Medsurg Reduction of Risk
A nurse is caring for a client who is scheduled for an electroencephalogram (EEG). Which statement by the client indicates a need for further education? Select one: a. "I will not eat or drink anything after midnight." b. "I will expect the procedure to be painless." c. "A tracing will be obtained to evaluate my brain activity." d. "I should wash my hair on the morning of the test."
a. "I will not eat or drink anything after midnight."
A nurse is providing discharge instructions to a client following cataract surgery. Which of the following statements by the client indicates the need for further teaching? Select one: a. "I will wear my bi-focal glasses when sitting outside on the deck." b. "I will report pain accompanied with nausea/vomiting." c. "I will avoid rapid, jerky movements such as vacuuming." d. "I will report a yellow or green discharge."
a. "I will wear my bi-focal glasses when sitting outside on the deck." This statement indicates the need for further teaching. Sunglasses should be worn outside or in brightly lit areas due to light sensitivity.
A client diagnosed with diabetes mellitus reports feeing shaky. Further assessment reveals diaphoresis, tachycardia, and a glucose level of 70 mg/dL. Which of the following should the nurse administer to prevent a hypoglycemia reaction? Select one: a. 6 ounces of orange juice b. 1 cup of whole milk c. 2 pieces whole grain toast d. 1 tablespoon of peanut butter
a. 6 ounces of orange juice The recommendation for treatment of hypoglycemia is for 10 to 15 g of a fast-acting, simple carbohydrate orally, such as three or four commercially prepared glucose tablets; 4 to 6 oz of fruit juice or regular soda; 6 to 10 hard candies; or 2 to 3 tsp of sugar or honey.
A client diagnosed with cervical cancer is prescribed a loop electrosurgical excision procedure (LEEP). Following the procedure, which of the following findings should the nurse instruct the client to report to the provider? Select one: a. Elevated temperature. b. Clear vaginal drainage. c. Mild pelvic pain. d. Spotting of blood.
a. Elevated temperature. The client should be instructed to report any heavy vaginal bleeding, foul-smelling discharge or fever.
A nurse is reinforcing teaching with a client who has been recently diagnosed with osteoporosis. Which of the following should be included? Select one: a. Eliminate safety hazards in the home b. Increase intake of dietary calcium c. Long-term estrogen replacement therapy will be required. d. Walking for one to two hours daily is recommended.
a. Eliminate safety hazards in the home
A nurse is caring for a client post aortofemoral bypass surgery. Which of the following interventions would be contraindicated? Select one: a. Encouraging client to sit in high Fowler's position. b. Monitoring client for changes in blood pressure. c. Maintaining NPO status until first postoperative day. d. Coughing and deep breathing every 1 to 2 hours.
a. Encouraging client to sit in high Fowler's position. Following an aortofemoral bypass surgery, the nurse should instruct the client to limit bending of the hip and knee to decrease the risk of clot formation.
A client is discharged following a cardiac catheterization procedure. Which of the following should the nurse include in the discharge teaching? Select one: a. Limit activity for several days after the procedure. b. Remove dressing the evening of the procedure. c. Notify provider if bruising is noted at the site. d. Tub baths the night following the procedure are acceptable.
a. Limit activity for several days after the procedure. The client should limit activity for several days after the procedure (avoiding lifting and exercise) to prevent bleeding of insertion site.
A nurse is caring for a client with dementia who has just returned from the postanesthesia care unit (PACU). Which of the following would be appropriate during the initial pain assessment? Select one: a. Observing the client's facial expressions. b. Asking the client to rate the pain on a scale of one to ten. c. Asking the client to rate the pain using a faces scale. d. Assessing the client's vital signs.
a. Observing the client's facial expressions. The American Geriatrics Society Panel found six common indicators that should be assessed in the cognitively impaired client: facial expressions (grimacing, crying); vocalizations (screaming); body movements (restlessness); changes in interpersonal interactions; changes in activity patterns or routines; mental status changes (increased confusion).
