra medication for a later dosage C) Have another nurse witness the disposal of the extra medication D) Sent the wasted amount to the pharmacy
C) Have another nurse witness the disposal of the extra medication
A nurse is teaching a pt w/type 1 diabetes about foot care. Which statement by the pt indicates an understanding A) I'll wear sandals in warm weather B) I'll put lotion between my toes after drying my feet C) I'll check my feet every day for sores and bruises D) I'll soak my feet in warm water every night before I go to bed
C) I'll check my feet every day for sores and bruises
A nurse is caring for a client who has herpes zoster. Which of the following findings should the nurse expect? A) Multiple furuncles located on the client's back B) Different sized papules in the genital area C) Painful lesions following a nerve pathway
C) Painful lesions following a nerve pathway
Which of the following medications require close monitoring for development of hyperglycemia among pt's w/diabetes? A) Metformin B) Glipizide C) Prednisone D) Gazyva (afutuzumab)
C) Prednisone
16. A nurse is caring for a client who has malignant melanoma. Which of the following findings should the nurse expect when assessing the lesion? A) Pain B) Pruritis C) Purplish in color D) Purulent Drainage
C) Purplish in color
A pt is being admitted with a dx of Cushing syndrome. Which findings are expected during the assessment A) Chronically low blood pressure B) Bronzed appearance of the skin C) Purplish streaks on the abdomen D) Decrease axillary and pubic hair
C) Purplish streaks on the abdomen
19. A pt from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure ulcer? A) Stage I B) Stage II C) Stage III D) Stage IV
C) Stage III
Which priority nursing intervention should be implemented for sudden onset of cluster headache? A) Notify the pt's health care provider immediately B) Give the ordered PRN acetaminophen C) Start the prescribed PRN O2 at 6 L/min D) Put a moist hot pack on the pt's neck
C) Start the prescribed PRN O2 at 6 L/min
18. What is the best method to prevent the spread of infection to others when the nurse is changing the dressing over a wound infected with Staphylococcus aureus? A) Change the dressing using sterile gloves B) Apply antibiotic ointment over the wound C) Wash hands and properly dispose of soiled dressings D) Soak the dressing in sterile normal saline before removal
C) Wash hands and properly dispose of soiled dressings
21. What is the best method to prevent the spread of infection to others when the nurse is changing the dressing over a wound infected with Staphylococcus aureus? A) Change the dressing using sterile gloves B) Apply antibiotic ointment over the wound C) Wash hands and properly dispose of soiled dressings D) Soak the dressing in sterile normal saline before removal
C) Wash hands and properly dispose of soiled dressings
Which nursing action will be most helpful in decreasing r/f drug-drug interactions w/ the older adults? A) Teach the pt to have all prescriptions filled at the same pharmacy B) Make a schedule for the pt as a reminder of when to take each med C) Not able to read from the picture D) Ask the pt to bring all meds, supplements, and herbs to each appointment
D) Ask the pt to bring all meds, supplements, and herbs to each appointment
24. A 37-year-old patient has just arrived to the floor after a thyroidectomy. Which information about the patient is most important to communicate to the surgeon A) Patient reports 7/10 incisional pain B) Patient is sleepy but answers questions C) Assessment reveals a heart rate of 116 beats/min D) Assessment reveals an increase in neck swelling
D) Assessment reveals an increase in neck swelling
A 1-day post-op pt is on a PCA pump and c/o N&V and loss of appetite What priority nursing action would you perform? A) inserts NG tube B) Administer an antiemetic C) Give Senna D) Auscultate bowel sounds
D) Auscultate bowel sounds
What is your priority action when finding your post-surg elderly pt unresponsive w/ resp of 6/min A) Slow down the basal rate of pt's dilaudid PCA B) Obtain vital signs and assess pain status C) Start CPR D) Call for the rapid response team
D) Call for the rapid response team
What information will the nurse include in teaching a businesswoman who has type 2 diabetes and sensory neuropathy of the feet and legs A) Set heating pads on a low temperature B) Soak feet in warm water for an hour each day C) Use callus shaver or callus removal D) Choose flat-soled properly fitted shoes
D) Choose flat-soled properly fitted shoes
Which often following adverse effects may be experienced by a pt with Parkinson's taking diphenhydramine for tremors? A) Excess salivation B) Diarrhea C) Insomnia D) Difficulty voiding
D) Difficulty voiding
22. A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure A) Shield any unaffected areas with lead lined drapes B) Apply petroleum jelly to the areas around the lesions C) Cleanse the skin carefully with antiseptic soap prior to PUVA D) Have the patient use protective eyewear while receiving PUVA
D) Have the patient use protective eyewear while receiving PUVA
12. The nurse is caring for a client who has multiple dysplastic nevi. Based on this assessment finding, what does the nurse include in client education A) Prevention of cellulitis B) The importance of getting immunized for herpes zoster C) Candidiasis prevention and treatment D) Self-examination of skin lesions
D) Self-examination of skin lesions
14. A nurse in an outpatient clinic is assessing a client who has psoriasis. The nurse should expect which of the following findings A) Unilateral lesions B) Serous drainage C) intense pain D) Silvery, white scales
D) Silvery, white scales
23. The nurse assesses a patient who has just arrived in the post-anesthesia recovery area (PACU) after having plates and screws put in the right radius to fix a fracture. Which data should be reported to the surgeon immediately? A) The patient complains of pain 5/10 B) The patient's heart rate is 115 beats/min C) The patient reports being nauseous and has vomited once D) The skin on the fingers is pale and cold when palpated
D) The skin on the fingers is pale and cold when palpated
13. The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient. Which action indicates the nursing assistant understands the instruction A) Bathing and drying the skin vigorously to stimulate circulation B) Keeping the head of the bed elevated 30 degrees C) Limiting intake of fluid and offer frequent snacks D) Turning the patient at least every 2 hours
D) Turning the patient at least every 2 hours
Which of the following patients would you prioritize after receiving change-of-shift report? A) Pt with Parkinson's disease who has developed shuffling gait B) The patient with epilepsy who is scheduled to receive a dose of phenytoin C) I wasn't able to read from the picture D) Your pt with myasthenia gravis reporting increase muscle weakness
D) Your pt with myasthenia gravis reporting increase muscle weakness
11. A nurse is assessing a client's wound dressing and observes a watery pink drainage the nurse should document as which of the following? Serous Purulent Sanguineous Serosanguineous
Serosanguineous
A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which of the following is an expected finding? a. Report of exposure to a skin irritant b. Denial of pruritus c. Systemic symptoms including elevated temperature d. Report of generalized joint discomfort
a. Report of exposure to a skin irritant The most common cause of contact dermatitis is exposure to a topical irritant therefore identifying this irritant is a component of treatment.
10. A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light brown serous drainage. Which of the following action should the nurse perform first? a. Check the clients' vital signs b. assess the client's pain level c. cover the wound with a moist sterile gas dressing d. obtain a culture and sensitivity of the wound drainage
c. cover the wound with a moist sterile gas dressing
9. A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient? a. Monitor white blood cell counts. b. Check the skin for areas of redness. c. Measure the temperature every 2 hours. d. Ask about feelings of fatigue or malaise
d. Ask about feelings of fatigue or malaise
