MEDICAL SURGICAL2 MIDDLE TERM 2
The nurse is reinforcing education for a female client paralyzed from a spinal cord injury (SCI). What statement made by the client demonstrates understanding of the education?
"I may begin to menstruate within 3 months following my injury."
The nurse explains to a client receiving packed RBCs that the blood product is produced by centrifuging (spinning) whole blood, which forces the RBCs to the bottom of the container. For which client would packed RBCs be the best choice?
) A client who has anemia
In which disease would the D antigen be particularly important?
) Erythroblastosis fetalis
A nurse is educating a client being treated for lymphoma about the side effects of antineoplastic drugs used for the treatment. Which is a common side effect of antineoplastic drug therapy?
) Neutropenia
Which is a sign of internal bleeding?
) Rapid pulse
The nurse is obtaining data from a client with fluid volume excess. When the nurse presses against the lower left leg, a slight indent remains for a second. How should this be documented?
+1 pitting edema
The nurse is reinforcing education regarding the use of eye drops during treatment for a client who has been diagnosed with conjunctivitis. What is a priority for the nurse to include?
. Be sure not to touch the eye with the dropper.
The nurse is assisting a visually impaired client with meals. What nursing interventions will assist the client with maintaining independence and dignity? Select all that apply.
. Place food in the same "clock position" on the plate./Tell the client what is being served./Tell the client where food is located.
The nurse is caring for a client who is admitted to the CICU after experiencing a myocardial infarction. The cardiologist has ordered three troponin laboratory tests over a 12- to 16-hour time frame. How soon do troponin levels rise following the onset of pain?
3 to 4 hours
The nurse is caring for a client following a supratentorial craniotomy, in which a large tumor was removed from the left side. In which position can the nurse safely place the client? Refer to Figures.
A
Which client would be at greatest risk for developing non-Hodgkin Lymphoma (NHL)?
A client who is undergoing immunosuppressive drug therapy
The nurse is caring for a client who has had a thyroidectomy with removal of the parathyroids. After observing positive Trousseau and Chvostek signs, what action should the nurse take? Group of answer choicesa. Administer morphine sulfate as ordered.
Administer calcium gluconate as ordered.
A client is admitted with vomiting and diarrhea and the nurse observes a potassium level of 2.9 mEq/L. What is an appropriate nursing action?
Administer potassium supplementation IV as ordered.
The nurse is caring for a client who was hit in the left eye with a softball. The eye is edematous and painful to touch. What is the priority intervention by the nurse?
Apply a cold pack.
The nurse is assisting with preparing a teaching plan for the client with diabetes mellitus regarding proper foot care. Which instruction should be included in the plan of care?
Apply a moisturizing lotion to dry feet, but not between the toes.
A client is scheduled for a cerebral angiogram where radiopaque dye will be utilized. What nursing intervention is essential before the client is transported for the test?
Ask the client if he or she is allergic to shellfish or iodine.
A client with varicose veins has recently undergone surgery. What information should the nurse include in the discharge teaching after venous stripping?
Avoid sitting for a lengthy time.
A client is diagnosed with leukemia. Which should the nurse include in the client teaching?
Avoidance of persons who are ill
A client is diagnosed with arthritis and wants to maintain an active lifestyle. What exercises should the nurse recommend to the client? Select all that apply.
Bicycling/Slow walking
A male client, aged 58 years, arrives at the community clinic reporting cramps in the calf muscles while exercising that subside with rest. During the assessment, the nurse understands that the client is a heavy smoker and observes hardened, painful areas along the course of blood vessels. The symptoms experienced by the client indicate what disorder?
Buerger disease
The femoral site was used to perform an angiocardiogram on a client with atherosclerosis. Which nursing consideration is recommended following the surgery?
Check peripheral pulses distal to the site and the color and warmth of the extremity.
A child has been treated for head lice but has remaining nits attached to the hair shaft. What should the nurse instruct the parent to do?
Comb the hair with a fine tooth comb.
A client is at risk for fluid volume excess related to heart failure. What information can the nurse provide to the client to assist with prevention of this occurrence?
Comply with diuretic therapy.
