Med-Surg Missed Questions

The nurse is performing a rapid neurologic assessment on a trauma client. Which assessment findings are considered normal? (Select all that apply.) a. Decerebrate posturing b. Lethargy c. Glasgow Coma Score 15 d. Minimal response to stimulation e. Pupil constriction to light

c. Glasgow Coma Score 15 e. Pupil constriction to light Normal rapid neurologic assessment findings include a GCS (Glasgow Coma Score) of 15 and pupil constriction to light. The GCS range is between 3 and 15. Pupil constriction is a function of cranial nerve III. The pupils would be equal in size and round and regular in shape and would react to light and accommodation (PERRLA).Decerebrate or decorticate posturing is not normal, as well as pinpoint or dilated and nonreactive pupils. Both of findings are a late sign of neurologic deterioration. In addition, minimal response to stimulation and increased lethargy are not normal findings.

The nurse is talking to a group of active senior citizens about making healthy lifestyle choices. Which suggestion is most important in promoting health and safety? a. Enroll in a safe driving refresher course and avoid risky driving situations. b. Continue to eat healthy foods, especially protein. c. Walk 30 minutes three to five times a week. d. Seek counseling for depression, because it is not a normal part of aging

a. "Enroll in a safe driving refresher course and avoid risky driving situations." Safe driving refresher courses are one method to help older adults identify and manage these lifestyle choices. Motor vehicle crashes are the most common cause of injury-related death for those between 65 and 74 years of age. To promote health and safety, driving should be discontinued when vision, reflexes, or confidence begin to suffer.Eating healthy foods and exercise promote health but not safety. Encouraging good mental health promotes well-being but not safety.

An older adult client admitted to a nursing home for rehabilitation asks the nurse if the client's care will be covered by Medicare. What response by the nurse is correct? a. "Medicare A should cover 100% of your rehabilitation skilled care for a limited period of time." b. "Medicare D should pay for the total costs of drugs you take while you are here." c. "Medicare G should pay 80% of your lab and x-rays while you are here." d. "Medicare B should pay 100% of your rehabilitation therapy sessions while you are here."

a. "Medicare A should cover 100% of your rehabilitation skilled care for a limited period of time." Medicare A pays for skilled care in hospitals and other settings. However, the client must be certified as requiring skilled care requiring licensed health professionals to provide assessments and interventions for the client. The maximum limit for skilled care with 100% Medicare coverage is 100 days.

Which client will the nurse consider to be a poor candidate for continuous positive airwya pressure (CPAP) management for obstructive sleep apnea? a. A 65 y/o with chronic confusion b. A 45 y/o with septal deviation who is a mouth-breather c. A 75 y/o who lives alone d. A 55 y/o with an unusally large uvula

a. A 65 year old with chronic confusion Use of CPAP for management of OSA requires client cooperation and understanding of the therapy, as well as maintaining the device in the correct position throughout sleeping. A confused client is not likely to keep any type of mask on tightly enough for CPAP to be effective.A deviated septum is not a contraindication to CPAP therapy because a mask that covers the mouth can be used. A large uvula is one cause of OSA and not a contraindication for CPAP therapy. Clients do not require a partner to use CPAP therapy.

The nurse is caring for a client who is diagnosed with middle stage (moderate) Alzheimer disease. What assessment findings would the nurse expect? (Select all that apply.) a. Agnosia b. Mild cognitive impairment c. Sleeping problems d. Seizures d. Wandering e. Psychoses

a. Agnosia c. Sleeping problems d. Seizures d. Wandering e. Psychoses All of these choices except for mild impairment of cognition would be expected. The client with moderate AD has a more marked cognitive impairment.

The nurse is in the room while the assistive personnel (AP) is providing incontinence care to a client. Which action by the AP would require the nurse to intervene? (Select all that apply.) a. Allowing the client to remain in the same position. b. Applying moisture barrier cream to the perineal area. c. Using soap and water to clean soiled areas on the perineum. d. Rubbing areas on the sacrum that are slightly red. e. Drying the sacral area carefully with a towel. f. Placing a bed pillow between the client's knees.

a. Allowing the client to remain in the same position. d. Rubbing areas on the sacrum that are slightly red The nurse will need to intervene if the AP attempts to rub reddened areas on the client's sacrum or allows the client to remain in the same position. Rubbing reddened areas can cause additional damage to the already fragile capillary system. The client should be repositioned at least every 2 hours. Since the AP is already providing incontinence care, this is an appropriate time to reposition the client to prevent skin breakdown.

