Learning System RN: Med Surg Finall

A client questions the nurse concerning the usual course of multiple sclerosis (MS). Which of the following is an appropriate response by the nurse?

ACUTE EPISODES ARE USUALLY FOLLOWED BY REMISSIONS, WHICH MAY LAST VARYING LENGTHS OF TIME.

A provider has ordered a client with diabetes to be discharged on a 2,000 calorie ADA diet. Which of the following actions should the nurse take first when developing a teaching plan for this client's diet?

ASK THE CLIENT TO IDENTIFY THE TYPES OF FOODS USUALLY EATEN AND PREFERRED.

A nurse is caring for a client with an upper gastrointestinal bleed who has an admission hematocrit of 24%. Prior to initiating a blood transfusion of whole blood, which of the following actions should the nurse take? (Select all that apply.)

ASSESS AND DOCUMENT THE CLIENT'S VITAL SIGNS VERIFY THE BLOOD TYPE AND Rh TO BE GIVEN TO WITH ANOTHER NURSE CHANGE THE IV TUBING TO A SET THAT HAS A FILTER

A nurse is caring for a client admitted 3 days ago for debridement of a large, stage III pressure ulcer if the heel. The wound was surgically debrided yesterday and the nurse is preparing to perform post-op wound care today. Which action should the nurse perform prior to changing the dressing?

ASSESS THE CLIENT'S LEVEL OF PAIN AND MEDICATE AS NEEDED.

A Client diagnosed with chronic lymphocytic leukemia has a platelet count of 18,000 cells/mL. An appropriate nursing intervention is to do which of the following?

AVOID INTRAMUSCULAR INJECTIONS (IM)

A nurse is caring for a client who has lost several pounds in the last few weeks due to an exacerbation of crohn's disease. The client is receiving total parenteral nutrition. (TPN) via a peripherally inserted central catheter (PICC line). Two days after starting the TPN, the client has developed excessive thirst, confusion and an increased urine output. Due to these manifestations, the nurse plans to obtain which of the following from the client?

CAPILLARY BLOOD GLUCOSE

A nurse is admitting a client to the burn treatment center following the client's rescue from a house fire. Which assessment is the highest priority?

CHARACTERISTICS OF THE COUGH AND SPUTUM.

A client arrives in the emergency department with fruity breath odor, dry mouth, and extreme thirst. The nurse should do which of the following?

CHECK THE CLIENT'S BLOOD GLUCOSE USING A GLUCOMETER.

A low cholesterol diet is prescribed for a client who has recently suffered a myocardial infarction. The nurse understands that effective teaching has occurred if the client selects which of the following for a meal?

CHICKEN BREAST AND MASHED POTATOES

A client is brought to the emergency department following a fall. The nurse, suspecting a basilar skull fracture, assesses the client for which of the following signs specific to basilar skull fracture?

CLEAR FLUID COMING FROM THE NARES.

A client in a community clinic tests positive on a Mantoux skin test but does not demonstrate active lesions on a chest x-ray. The provider provides tuberculosis (TB) prophylaxis for the client in the form of isoniazid (INH) therapy. In planning care for this client, the nurse will need to teach the client that isoniazid will have to be taken for which of the following time frames?

DAILY FOR APPROXIMATELY ONE YEAR

A client is diagnosed with active pulmonary tuberculosis and begins a treatment regimen of rifampin (Rifadin) and ethambutol (myambutol). The nurse should instruct the client to report which of the following adverse effects to the provider?

DECREASED VISUAL ACUITY.

A client with diabetes mellitus has a capillary blood glucose reading of 48mg/dL. Which of the following should the nurse expect to find?

DIAPHORESIS

A client who works in carpentry is seen by the triage nurse. The client complains of several right eye pain with a gritty sensation. When obtaining a history from this client, which question has the highest priority?

DID YOU FLUSH YOUR EYE OUT AT WORK?

A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse the reason for having two chest tubes. The nurse's response is based on the knowledge that the lower chest tube is placed to do which of the following?

DRAIN BLOOD AND FLUID FROM THE PLEURAL SPACE.

A Nurse is caring for a client who underwent a transurethral resection of prostate (TURP) for benign prostatic hypertrophy (BPH). The client's bladder is continuously irrigated with saline via a three-way catheter PRN. Which of the following findings should be reported immediately to the provider?

DRAINAGE THAT RESEMBLES KETCHUP COMING FROM THE CATHETER.

The Nurse is completing the evening assessment on a client in balanced skeletal traction who was admitted the previous evening for a fractured left femur. Which assessment finding should the nurse report to the surgeon?

