MED SURG FINAL

The nurse is assessing an older adult client with numerous health problems. What assessment data indicates an increase in the client's risk for heart failure (HF)?

The client's age is greater than 65

A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client's current health status is most likely to have precipitated this event?

The client's urinary catheter became occluded

A client with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the client about what potential adverse effects?

Throbbing headache or dizziness

A nurse is developing a care plan for a client with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention?

To prevent contractures

A nurse working in an emergency department is responsible for determining the severity of the patients' problems and how fast each needs to be seen. The nurse is implementing which of the following?

Triage

A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?

Two to three soft bowel movements daily

The nurse is creating a plan of care for a client with a cardiomyopathy. What priority goal should underlie most of the assessments and interventions that are selected for this client?

Improved cardiac output

A nurse is caring for a client with liver failure and is performing an assessment in the knowledge of the client's increased risk of bleeding. The nurse recognizes that this risk is related to the client's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function?

Inability of the liver to use vitamin K

A cardiac care nurse is caring for a client who is experiencing positive chronotropy. What effect should the nurse prepare for?

Increased heart rate

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority?

Ineffective airway clearance related to edema of the respiratory passages

The hospital nurse is caring for a client who tells the nurse that he has an angina attack beginning. What is the nurse's most appropriate initial action?

Place the client on bed rest in a semi-Fowler position.

A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage her potential sensory and perceptional difficulties?

Place the client's extremities where she can see them

The nurse is caring for an adult client whom the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what assessment information?

Potassium level

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication?

Provide a board of commonly used needs and phrases.

A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement?

"TIA is a warning sign. Let's talk about lowering your risks."

A monitor technician on the telemetry unit asks a charge nurse why every client whose monitor shows atrial fibrillation is receiving warfarin. Which response by the charge nurse is best?

"Warfarin prevents clot formation in the atria of clients with atrial fibrillation."

A 30-year-old female patient has deep partial thickness burns on the back of the right arm, posterior trunk, front of the left leg, anterior head and neck, and perineum. The patient weighs 150 lbs. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours?

10,064 mL

A nurse is caring for a client with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the client has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?

Asterixis

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client?

Bradycardia and hypertension

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client?

Absolute bed rest in a quiet, nonstimulating environment

A nurse is caring for a client who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis?

Acute pain

A client presents to the ED reporting increasing shortness of breath. The nurse assessing the client notes a history of left-sided heart failure. The client is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem?

Acute pulmonary edema

An emergency department nurse has just received a client with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the client's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period?

Administer IV fluids

A client is admitted to the ED with an apparent overdose of IV heroin. After stabilizing the client's cardiopulmonary status, the nurse should prepare to perform what intervention?

Administer naloxone hydrochloride (Narcan)

A nurse is amending a client's plan of care in light of the fact that the client has recently developed ascites. What should the nurse include in this client's care plan?

Administration of diuretics as prescribed

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration?

Alteration in level of consciousness (LOC)

A client with a history of rheumatic heart disease knows that she is at risk for bacterial endocarditis when undergoing invasive procedures. Prior to a scheduled cystoscopy, the nurse should ensure that the client knows the importance of taking which of the following drugs?

Amoxicillin

A nurse is caring for a client who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this client's plan of care?

Assessment for variceal bleeding

The triage nurse in the ED is assessing a client with chronic heart failure who has presented with worsening symptoms. In reviewing the client's medical history, what is a potential primary cause of the client's heart failure?

Atherosclerosis

A client is admitted to the ED who has been exposed to a nerve agent. The nurse should anticipate the STAT administration of what drug?

Atropine

The nurse is planning discharge teaching for a client with a newly inserted permanent pacemaker. What is the priority teaching point for this client?

Avoid exposure to strong electromagnetic fields

A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture?

Basilar

A workplace explosion has left a 40-year-old man with full thickness burns over 75% of his body. Despite his injuries, the man is conscious. How would this person be triaged?

Black

During a mass casualty event, a person whose injuries are extensive and whose chances of survival are unlikely even with definitive care would receive which color tag?

Black

A client with an occluded coronary artery is admitted and has an emergency percutaneous transluminal coronary angioplasty (PTCA). The client is admitted to the cardiac critical care unit after the PTCA. The complications for which the nurse should monitor the client include which of the following?

Bleeding at insertion site

The nurse is caring for a client who is receiving a loop diuretic for the treatment of heart failure. What assessment should the nurse prioritize?

Blood pressure

The ED nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture?

Bruising over the mastoid

A client who just experienced a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus?