The nurse is caring for a client who is scheduled to have a transcranial Doppler (TCD). What does this diagnostic test evaluate? a. Cerebral vasospasm b. Intracranial pressure c. Cerebrospinal fluid d. Evoked potentials

a. Cerebral vasospasm A transcranial Doppler (TCD) is used to evaluate cerebral vasospasm or narrowing of arteries. It is noninvasive. Cerebrospinal fluid is obtained and measured during a lumbar puncture (LP). Evoked potentials measure the electrical signals in the brain during an EEG. Intracranial pressure is a measurement of blood, brain tissue, and cerebral spinal fluid and is not measured by TCD.

For which symptom or problem will the nurse instruct a client who is being discharged after a modified uvulopalatopharyngoplasty (modUPPP) surgery to notify the surgeon immediately? (Select all that apply.) a. Fever b. Anorexia c. Pain only during swallowing d. Oozing of bright red blood where the uvula was removed e. Beefy red color of the soft palate f. Foul smelling breath

a. Fever d. Oozing of bright red blood where the uvula was removed e. Beefy red color of the soft palate f. Foul smelling breath The two major complications requiring immediate action are infection and bleeding. Indicators of infection including the present of purulent exudate, foul-smelling breath, or a change in color of mucous membranes to beefy red. Although oozing of some dark red blood is expected; however, bright red oozing is an indication of new-onset bleeding that could lead to hemorrhage.Pain during swallowing is expected during the first week or so after surgery, and contributes to anorexia.

The nurse is assessing a client for cerebellar function. Which assessments will the nurse perform? a. Gait pattern b. Muscle strength c. Coordination d. Sensation e. Speech and language

a. Gait pattern c. Coordination The cerebellum controls gait, equilibrium, and coordination ability. Muscle strength and speech are functions of the motor strip and Broca area of the frontal lobe of the brain. The sensory strip is located in the parietal lobe.

The nurse is teaching a group of senior citizens about recommended immunizations. What immunizations would the nurse include? (Select all that apply.) a. Herpes zoster vaccine b. Pneumococcal vaccine polyvalent vaccine c. Adult Tdap with Td booster every 10 years d. Annual influenza vaccine e. Pneumococcal 13- valent conjugate vaccine

a. Herpes zoster vaccine b. Pneumococcal vaccine polyvalent vaccine c. Adult Tdap with Td booster every 10 years d. Annual influenza vaccine e. Pneumococcal 13- valent conjugate vaccine All of these immunizations are very important for people over 65 years of age to obtain due to the high risk of the diseases that they help prevent

The nurse is preparing a client for cerebral angiography. Which nursing actions are appropriate as part of care for the client? (Select all that apply.) a. Hold any drug that can interfere with kidney function b. Communicate any reaction to iodinated contrast to the primary health care provider c. Check for a history of acute or chronic kidney disease d. Provide adequate hydration before and after the diagnostic test e. Ask about the client's history of any and all allergies

a. Hold any drug that can interfere with kidney function b. Communicate any reaction to iodinated contrast to the primary health care provider c. Check for a history of acute or chronic kidney disease d. Provide adequate hydration before and after the diagnostic test e. Ask about the client's history of any and all allergies The care for the client involves all of these important nursing actions. The client needs adequate hydration to prevent kidney damage from the contrast medium. The nurse ensures that any client allergies are reported to the primary health care provider.

The nurse is caring for an adult client who has been prescribed quetiapine last year for bipolar disorder. For which adverse drug effects would the nurse observe? (Select all that apply.) a. Urinary retention b. Hypoglycemia c. Restlessness d. Hypertension e. Parkinsonism

a. Urinary retention c. Restlessness e. Parkinsonism The nurse would observe for adverse effects, as well as hypotension and hyperglycemia.