DYSPNEA AND CHEST PETECHIAE.

A nurse is preparing to make rounds after receiving report from the previous shift. Which of the following client's should the nurse see first? The client with

EMPHYSEMA WHO REPORTS DYSPNEA.

Supportive therapy provided by the nurse for a client during a sickle cell crisis would include which of the following?

ENCOURAGING THE CLIENT TO DRINK A LOT OF FLUIDS.

A provider is planning to remove a client's chest tube. Which instruction should the nurse give to the client to ensure understanding regarding the removal procedure?

EXHALE AND BEAR DOWN GENTLY.

A nurse is teaching a client about transmission prevention of hepatitis A. By which of the following routes is hepatitis A transmitted?

FECAL/ORAL CONTAMINATION

A nurse is asked to assist in changing the bed linens of a client with acquired immune deficiency syndrome (AIDS) who has been incontinent of a formed stool. Prior to entering the room, the nurse first performs thorough handwashing then dons which of the following? (Select all that apply.)

GOWN GLOVES

In providing health teaching to a group of clients, it is important for the nurse to emphasize that melanoma is characterized by lesions that have which of the following appearances?

HAVE AN IRREGULAR BORDER

A nurse is providing teaching to a client recently diagnosed with systemic lupus erythematosus (SLE). Which statement made by the client indicates to the nurse an accurate understanding of the home management of SLE?

I WILL NEED TO TAKE PREDNISONE WHEN I AM HAVING AN EXACERBATION OF THE DISEASE."

A client is diagnosed with endocarditis following rheumatic heart disease. Which comment made by the client indicates to the nurse that she understands discharge teaching in relation to endocarditis?

I WILL NOTIFY MY DOCTOR BEFORE I HAVE AN INVASIVE SURGERY OR DENTAL PROCEDURE.

A client is experiencing stomatitis as a result of chemotherapy and radiation therapy. Which statement made by the client indicates to the nurse that additional teaching is necessary?

I WILL USE LEMON AND GLYCERINE SWABS AFTER MEALS.

When a nurse brings a hospitalized client AIDS (acquired immune deficiency syndrome) the morning dose of zalcitabine (Hivid), the client states, "I have this awful burning sensation in my fingers and toes. They are numb and tingling." What response by the nurse is appropriate at this time?

I'LL HOLD THE MEDICATION AND NOTIFY YOUR PROVIDER IMMEDIATELY."

A middle-adult assistive personnel (AP) is assigned to give a bath to a client with herpes zoster (shingles). The AP asks if this disease is contagious because there is an isolation sign in the client's door. Which response by the nurse would be appropriate at this time?

IF YOU HAVE HAD CHICKENPOX, THEN YOU CAN CARE FOR THE CLIENT WITHOUT CONCERNS.

A nurse is caring for a client with thrombophlebitis who is receiving a continuous IV heparin drip and is also started on an IV antibiotic for a wound infection. When checking compatibility of these two medications, the nurse determines that the prescribed antibiotic is not compatible in the same IV as the heparin. The nurse should plan to do which of the following?

INSERT ANOTHER IV LINE.

A nurse is caring for a client with hypoparathyroidism. Because of the potential electrolyte disturbance associated with the diagnosis, the nurse should assess the client for evidence of which of the following?

INVOLUNTARY MUSCLE SPASMS.

A Nurse is caring for a client with Arterisclerosis. When reviewing the client's chart, which of the following factors should the nurse realize is associated with the development of arteriosclerosis?

LDL SERUM LEVELS ARE ELEVATED

A client who had a craniotomy is sitting in a chair with the nurse present in the room. While the client is sitting, he begins to experience a grand mal seizure. At this time, the most important nursing intervention is which of the following?

LOWER THE CLIENT TO THE FLOOR.

A client is diagnosed with viral encephalitis secondary to west nile virus is admitted to the hospital for treatment. When developing a nursing care plan, which interventions are consistent with the client's diagnosis? (Select all that apply.)

MONITOR VITAL SIGNS EVERY 4 HOURS. ASSESS NEUROLOGICAL STATUS EVERY 4 HOURS. ASSESSING FOR BRUDZINSKI'S SIGN. IMPLEMENTING SEIZURE PRECAUTIONS.

In preparation for a sigmoid colon resection, the nurse is giving the client instructions about the colostomy that will be performed. Which statement by the client will require further clarification?

MY DIET WILL HAVE TO CHANGE DRASTICALLY.