A nurse is caring for a client at risk for atelectasis. Which of the following should the nurse monitor for manifestations of atelectasis? Select one: a. Pulse oximetry b. Daily weight c. Intake and output d. Lung sounds
a. Pulse oximetry
A nurse is caring for a client is recovering from a surgical procedure. Which of the following indicates that the client is experiencing orthostatic hypotension? Select one: a. Client reports leg discomfort when ambulating. b. A decrease in systolic pressure when changing positions. c. An increase in diastolic pressure when changing positions. d. A client reporting feelings of weakness when standing for the first time after surgery.
b. A decrease in systolic pressure when changing positions.
A nurse is preparing a bolus tube feeding for a client with a gastrostomy tube. Which of the following would be an appropriate action? Select one: a. Assess the blood glucose before administering the feeding. b. Check gastric pH to assess placement of gastrostomy tube. c. Don sterile gloves when adding feeding to the system. d. Flush tubing with a small amount of saline before feeding.
b. Check gastric pH to assess placement of gastrostomy tube. Checking the pH of the aspirate is currently a preferred method for placement after a x-ray has confirmed placement. If the correct position of the tube is in question, x-ray should be utilized to confirm placement.
A nurse is caring for a client with a new onset bowel obstruction. What assessment finding would be anticipated when completing an abdominal assessment? Select one: a. Absent bowel sounds. b. Hyperactive bowel sounds. c. Normal bowel sounds. d. Hypoactive bowel sounds.
b. Hyperactive bowel sounds. Early obstruction is accompanied by heightened peristaltic action as the intestines attempt to propel contents forward. As a result, hyperactive bowel sounds are an expected finding in this stage of obstruction.
A client is admitted to the hospital with a diagnosis of Grave's disease. Which of the following findings should be reported to the provider immediately? Select one: a. Hyperactive deep tendon reflexes b. Increase in temperature from 99.5 F to 100.5 F c. Increased number of stools d. Increase in white blood cell count from 6,000 mm3 to 8,000 mm3
b. Increase in temperature from 99.5 F to 100.5 F An increase in body temperature of even one degree should be reported to the provider immediately as it can signify the onset of 'thyroid storm'.
A nurse is evaluating placement of a nasogastric (NG) tube. Which of the following is the least reliable method to determine correct NG tube placement? Select one: a. Aspirate to collect gastric content. b. Inject air into tube and listen over abdomen. c. Ask the client to talk. d. Test pH of gastric contents.
b. Inject air into tube and listen over abdomen.
A client who has been experiencing prolonged vomiting has the following ABG results: pH 7.48; pCO2 40 mm Hg; HCO3 34 mEq/L; pO2 85 mm Hg. The nurse determines that the client is experiencing which of the following imbalance? Select one: a. Respiratory Alkalosis b. Metabolic Alkalosis c. Respiratory Acidosis d. Metabolic Acidosis
b. Metabolic Alkalosis Alkalosis is reflected by an arterial pH greater than 7.45. Because this client has an increase in the base component, HCO3, this is a metabolic alkalosis. Metabolic alkalosis results from: • Base excess - Oral ingestion of bases (antacids) - Venous administration of bases (blood transfusions, TPN, or sodium bicarbonate) - Acid deficit - Loss of gastric secretions (through prolonged vomiting, NG suction) - Potassium depletion (due to thiazide diuretics, laxative abuse, Cushing's syndrome) - Metabolic alkalosis results in: - Increased HCO3
A client is undergoing cystoscopy. Which of the following interventions should the nurse include in the client's plan of care? Select one: a. Provide education on home urinary catheter care. b. Monitor for infection for 48-72 hours following procedure. c. Increase oral fluid intake to flush contrast dye from system. d. Educate client on the need for anticoagulant therapy.
b. Monitor for infection for 48-72 hours following procedure. Instrumentation of the urinary tract increases the risk of infection so this client should be monitored for s/s of infection for several days following the procedure.