The nurse recognizes that handwashing is the best method for preventing infection. Which action(s) by the Centers for Disease Control (CDC) about hand hygiene are recommended? (Select all that apply.) a. If hands are not visibly soiled, use an alcohol-based hand rub b. Wash hands before and after wearing gloves c. If hands are visibly soiled, wash them with soap and water d. use only soap and water for hand hygiene when planning client contact e. Wash hands before performing any invasive client procedure

a. If hands are not visibly soiled, use an alcohol-based hand rub b. Wash hands before and after wearing gloves c. If hands are visibly soiled, wash them with soap and water e. Wash hands before performing any invasive client procedure All of these choices are best practices except for using only soap and water for hand hygiene before client contact. An alcohol-based hand rub is also acceptable for direct or indirect client contact.

The nurse is teaching a class of older adults about ways to promote their cognitive health. Which collaborative interventions will be most helpful for them? (Select all that apply.) a. Joining a peer group with a common learning goal b. Meditating for 30 minutes every day c. Allowing for increased rest and relaxation time. d. Having solitary times to reminisce about life experiences e. Starting a new physical activity f. Learning a new skill

a. Joining a peer group with a common learning goal e. Starting a new physical activity f. Learning a new skill Cognitive health problems (depression, delirium, and dementia) can be offset by social engagement with a peer group, learning a new skill, and physical activity.Increased rest time, meditation, and increased solitude may be helpful for other aspects of aging but do not benefit the older adult's cognitive capabilities.

The nurse is assessing an older adult client to identify possible factors that may negatively impact the client's nutritional status. Which risk factors would the nurse include? (Select all that apply.) a. Loneliness or depression b. Inadequate financial resources c. Constipation d. Lack of transportation e. Tooth loss or poorly fitting dentures f. Decreased mobility

a. Loneliness or depression b. Inadequate financial resources c. Constipation d. Lack of transportation e. Tooth loss or poorly fitting dentures f. Decreased mobility All of these factors can prevent clients from eating adequate amounts of healthy foods.

The nurse is caring for a client who had a lumbar puncture. What priority action would the nurse perform to ensure client safety? a. Monitor for increased ICP, such as decreased LOC b. Observe the needle insertion site for CSF leakage or infection c. Give an analgesic for client report of a headache if it is moderate or severe d. Take vital signs every hour after the procedure until the client is stable

a. Monitor for increased intracranial pressure, such as decreased level of consciousness (LOC). After a lumbar puncture, the client has less CSF which can cause an expected mild to moderate headache. However, the client may experience increased intracranial pressure which is manifested by decreasing LOC, severe headache, nausea, and vomiting. The nurse monitors for these potentially life-threatening changes. The nurse also monitors for CSF leakage, takes vital signs as per agency protocol, and provides analgesia as needed. However, these actions are not the priority for the nurse at this time.

Which nursing actions aid in the prevention and early detection of infection in a client at risk? (Select all that apply.) a. Obtain cultures as needed b. Remove unnecessary medical devices c. Monitor RBC count d. Inspect the skin for coolness and pallor e. Promote sufficient nutritional intake f. Encourage fluid intake, as appropriate

a. Obtain cultures as needed b. Remove unnecessary medical devices d. Inspect the skin for coolness and pallor Promoting sufficient nutritional intake helps prevent and detect early infection in at risk clients. Nutrition has a direct correlation to improvement of general health. Malnutrition, especially protein-calorie malnutrition, places clients at increased risk for infection. Blood cultures would be used to detect a possible systemic infection. Advocating for the removal of unnecessary medical devices (e.g., intravascular or urinary catheters, endotracheal tubes, synthetic implants) may also interfere with normal host defense mechanisms and may help prevent infection.Inspecting the skin does not prevent or detect systemic infections. Fluid intake is important but does not directly relate to prevention or detection of infection. Monitoring the RBC count does not prevent, nor would it detect, infection.

