Med Surg: Final
A nurse is caring for a client who is to have his chest tube removed. Which of the following actions should the nurse take?
Instruct the client to perform the Valsalva maneuver during removal.
A nurse is providing discharge teaching about improving gas exchange to a client who has emphysema. Which of the following instructions should the nurse include in the teaching?
Use pursed-lip breathing during periods of dyspnea.
A nurse is providing teaching to a client who has a new diagnosis of multiple sclerosis (MS). The clients asks the nurse about the usual course of MS. Which of the following responses should the nurse make?
"Acute episodes are usually followed by remissions, which can vary in duration."
A nurse is providing teaching to a client who has cervical cancer and is scheduled to receive brachytherapy in an ambulatory care clinic. Which of the following statements by the client indicates an understanding of the teaching?
"I need to lie still in bed during my brachytherapy treatment."
A nurse is providing discharge teaching to a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching?
"I should check my heart rate at the same time each day."
A nurse is providing discharge teaching to a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching?
"I will need to take methotrexate even if I'm in remission."
A nurse is providing discharge teaching to an adult female client who has infective endocarditis about how to prevent recurrence. Which of the following statements by the client indicates understanding of the teaching?
"I will notify my doctor before I have dental procedures."
A nurse is providing teaching to a client who has stomatitis due to chemotherapy and radiation therapy. Which of the following statements by the client indicates a need for further teaching?
"I will use lemon and glycerine swabs after meals."
A nurse is providing teaching to a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching?
"My diet will have to change to a soft diet after surgery."
A nurse is providing teaching about antiretroviral medication therapy to a client who has a new diagnosis of AIDS. Which of the following statements should the nurse include in the teaching?
"You should take antiretroviral medications on a routine schedule."
A nurse is providing teaching to a client who has tuberculosis (TB) and a prescription for isoniazid. Which of the following instructions should the nurse include?
"You should take this medication on an empty stomach."
A nurse is preparing to care for a group of clients after receiving change-of-shift report. Which of the following clients should the nurse assess first?
A client who has emphysema and reports dyspnea
A nurse is teaching a client how to perform a breast self exam (BSE). The nurse should identify which of the following findings as an indication of breast cancer?
A nontender, hard lump that is palpated in one breast
A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first?
Ask the client to identify the specific food allergies.
A nurse is planning dietary teaching for a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first?
Ask the client to identify the types of foods she prefers.
A community health nurse is teaching a group of clients about melanoma. Which of the following characteristics of lesions associated with melanoma should the nurse include in the teaching?
An irregular border
A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take?
Apply lateral pressure to the client's nose for 10 min.
A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take?
Apply pressure to the puncta after instilling the medication.
A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first?
Ask the client about first aid performed at the scene.
A nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit of 24%. Prior to initiating a transfusion of packed red blood cells (RBCs), which of the following actions should the nurse take? (Select all that apply.)
Assess and document the client's vital signs. Verify with another nurse the blood type and Rh of the packed RBCs. Change IV tubing to a set that has a filter.
A nurse is caring for a client who is 72 hr postoperative following an above-the-knee amputation. Which of the following actions should the nurse take?
Assist the client to a prone position every 4 hr.
A nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000/mm3. Which of the following interventions should the nurse include?
Avoid IM injections.
A nurse in the emergency department is caring for a client who has fruity breath odor, dry mouth, and extreme thirst. Which of the following assessments should the nurse make?
Blood glucose level
A nurse is teaching about a low-cholesterol diet to a client who had a myocardial infarction. Which of the following meal selections by the client indicates an understanding of the teaching?
Chicken breast and corn on the cob
A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture?
Clear fluid coming from the nares
A nurse in an emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first?
Characteristics of the cough and sputum
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?
Check the client's capillary blood glucose level every 4 hr.
A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first?
Check the client's pain level.
A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider?
Chest petechiae
A nurse is planning care for a client who has thrombophlebitis and a prescription to receive heparin via continuous IV infusion. Which of the following actions should the nurse include in the plan of care?
Infuse the heparin using an electronic IV pump.
A nurse is providing teaching to a client who has tuberculosis and prescriptions for rifampin and ethambutol. The nurse should identify which of the following findings as an adverse effect of these medications that the client should report to the provider?
Decreased visual acuity
A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect?
Diaphoresis
A nurse is providing postoperative care for a client who has two chest tubes in place following a lobectomy. The client asks the nurse the reason for having two chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons?
Draining blood and fluid from the pleural space
A nurse is caring for an adult male client who is undergoing screening tests for atherosclerosis. Which of the following laboratory findings should the nurse identify as an increased risk for this disorder?
Elevated LDL levels
A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should the nurse include in the client's plan of care?
Encourage increased fluid intake.
A nurse is teaching a client about transmission prevention of hepatitis A. The nurse should identify that hepatitis A is transmitted by which of the following routes?
Fecal-oral contamination
A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) should the nurse don prior to providing client care? (Select all that apply.)
Gown Gloves
A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first?
Lower the client to the floor.
A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the following actions should the nurse take? (Select all that apply.)
Monitor vital signs every 2 hr. Assess neurological status every 4 hr. Keep the client's room darkened.
A nurse is planning care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following actions should the nurse include in the client's plan of care?
Offer the client a bedpan every 2 hr.
A home health nurse enters a client's home and finds a used insulin syringe, without a cap, on the table. Which of the following actions should the nurse take?
Place the syringe in a puncture-proof disposal container.
A nurse is caring for a client following a hip arthroplasty. The nurse places an abduction pillow on the client for which of the following purposes?
Preventing dislocation of the hip during position changes or movement
A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mm HG, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances?
Respiratory alkalosis
A nurse is providing teaching to a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse make? (Select all that apply.)
Take allopurinol as prescribed. Exercise several times a week. Limit intake of foods high in purine.
A nurse is providing teaching to a client who has a history of tonic-clonic seizures and is scheduled for a standard electroencephalogram (EEG). Which of the following instructions should the nurse include in the teaching?
Thoroughly shampoo hair prior to the EEG.
A nurse is caring for a client who is receiving intermittent peritoneal dialysis. The nurse observes that the peritoneal fluid is not adequately draining. Which of the following actions should the nurse take?
Turn the client from side to side.
A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider?
Viscous urinary output with clots
A nurse is obtaining a weekly weight for a client who has obesity and osteoarthritis and is on a weight management program. The nurse determines that the client gained 1.36 kg (3 lb) in the past week. Which of the following statements should the nurse make?
"Were there any issues last week that kept you from focusing on your diet?"
A nurse is monitoring a client following a thyroidectomy for the presence of hypoparathyroidism. Which of the following findings should the nurse expect?
Involuntary muscle spasms
A nurse is working with an assistive personnel (AP) who is assigned to bathe a client who has herpes zoster. The AP asks the nurse if the herpes zoster is contagious. Which of the following responses should the nurse make?
"Herpes zoster is not contagious to people who have had chickenpox."