Cardiac and respiratory status

A nurse is caring for a client with a history of cardiac disease and type 2 diabetes. The nurse is closely monitoring the client's blood glucose level. Which medication is the client most likely taking?

Carvedilol

A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?

Call the health care provider immediately

The nurse is caring for a client who has had a dysrhythmic event. The nurse is aware of the need to assess for signs of diminished cardiac output (CO). What change in status may signal to the nurse a decrease in cardiac output?

Changes in level of consciousness

A client with a C5 spinal cord injury has tetraplegia. After being moved out of the ICU, the client reports a severe throbbing headache. What should the nurse do first?

Check the client's indwelling urinary catheter for kinks to ensure patency

A nursing home resident has been diagnosed with Clostridium difficile. What type of precautions should the nurse implement to prevent the spread of this infectious disease to other residents?

Contact

A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock?

Decreased blood pressure

A nurse is caring for a client who is exhibiting ventricular tachycardia (VT). Because the client is pulseless, the nurse should prepare for what intervention?

Defibrillation

A client who has undergone a valve replacement with a mechanical valve prosthesis is due to be discharged home. During discharge teaching, the nurse should discuss the importance of antibiotic prophylaxis prior to which of the following?

Dental procedures

The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image?

Depression

The nurse is caring for a client with a brain tumor. What drug would the nurse expect to be prescribed to reduce the edema surrounding the tumor?

Dexamethasone

The nurse is reviewing the echocardiography results of a client who has just been diagnosed with dilated cardiomyopathy (DCM). What changes in heart structure is this client experiencing?

Dilated ventricles without hypertrophy of the ventricles

The nurse is assessing a client who is known to have right-sided heart failure. What assessment finding is most consistent with this client's diagnosis?

Distended neck veins

A client is brought to the ED by friends. The friends tell the nurse that the client was using cocaine at a party. On arrival to the ED the client is in visible distress with an axillary temperature of 40.1ºC (104.2°F). What would be the priority nursing action for this client?

Ensure airway and ventilation

The ED nurse is caring for a client who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform?

Ensure no one is touching the client at the time shock is delivered

The nurse and the other members of the team are caring for a client who converted to ventricular fibrillation (VF). The client was defibrillated unsuccessfully and the client remains in VF. The nurse should anticipate the administration of what medication?

Epinephrine 1 mg IV push

Medical and nursing interventions for patients who present with multiple injuries follow a sequence of treatment priorities. Which of the following is the first priority of care?

Establish an airway

For a patient who is experiencing multiple injuries, which sequence of medical or nursing management would the nurse identify as a priority?

Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries.

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what?

Evidence of hemorrhagic stroke

The nurse is caring for a client who has developed SIADH. What intervention is most appropriate?

Fluid restriction

A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care?

Fluid status

During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus?

Following proper hand-washing techniques

A medical nurse is careful to adhere to infection control protocols, including handwashing. Which statement about handwashing supports the nurse's practice?

Frequent handwashing reduces transmission of pathogens from one client to another

Skin grafts are necessary for which of the following burns?

Full-thickness

A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize?

Generalized seizure

When planning the care of a client with an implanted pacemaker, what assessment should the nurse prioritize?

Heart rate and rhythm

A client with a fractured femur presenting to the ED exhibits cool, moist skin, increased heart rate, and falling BP. The care team should consider the possibility of what complication of the client's injuries?

Hemorrhage

A nurse who provides care in a busy ED is in contact with hundreds of clients each year. The nurse has a responsibility to receive what vaccine?

Hepatitis B vaccine

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

Hoarseness of the voice

Which of the following types of shock will a nurse observe in a client with extensive burns?

Hypovolemic shock

The nurse is caring for an adult client who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina?

Ineffective breathing pattern related to decreased cardiac output

Anthrax acquired by which method develops into the most severe?

Inhalation

A client is admitted to the neurologic ICU with a spinal cord injury. In writing the client's care plan, the nurse specifies that contractures can best be prevented by what action?

Initiating (ROM) exercises as soon as possible after the injury

The triage nurse in the ED assesses an adult client who presents with reports of midsternal chest pain that has lasted for the last 5 hours. If the client's symptoms are due to an MI, what will have happened to the myocardium?

It may have developed an increased area of infarction during the time without treatment

A client's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid?

Lactated Ringer's

Which of the following is the preferred IV fluid for burn resuscitation?

Lactated Ringer's (LR)

A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be:

Pain management

A nurse is reviewing the trend of a client's scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the client's status?