What roles does the rehabilitation nurse have in the functioning of the rehabilitation team? (Select all that apply.) a. Plans continuity of care for discharge. b. Coordinates rehabilitation team activities. c. Coordinates holistic care d. Develops the client's fine motor skills. e. Retrains clients with swallowing challenges.

a. Plans continuity of care for discharge. b. Coordinates rehabilitation team activities. c. Coordinates holistic care Providing holistic care and coordinating all activities of the rehabilitation team is a role for the rehabilitation nurse—perhaps the primary role. The rehabilitation team is diverse and multi-skilled; getting the right skills and services to the client is a primary role for the rehabilitation nurse. The rehabilitation nurse coordinates the care that the client will continue to receive after discharge; this coordination actually begins as the client is admitted to the rehabilitation unit.

The hospital nurse is assigned to establish a rehabilitation milieu on the unit. What elements will the nurse include? (Select all that apply.) a. Protecting clients from embarrassment b. Making the inpatient unit a more homelike environment c. Allowing time for clients to practice self-management skills d. Keeping a structured hospital schedule e. Carefully monitoring fluid and dietary intake f. Encouraging clients and providing emotional support

a. Protecting clients from embarrassment b. Making the inpatient unit a more homelike environment c. Allowing time for clients to practice self-management skills f. Encouraging clients and providing emotional support As clients undergo rehabilitation, they must learn skills to function independently after they are discharged. Incorporating self-management skills in the environment is crucial. Rehabilitation nurses in hospital settings must provide an environment that encourages and supports clients who are undergoing rehabilitative efforts. The rehabilitative milieu needs to be less structured and more homelike for the client to begin to develop the skills and behaviors that will be needed after discharge. Along with the homelike environment, clients need to be protected from embarrassing situations in this milieu.

The nurse is performing a neurologic assessment for a client and suspects damage to the client's brainstem. Which assessment findings are consistent with brainstem involvement? (Select all that apply.) a. Pupil constriction b. Dysrhythmias c. Aphasia d. Irregular respiratory pattern e. Dysphagia

a. Pupil constriction b. Dysrhythmias d. Irregular respiratory pattern e. Dysphagia The brainstem is comprised of the medulla, pons, and midbrain. The nuclei of the cranial nerves that control vital signs (CN X) and swallowing (CN IX-XII) are located in the pons and medulla. CN X (vagus nerve) also controls cardiac and breathing functions. The nuclei of the oculomotor nerve (CN III) causes pupil reaction. When the nerve is damaged, the pupils constrict. Aphasia occurs when the speech and/or language centers in the cerebrum are affected.

Which client conditions will the nurse recognize as most likely to cause a "right shift" of the oxyhemoglobin dissociation curve? (Select all that apply.) a. Reduced blood and tissue levels of oxygen b. Alkalosis c. Increased metabolic demands d. Reduced blood and tissue levels of diphosphoglycerate (DPG) e. Increased body temperature f. Reduced blood and tissue pH

a. Reduced blood and tissue levels of oxygen c. Increased metabolic demands e. Increased body temperature f. Reduced blood and tissue pH The oxyhemoglobin dissociation curve is shifted to the right when conditions are present that increase overall oxygen needs. This right shift makes it easier for oxygen to dissociate from the hemoglobin molecule. Such conditions are those associated with higher metabolism and oxygen need. These include increased body temperature, increased metabolic demand, hypoxia, and acidosis (low pH with higher concentration of hydrogen ions. Reduced DPG and alkalosis (fewer hydrogen ions) are associated with increased oxygen need and a left shift in the oxyhemoglobin dissociation curve.

A client with lower motor neuron spinal cord dysfunction has not voided, and a bladder scan shows 700 mL of urine in the bladder. Using the client's bladder training plan, what action does the staff RN advise a new graduate nurse to take first with this client? a. Remind the client to try the Valsalva maneuver. b. Insert a straight catheter to empty the bladder. c. Reassess the client's bladder volume in 2 hours. d. Administer a dose of oxybutynin chloride (Ditropan).

a. Remind the client to try the Valsalva maneuver. The RN advises the new graduate nurse to first try the Valsalva maneuver. Clients with lower motor neuron problems have a flaccid bladder. Increasing pressure on the bladder with the Valsalva maneuver may help the client void.