Following a transient ischemic attack (TIA), a client is alert, slightly confused and has a blood pressure of 204/102 mm Hg. The client is incontinent of urine. In planning the client's care, which nursing action would be appropriate?

OFFER THE CLIENT A BEDPAN EVERY 2 HOURS.

A nurse is teaching a client how to perform a breast self examination (BSE). Which finding should the nurse instruct the client to report promptly to her provider?

ONE NON-TENDER, HARD LUMP THAT IS PALPATED IN THE UPPER-OUTER QUADRANT OF THE BREAST.

Which Nursing action is appropriate when trying to control epistaxis?

PINCH THE SOFT PORTION OF THE NARES FOR 10 TO 15 MIN.

A client with glaucoma is admitted for surgery the following day. The client is to continue treating the glaucoma with pilocarpine (Pilocar) 2% 1 drop 4 times a day. While instilling this medication, an appropriate nursing action is which of the following?

PLACE THE MEDICATION IN THE CONJUNCTIVA SAC APPLYING PRESSURE TO THE PUNCTA FOR 1 TO 2 MIN.

A client has left a used insulin syringe on the bedside table. At this time, the appropriate nursing action is to do which of the following?

PLACE THE UNCAPPED SYRINGE IN THE PUNCTURE-PROOF SHARPS DISPOSAL CONTAINER.

A nurse is caring for a client who has undergone a hip arthroplasty. The nurse explains to a client that the purpose of an abduction pillow following arthroplasty is to do which of the following?

PREVENT DISLOCATION OF THE HIP DURING POSITION CHANGES OR MOVEMENT.

While performing an admission assessment for a client with an exacerbation of asthma, the nurse learns the client has several food allergies. The most important nursing action in promoting this client's safety is to do which of the following?

PROVIDE THE DIETITIAN WITH A LIST OF THE CLIENT'S ALLERGIES.

A client who is admitted to the hospital after experiencing a tonic clonic seizure is scheduled for a routine electroencephalogram (EEG). In preparing the client for the EEG, the nurse should explain that the client will undergo which of the following?

RECEIVE A THOROUGH SHAMPOO PRIOR TO THE EEG.

A client's arterial blood gas (ABG) levels are pH 7.5, pCO2 32, bicarbonate (HCO3)24. The nurse interprets that the client is in which of the following?

RESPIRATORY ALKALOSIS

A client has undergone a below the knee amputation (BKA) because of peripheral vascular disease. The provider prescribes wet to dry dressing changes twice a day. The nurse knows that it is appropriate to perform these dressing changes using which of the following?

STERILE TECHNIQUE AND STERILE GLOVES

A nurse is planning to teach a client with a history of urolithiasis with uric acid stones how to prevent development of stones in the future. Which of the following suggestions by the nurse would be appropriate to include? (Select all that apply.)

TAKING ALLOPURINOL (ZYLOPRIM) AS PRESCRIBED FOR GOUT. PLANNING FOR MODERATE EXERCISE SEVERAL TIMES A WEEK. LIMITING INTAKE OF FOODS HIGH IN PROTEIN AND PURINE. DRINKING 2 GLASSES OF WATER AT BEDTIME

A client diagnosed with emphysema is being prepared for discharge. Which instruction given by the nurse would be beneficial for improving the client's gas exchange?

TEACHING THE CLIENT PURSED-LIP BREATHING.

A client has received a cardiac pacemaker. Which statement by the client demonstrates to the nurse an understanding of the pacemaker's purpose?

THE PACEMAKER WILL HELP STIMULATE MY HEART TO BEAT WHEN MY HEART RATE IS SLOW OR IRREGULAR.

A nurse is caring for a client who was diagnosed with cervical cancer and has a radioactive vaginal implant. The client questions the nurse in regard to the reason for insertion of an indwelling urinary catheter. Which of the following reasons is appropriate for the nurse to provide?

TO PREVENT DISLODGEMENT OF THE IMPLANT.

A client with chronic renal failure is undergoing peritoneal dialysis. Which nurse measure will be most helpful in promoting outflow drainage of the dialyzing solution?

TURN THE CLIENT FROM SIDE TO SIDE

An obese client that has decreased mobility secondary to osteoarthritis of the knees has been on a weight management program for 2 months. During the past week, the client regained 3 lb. In regard to the client's weight gain, an appropriate response by the nurse is which of the following?

WERE THERE ANY ISSUES LAST WEEK THAT KEPT YOU FROM FOCUSING ON YOUR DIET?