Level of consciousness

The nurse is caring for a client who is scheduled to undergo mechanical valve replacement. Client education should include which of the following?

Long-term anticoagulant therapy

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?

Loosen the client's restrictive clothing

The nurse is providing care for a client with high cholesterol and triglyceride values. In teaching the client about therapeutic lifestyle changes such as diet and exercise, the nurse realizes that the desired goal for cholesterol levels is which of the following?

Low LDL values and high HDL values

The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment?

Lumbar puncture

In a client who has been burned, which medication should the nurse expect to use to prevent infection?

Mafenide (Sulfamylon)

The nurse is writing a plan of care for a client with a cardiac dysrhythmia. What would be the priority goal for the client?

Maintain adequate cardiac output

A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized?

Maintain and improve cerebral tissue perfusion

During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has which type of injury?

Minor; treatment can be delayed hours to days

The nurse places a client in isolation. Isolation techniques have the potential to break the chain of infection by interfering with what component of the chain of infection?

Mode of transmission

An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what?

Motor vehicle accidents

A family member brings a client to the ED following an apparent oxycodone overdose. The client is experiencing severe respiratory depression. Which medication will the nurse administer?

Naloxone hydrochloride

The nurse is caring for a client with a history of endocarditis. What topic should the nurse prioritize during health promotion education?

Oral hygiene

To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform?

P wave

A client with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse's best intervention for preventing injury?

Pad the side rails of the client's bed

A client is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the health care provider will perform which of the following actions?

Perform endotracheal intubation

The nurse is caring for a client who is colonized with methicillin-resistant Staphylococcus aureus (MRSA). What infection control measure has the greatest potential to reduce transmission of MRSA and other nosocomial pathogens in a health care setting?

Performing hand hygiene before and after contact with every client

A nurse is performing an admission assessment of a client with a diagnosis of cirrhosis. What technique should the nurse use to palpate the client's liver?

Place hand under right lower rib cage and press down lightly with the other hand.

A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety?

Place the client in a side-lying position

When a disease infects a host a portal of entry is needed for an organism to gain access. What has been identified as the usual portal of entry for tuberculosis?

Respiratory system

A client is being discharged after a liver transplant and the nurse is performing discharge education. When planning this client's continuing care, the nurse should prioritize what risk diagnosis?

Risk for Infection Related to Immunosuppressant Use

A client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect?

Spinal shock

A client is admitted to the emergency department after sustaining a penetrating injury to the abdomen. Which of the following would the nurse identify as a possible cause?

Stabbing with a knife

A nurse takes a shift report and will be caring for a client who has been exposed to anthrax by inhalation. What precautions does the nurse know must be put in place when providing care for this client?

Standard precautions

A nurse in the CCU is caring for a client with heart failure who has developed an intracardiac thrombus. The nurse should assess for signs and symptoms of what sequela?

Stroke

Which type of burn is similar to a sunburn?

Superficial partial-thickness

The nurse is analyzing a rhythm strip. What component of the ECG corresponds to the resting state of the client's heart?

T wave

A nurse is caring for a child who was admitted to the pediatric unit with infectious diarrhea. The nurse should be alert to what assessment finding as an indicator of dehydration?

Weak pulse

The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four clients who might be at risk for a stroke. Which client is likely at the highest risk for a hemorrhagic stroke?

White male, age 60, with history of uncontrolled hypertension

A client's physician has ordered a "liver panel" in response to the client's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply.

a. Alanine aminotransferase (ALT) b. Gamma-glutamyl transferase (GGT) d. Aspartate aminotransferase (AST)

A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is:

maintaining the client's fluid, electrolyte, and acid-base balance

A client's electrocardiogram reveals an irregular rhythm of 75 bpm with a normal QRS and P wave. The nurse who is caring for the client should anticipate:

no immediate treatment

The nurse is caring for a client who is believed to have just experienced an MI. The nurse notes changes in the ECG of the patient. What change on an ECG most strongly suggests to the nurse that ischemia is occurring?

T wave inversion

The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education?

Take antihypertensive medication as prescribed.

The critical care nurse is caring for a client who is receiving cyclosporine postoperative heart transplant. What outcome represents a therapeutic outcome of this pharmacologic treatment?

The client does not experience organ rejection

A triage nurse in the emergency department is assessing a client who presented with reports of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this client's presentation?

"How many alcoholic drinks do you typically consume in a week?"

A 45 year old female patient has superficial partial thickness burns on the posterior head and neck, front of the left arm, front and back of the right arm, posterior trunk, front and back of the left leg, and back of right leg. The patient weighs 91 kg. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours?