Which oral hygiene measures will the nurse teach a client to use during the first week after having modified uvulopalatopharyngoplasty (modUPPP) surgery? a. Rinsing with mouthwash and gently wiping oral structures with oral sponges b. Only flossing and forgoing toothbrushing c. Avoiding all oral hygiene practices except saline rinses d. Swishing and swallowing an oral antibiotic solution

a. Rinsing with mouthwash and gently wiping oral structures with oral sponges After modUPPP surgery, the oral mucous membranes are at an increased risk for bleeding from trauma and for infection. Clients must continue good oral hygiene practices to prevent infection while avoiding trauma from flossing and using a toothbrush. Oral antibiotic solutions are not used for oral hygiene. Saline rinses are encouraged to help with pain and mouth dryness but are not sufficient alone to prevent infection.

The nurse is caring for a client who has Parkinson disease (PD). What assessment findings would the nurse expect? (Select all that apply.) a. Stooped posture b. Masklike facial expression c. Drooling at times d. Shuffled gait e. Dysarthria f. Muscle rigidity

a. Stooped posture b. Masklike facial expression c. Drooling at times d. Shuffled gait e. Dysarthria f. Muscle rigidity All of these signs and symptoms commonly occur in clients who have PD.

A client has been admitted with new-onset status epilepticus. Which seizure precautions would the nurse implement? (Select all that apply.) a. Suction equipment at the bedside b. Continuous sedation c. Intravenous access d. Bite block at the bedside e. Side rails raised

a. Suction equipment at the bedside c. Intravenous access e. Side rails raised Seizure precautions the nurse institutes for an admitted client with new-onset status epilepticus include IV access, suctioning equipment at the bedside, and raised side rails. IV access is needed to administer medications. Suctioning equipment must be available to suction secretions and facilitate an open airway during a seizure. Raised, padded side rails may be used to protect the client from falling out of bed during a seizure.Bite blocks or padded tongue blades would not be used because the client's jaw may clench, causing teeth to break and possibly obstructing the airway. Continuous sedation is a medical intervention and not a seizure precaution.

A diabetic client is scheduled to have a computed tomography-positron emission tomography scan to rule out a brain tumor. What health teaching would the nurse include? a. Take your anti-diabetic medications as usual before the test b. This test will only take about 20 to 30 minutes c. You'll need to let your doctor know if you have seafood allergies d. You may drink liquids up until an hour before the test

a. Take your anti-diabetic medications as usual before the test The test requires the client to be NPO for at least 4 hours before the test, but the client should take any prescribed anti-diabetic drugs as usual. The test takes between 2 and 3 hours after the client receives an isotope. This contrast medium is safe for clients who have allergies to seafood.

A rehabilitation nurse is teaching the client with a spastic bladder to perform intermittent catheterizations. Which client statement indicates the need for further education? a. "Before I catheterize myself, I will try to urinate." b. "I will catch myself at 9 a.m. and 9 p.m." c. "I will use the Valsalva and Credé maneuvers before trying to urinate." d. "You can teach my son to help me with the catheterizations."

b. "I will catch myself at 9 a.m. and 9 p.m." The statement by the client that, "I will catch myself at 9 a m and 9 p.m.," indicates the need for further education. The client should not go beyond 8 hours between catheterizations. The time between catheterizations in this scenario is 12 hours. This concept needs to be reinforced to the client.

The nurse is caring for a client with impaired vision. The nurse knows the cranial nerve that controls visual acuity is which of the following? a. CN V - trigeminal b. CN II - optic CN III - oculomotor CN VII - facial

b. CN II - optic Cranial nerve II (optic) is responsible for vision and cranial nerve III (oculomotor) is responsible for eye movement.

Which action will the nurse safely assign to an experienced assistive personnel (AP) to perform with a client who returned an hour ago to the medical-surgical unit after a bronchoscopy? a. Offering clear liquids when gag reflex returns b. Determining level of consciousness c. Assessing breath sounds d. Monitoring blood pressure and pulse

b. Determining level of consciousness The best nursing action for the nurse to assign to the experienced AP is monitoring blood pressure and pulse. An experienced AP would have experience in taking client vital signs after procedures requiring conscious sedation or anesthesia.Evaluating breath sounds, gag reflex, and determining level of consciousness are considered nursing assessments and require the skill and knowledge of a higher-level provider or professional nurse.