A client is scheduled for a bleeding time test. For which reasons is this test is performed? Select all that apply
Detect platelet disorders/Diagnose infections/) Evaluate for capillary defects/Determine ability to stop bleeding.
The nurse is caring for a client who has had a lower extremity amputation. What intervention by the nurse will best prevent hip contractures?
Do not place a pillow under the residual limb.
A client is hyperventilating and has a pH of 7.52 and a PCO2 of 68 mm HG. What intervention by the nurse will assist in correcting this acid-base imbalance?
Have the client use a rebreather mask.
The nurse is caring for a client who is diagnosed with sinus bradycardia. What are the criteria for this diagnosis?
Heartbeat is <60 beats per minute
The nurse is administering heparin to a client who has had a cerebrovascular accident (CVA). For which complications should the nurse monitor this client?
Hemorrhage
A client who is a heavy smoker is living in a high-altitude area. A red blood cell count confirms a diagnosis of secondary polycythemia. What condition causes this blood disorder?
Hypoxia
The nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the priority?
Immobilize the leg before moving the client.
The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising?
Increasing temperature, decreasing pulse, decreasing respirations, increasing BP
The nurse is caring for a client after undergoing a total thyroidectomy. What action should the nurse take to prevent complications? Select all that apply.
Inspect dressings for excessive bleeding./Check for edema in the neck./Keep an endotracheal tube at the bedside.
The nurse is documenting the blood type of a newborn as "type O." Which statement describes the antigens and antibodies related to this blood type?
It does not have the A or B antigen, but it does have the anti-A and the anti-B antibody.
The nurse is administering nifedipine to a client diagnosed with stage II hypertension. What is the therapeutic action of this medication?
It slows cardiac conduction through the AV node, which decreases heart rate, dilates peripheral arteries, and decreases peripheral vascular resistance.
A client developed angioedema after taking lisinopril. What priority nursing action is essential when caring for this client?
Maintain a patent airway.
A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply
Pad the bed's side rails./Place an airway at the bedside./Place oxygen equipment at the bedside/Place suction equipment at the bedside.
The nurse is observing a client with a calcium level of 4.2 mEq/L. What clinical manifestations may correlate with this level? Select all that apply.
Paresthesia/ Hypotension/Tetany
The nurse is caring for a client postoperatively who has had cervical decompression. What statements by the client should the nurse immediately report to the primary care provider? Select all that apply.
Reports of change in sensation of arms/Difficulty breathing/. Difficulty moving arms
A client who has been newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. Which teaching information should the nurse reinforce upon discharge?
Rotate the insulin injection sites systematically.
The nurse is assisting with caring for a client after a craniotomy. Which is the best position for the client to be placed?
Semi-Fowler's position
The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding?
Serous drainage
The nurse reinforces teaching with a client with diabetes mellitus regarding differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that glucose will be taken if which symptom develops?
Shakiness
The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action?
Stay with the person and encourage the person to remain still.
A client is being considered as a candidate for a cochlear implant. What data gathered by the nurse would support the client's candidacy?
The client is unable to recognize words spoken.
The nurse is requested to place an ice pack on the eyelid for 2 minutes for a client suspected of having myasthenia gravis (MG) with diplopia. What outcome does the nurse anticipate if the diagnosis is confirmed?
The client will have a temporary improvement in eye symptoms.
The primary care provider orders ear irrigation for a client. What situation requires the nurse to question this order?
The eardrum may be punctured.
A client is prescribed hydroxyzine HCL for the treatment of pruritus. What information should the nurse provide to the client? Select all that apply
The medication may cause drowsiness./Drink water, juice, and other fluids./Use sunscreen when exposed to the sun.
A client with type 1 diabetes has a consistent glucose reading of 200 to 320 mg/dL. For what test should the nurse prepare the client?
Urine for detection of ketones
The nurse is caring for a client with herpes zoster. What priority measures to avoid cross-contamination should the nurse provide
Use transmission-based precautions.
A client is suspected of developing diabetes insipidus after sustaining a head injury. What observation made by the nurse should be documented that supports the diagnosis of diabetes insipidus? Select all that apply.
Voiding 20 L in 24 hours