22,932 mL

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?

27%

Thrombolytic therapy for the treatment of an ischemic stroke should be initiated within how many hours of the onset of symptoms to obtain the best functional outcome?

3 hours

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?

36%

Which Glasgow Coma Scale score is indicative of a severe head injury?

7

The nurse is working with a client who had an MI and is now active in rehabilitation. The nurse should teach this client to cease activity if which of the following occurs?

The client experiences chest pain, palpitations, or dyspnea.

A client who has been exposed to anthrax is being treated in the local hospital. The nurse should prioritize what health assessments?

Assessment of respiratory status

A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens' center. What nonmodifiable risk factor for stroke should the nurse cite?

Advanced age

A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation?

Airway management

A client has been admitted to the medical unit with signs and symptoms suggestive of endocarditis. The health care provider's choice of antibiotics would be primarily based on what diagnostic test?

Blood cultures

An infectious outbreak of unknown origin has occurred in a long-term care facility. The nurse who oversees care at the facility should report the outbreak to what organization?

Centers for Disease Control and Prevention (CDC)

The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled and some that cannot. What risk factors should the nurse list that can be controlled or modified?

Cholesterol levels, hypertension, and smoking

A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the client's peritoneum, the nurse should anticipate what diagnostic test?

Computed tomography (CT) scan

The nurse is caring for an adult client with heart failure who is prescribed digoxin. When assessing the client for adverse effects, the nurse should assess for which of the following signs and symptoms? Select all that apply.

Confusion Bradycardia

When discussing angina pectoris secondary to atherosclerotic disease with a client, the client asks why he tends to experience chest pain when he exerts himself. The nurse should describe which of the following phenomena?

Exercise increases the heart's oxygen demands

What should be included in the client's care plan when establishing an exercise program for a client affected by a stroke?

Exercise the affected extremities passively four or five times a day

The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client?

Maintain head of bed (HOB) elevated at 30 to 45 degrees

A client is brought to the ED by her family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention?

Making openings in the skull

The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action?

Prepare for interventions to increase the client's BP

The nurse notes that a client has developed a cough productive for mucoid sputum, is short of breath, has cyanotic hands, and has noisy, moist-sounding, rapid breathing. These symptoms and signs are suggestive of what health problem?

Pulmonary edema

The nursing educator is presenting a case study of an adult client who has abnormal ventricular depolarization. This pathologic change would be most evident in what component of the ECG?

QRS complex

A community health nurse is presenting an educational event and is addressing several health problems, including rheumatic heart disease. What should the nurse describe as the most effective way to prevent rheumatic heart disease?

Recognizing and promptly treating streptococcal infections

Clients involved in a mass casualty incident are triaged and assigned a color-coded tag. When prioritizing care, clients tagged with which color would be treated first?

Red

A client with cardiovascular disease is being treated with amlodipine, which is intended to cause what therapeutic effect?

Reducing the heart's workload by decreasing heart rate and myocardial contraction

A client with liver disease has developed ascites; the nurse is collaborating with the client to develop a nutritional plan. The nurse should prioritize which of the following in the client's plan?

Reduction in sodium intake

The nurse is caring for a client admitted with a drug overdose. What is the nurse's priority responsibility in caring for this client?

Support the client's respiratory and cardiovascular function

A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client?

The client should be approached on the side where visual perception is intact

A client who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize?

The client will take immunosuppressive agents as required

A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply.

a. Immunization b. Use of standard precautions

During the acute phase of a burn, a nurse should assess:

circulatory status

The public health nurse is participating in a health fair and interviews a client with a history of hypertension, who is currently smoking one pack of cigarettes per day. The client denies any of the most common manifestations of CAD. The nurse should expect the focuses of CAD treatment to be:

diet therapy and smoking cessation

The health care provider prescribes esmolol for a client with supraventricular tachycardia. During esmolol therapy, what should the nurse monitor?

heart rate and blood pressure

During a mass casualty incident (hurricane), a triage nurse participated in separating patients according to the severity of their injuries. She tagged a patient with a sucking chest wound with the color:

red

A physician orders aspirin, 325 mg P.O. daily for a client who has experienced a transient ischemic attack (TIA). The nurse should teach the client that the physician has ordered this medication to:

reduce the chance of blood clot formation

The nurse is evaluating a skin lesion on a client brought to the emergency department. The nurse notes characteristics of chickenpox but has the physician evaluate the lesion for which biologic disaster agent?

smallpox