A client with Parkinson disease (PD) reports having auditory hallucinations. What drug would the nurse anticipate may be prescribed for the client? a. Ubrogpant b. Pimavanserin c. Phenytoin d. Levodopa

b. Pimavanserin Pimavanserin is a drug that is used when clients with PD have hallucinations. Phenytoin is used to manage seizures and ubrogepant is used for clients who have migraine headaches. Levodopa, usually in combination with carbidopa, is a commonly used drug for most clients at some time for their PD.

For which symptoms would a nurse assess a client who worries a thoracentesis earlier today may have caused a pneumothorax? (Select all that apply.) a. Slowing heart rate b. Sensation of air hunger c. Pain at the insertion site d. Cyanosis of oral mucous membranes e. Wheezing on inhalation and exhalation f. Tracheal deviation

b. Sensation of air hunger d. Cyanosis of oral mucous membranes f. Tracheal deviation Signs and symptoms of a pneumothorax include sensation of air hunger, tracheal deviation, and cyanosis. Other symptoms include pain on the affected side (not at the needle insertion site), rapid heart rate, rapid, shallow respirations, prominence of the affected side that does not move in and out with respiratory effort, and new onset of "nagging" cough. Wheezing is a bronchial and bronchiolar problem. It is not produced as a result of a pneumothorax.

The nurse is caring for a client who has methicillin-resistant staphylococcus aureus (MRSA) infection and is starting oral delafloxacin therapy. What health teaching would the nurse include about this drug? a. Take the drug every day until you feel better or until your fever does away b. Take the drug at least 2 hours before or 6 hours after any antacids or minerals c. Take the drug every other day as prescribed unless you feel nauseated d. If you forget a dose of the drug, wait until the next day to take the next dose

b. Take the drug at least 2 hours before or 6 hours after any antacids or minerals Delafloxacin interacts with metals such as magnesium and iron. Therefor, the drug must not be given when drugs containing metals are in the stomach

The nurse is caring for a client in a bowel retraining program. Which nursing actions will facilitate consistent defecation patterns? (Select all that apply.) a. Use digital stimulation inserting the finger into the anus for one minute b. Administering bisacodyl suppository daily c. Administer the bisacodyl suppository after the client eats a meal d. Encourage consumption of a high-fiber diet e. Insert the bisacodyl suppository just inside the anal sphincter

c. Administer the bisacodyl suppository after the client eats a meal d. Encourage consumption of a high-fiber diet Nursing actions that are part of bowel retraining include administering a bisacodyl suppository after the client eats a meal and encouraging a high-fiber diet. The bisacodyl suppository should be administered when the client would expect to defecate, such as after a meal. High-fiber meals soften the stool and can promote regularity.

The nurse is assessing a client who was diagnosed with Alzheimer disease (AD) and notes the client has difficulty finding the correct words at times during conversation. What communication alteration would the nurse document? a. Aphasia b. Apraxia c. Anomia d. Agnosia

c. Anomia Anomia is the inability to find words for objects, places, and events, and is a common assessment finding in clients with early AD. Aphasia is a general problem with speaking, understanding, to both. Apraxia is the inability to use an object correctly and agnosia, a later AD finding, is a lack of sensory comprehension.

The nurse is reviewing the history of a client who has been prescribed topiramate for prevention of migraines. The nurse plans to contact the primary health care provider if the client has which condition? a. Diabetes mellitus b. Hypothyroidism c. Bipolar disorder d. Glaucoma

c. Bipolar disorder The nurse contacts the primary health care provider after reviewing the history of a client with bipolar disorder who has been prescribed topiramate. Cases of suicide have been associated with topiramate when it is used in larger doses of 400 mg daily, most often in clients with bipolar disorder.Topiramate is not contraindicated in clients with diabetes mellitus, glaucoma, or hypothyroidism.

The medical-surgical nurse is coordinating transfer from acute care to community-based care for a client who requires rehabilitation. Which interprofessional team members will be the primary decision makers in this transition? a. Medical-surgical nurses b. Rehabilitation nurses c. Client and family d. Case managers

c. Client and family Clients in a rehabilitation setting are managed by an interprofessional team, but the client and client's family are at the center of the team and should be the primary decision makers

The nurse is caring for an older hospitalized client. Which physiologic age-relatedchange(s) increase(s) the client's risk for infection? (Select all that apply.) a. Increased cough and gag reflexes b. Urinary incontinence c. Decreased intestinal motility d. Decreased immune response e. Thinning skin

c. Decreased intestinal motility d. Decreased immune response e. Thinning skin Older clients have a decreased immune system, decreased intestinal motility, and thinning skin which make them at risk for infection, especially when hospitalized. Urinary incontinence is not a physiologic change of aging; it is a health problem that can be managed. Cough and gag reflexes are decreased rather than increased, which makes older adults at high risk for respiratory infections.

A client is scheduled for an electroencephalogram (EEG). Which instruction does the nurse give the client before the test? a. You may bring some music to listen to for distraction b. Please do not have anything to eat or drink after midnight c. Do not take any sedatives 12 to 14 hours before the test d. You will need to have someone to drive you home

c. Do not take any sedatives 12 to 14 hours before the test Before an EEG, the client needs to be instructed not to use sedatives or stimulants for 12 to 24 hours prior to the test.

Which behavior indicates to the nurse that a client preparing for discharge after surgery understands how to perform self-care to prevent harm from aspiration? a. Eats small frequent meals that include a variety of textures and nutrients b. Uses a straw when drinking liquid nutrition supplements c. Positions self upright before eating or drinking anything d. Chooses thin liquids that cause coughing but knows to take small sips

c. Positions self upright before eating or drinking anything Remaining upright while eating and drinking reduces the risk for aspiration by preventing substances from pooling in the pharynx.Drinking thin liquids and using a straw can result in excessive liquids entering the mouth more quickly than the client can swallow, which increases aspiration risk. Eating frequent meals that include a variety of textures and nutrients does not help prevent aspiration.

How will the nurse expect a client's age-related decreased skeletal muscle strength to affect gas exchange? a. Reduced gas exchange as a result of decreased alveolar surface b. Reduced gas exchange as a result of longer relaxation of bronchiolar smooth muscles c. Reduced gas exchange as a result of decreased changes in pressures of the chest cavity d. Reduced gas exchange as a result of failure of pulmonary circulation to fully perfuse lung tissue

c. Reduced gas exchange as a result of decreased changes in pressures of the chest cavity Breathing occurs through changes in the size of and pressure within the chest cavity. Contraction and relaxation of chest muscles (and the diaphragm) cause changes in the size and pressure of the chest cavity. When skeletal muscle strength is decreased in these muscles, pressure changes are decreased and less air moves in and out of the lungs. This reduced airflow limits gas exchange at the alveolar-capillary membrane. The alveolar surface itself is not decreased by weaker skeletal muscles, nor does this cause any relaxation of bronchiolar smooth muscle. Weaker skeletal muscles do not directly affect pulmonary circulation.

Which client will the nurse consider to be at greatest risk for an airway obstruction? a. A 25 y/o with a sinus infection b. A 65 y/o who has chronic mouth dryness and many dental caries c. A 35 y/o with a TBI d. A 55 y/o who wears upper and lower dentures

d. A 55 year old who wears upper and lower dentures Clients at greatest risk for an obstructed airway from any cause, including foreign body presence or mucoid impaction, are those who are unable to protect the airway, such as clients who are unconscious or with poor cognition.None of the other client factors contribute to risk for obstruction in an alert client of any age.

What is the most relevant technique for the nurse to use when assessing a client for dyspnea? a. Checking oxygen saturation by pulse oximetry b. Observing the client's rate, depth, and ease of inhalation and exhalation c. Comparing previous respiratory assessment information with current data d. Asking the client about whether any breathlessness is present

d. Asking the client about whether any breathlessness is present Dyspnea, difficulty in breathing or breathlessness, is a subjective perception and varies among clients. Thus, only the client can rate his or her level of dyspnea.The other measures listed for assessment of respiratory status and adequacy of ventilation and oxygenation are objective measures.

What is the nurse's best first action when finding that a client's skin flap created after laryngectomy now appears dusky in color? a. Massaging the flap site gently with the palms rather than the fingers b. Notifying the surgeon or the primary health care provider c. Applying moist heat over the flap site and surrounding tissue d. Assessing blood flow in the flap using a Doppler device

d. Assessing blood flow in the flap using a Doppler device A complete assessment of the area, including Doppler activity of major feeding vessels, needs to be completed before the surgeon is notified.Neither hot nor cold packs nor dressings (nor anything, for that matter) should be applied to the flap site. The site is delicate and should not be massaged.

The nurse has just received report on a group of clients on the neurosurgical unit. Which client is the nurse's first priority? a. Client who consistently demonstrates decortication when stimulated b. Client whose deep tendon reflexes have become hyperactive c. Client who displays plantar flexion when the bottom of the foot is stroked d. Client whose Glasgow Coma Scale has changed from 15 to 13

d. Client whose Glasgow Coma Scale (GCS) has changed from 15 to 13. After receiving report on a group of clients, the nurse's first priority is to assess the client whose GCS has changed from 15 to 13. A decrease of two or more points in the Glasgow Coma Scale total is clinically significant and indicates a major change in neurologic status. This finding must be reported immediately to the primary health care provider (PHCP).The client with hyperactive reflexes, the client displaying plantar flexion when the bottom of the foot is stroked, and the client with decortication upon stimulation will need to be assessed, but they do not require immediate attention.

Which information is most important for the nurse to communicate to the primary health care provider about a client who is scheduled for CT angiography? a. Allergy to penicillin b. History of bacterial meningitis c. The client's dose of metformin held today d. Poor skin turgor and dry mucous membranes

d. Poor skin turgor and dry mucous membranes The most important information for the nurse to communicate to the PCP about a client scheduled for a CT angiography is the client with poor skin turgor and dry mucous membranes. This assessment indicates dehydration which places the client at risk for contrast-induced nephropathy.Allergy to penicillin, history of bacterial meningitis, and withheld metformin will need to be reported as part of the client hand-off to radiology.

What is the nurse's best first action on finding the client's oxygen saturation by pulse oximetry on the finger is 84%? a. Apply supplemental oxygen by mask or nasal cannula b. Notify the Rapid Response Team immediately c. Assess the client's cognitive function d. Recheck the value on the forehead

d. Recheck the value on the forehead Although a true low oxygen saturation is an emergency, there are many causes of a low reading using pulse oximetry. The value should be verified immediately before any interventions are implemented.

The nurse is reinforcing the physical therapist's teaching on gait training for a client who had a total knee replacement 6 weeks ago. Which ambulatory aid does the nurse expect the client to be using? a. Walker with rollers b. Crutches c. Walker with built-in seat d. Straight Cane

d. Straight Cane A straight cane is the most likely ambulatory aid for a client who is 6 weeks post-surgery from a knee replacement. The client should be weight bearing, with some assistance, on the affected leg.

Which primary health care provider's instruction will the nurse question for a client being discharged with nasal packing in place after a posterior nosebleed? a. Sleep in a recliner or with the head in an elevated position b. Go to the nearest emergency room if bleeding recurs c. Use a home humidified for at least 5 days d. Take ibuprofen 800 mg every 8 hours as needed for pain

d. Take ibuprofen 800 mg every 8 hours as needed for pain. The nurse must question the prescription for ibuprofen. Ibuprofen is contraindicated in a client with a nosebleed because NSAIDs inhibit clotting and increase the risk for bleeding.Elevation of the head of the bed is recommended for client comfort and to facilitate drainage of secretions. Humidified air is recommended because dryness of the nasal mucosa can be a cause of epistaxis (nosebleed). Recurrence of excessive bleeding from posterior epistaxis is an emergency.

Which type of ADL assistance will the nurse plan for a client with long-standing pulmonary problems who has Class IV dyspnea? a. Dyspnea is minimal and no assistance is required b. The client is severely dyspneic at rest and cannot participate in any self-care c. The client may complete ADLs without assistance but requires rest periods during performance d. The client is severely dyspneic with activity and requires assistance for bathing and dressing

d. The client is severely dyspneic with activity and requires assistance for bathing and dressing Class IV dyspnea occurs during usual activities, such as showering and dressing, and requires assistance from others. Dyspnea is usually not present at rest, but is with minimal exertion.