A nurse is caring for a client who is having difficulty swallowing. Which intervention is effective in preventing injury? Select one: a. Weigh the patient weekly. b. Position in High Fowler's for meals. c. Discourage visitors at meal time. d. Observe for evidence of aspiration.
b. Position in High Fowler's for meals. Clients with dysphagia are at risk for aspiration and need more assistance with feeding and swallowing. The client should be positioned in an upright, seated position in a chair or the HOB should be raised to 90 degrees at mealtime. Flexing the head to a chin-down position also helps prevent aspiration.
A nurse is caring for a client who is taking furosemide for heart failure. Which of the following statements by the client indicates a need for further instruction? Select one: a. "I will eat an orange each day with my breakfast." b. "I will call my provider if I gain 2 pounds in one day." c. "I will take my medication before I go to bed." d. "I will drink at least 8 ounces of water with each meal."
c. "I will take my medication before I go to bed." This statement indicates a need for more education. Clients who are taking furosemide should be instructed to take their medication in the morning (or at 0800 and 1400 if using twice a day dosing). Dosing medication in this manner is done to minimize nocturia.
A client is scheduled for surgery. Which of the following findings should the nurse report to the provider prior to surgery? Select one: a. Serum potassium of 3.8 mEq/L b. Increased anxiety level c. A decrease in blood pressure d. A missing identification band
c. A decrease in blood pressure A decrease in blood pressure outside should be reported to the provider prior to surgery. This is an indicator of a potential complication and surgery may need to be postponed.
Reduction of Risk: ARDS A client is recovering from acute respiratory distress syndrome (ARDS). Which clinical manifestation requires immediate attention by the nurse? Select one: a. Increased oxygen saturation b. Increase in pulse rate c. A decrease in blood pressure d. A decrease in temperature
c. A decrease in blood pressure Hypotension is commonly a result of hypovolemia. This reaction requires immediate intervention secondary to the leakage of fluid into the interstitial space causing a depressed cardiac output.
Following a TURP (transuretheral resection of the prostate) with CBI (continuous bladder irrigation), the client states he has severe lower abdominal cramping. Which of the following actions should the nurse take first? Select one: a. Increase the flow of the irrigate b. Discontinue the bladder irrigation c. Check the catheter for kinks d. Irrigate the catheter
c. Check the catheter for kinks observing for kinks is the best first action and following a TURP, CBI is ordered to keep the catheter free of obstructions and is necessary.
A nurse is providing education to a client with coronary artery disease. Which of the following cholesterol values should the nurse identify as a goal for this client? Select one: a. HDL-C level 20 mg/dL b. LDL-C level 120 mg/dL c. HDL-C level 60 mg/dL d. LDL-C level 98 mg/dL
c. HDL-C level 60 mg/dL
A client is prescribed TPN (total parenteral nutrition) to be infused through a single lumen PICC (peripherally inserted central catheter). Which of the following actions should the nurse take if the client is prescribed intravenous antibiotic therapy? Select one: a. Stop the TPN to administer the antibiotic as ordered. b. Administer the antibiotic through the TPN line. c. Identify alternative methods of administration. d. Request the provider insert a second PICC line.
c. Identify alternative methods of administration. The nurse should seek out alternative methods of administration and then collaborate with the provider.
A nurse is providing care for a client with a Jackson-Pratt drain. Which of the following nursing interventions has the highest priority? Select one: a. Securing the tubing and drainage bulb to the client. b. Cleansing the insertion site of the tube with betadine. c. Keeping the drainage bulb depressed to manual suction. d. "Milking" the tubing before emptying the drain.
c. Keeping the drainage bulb depressed to manual suction. maintaining the bulb to suction is this highest priority nursing intervention.
A client diagnosed with diabetes mellitus consumed less than 50% of the lunch tray and reports feeling shaky. Which of the following is the first action the nurse should take? Select one: a. Provide a low carbohydrate snack b. Notify the charge nurse c. Obtain a blood glucose reading d. Observe for signs of hypoglycemia
c. Obtain a blood glucose reading Obtaining a blood glucose reading is necessary for the client demonstrating signs of hypoglycemia the first action taken.
A nurse is caring for a client with heart failure. Which of the following interventions should the nurse take if the client is experiencing dyspnea? Select one: a. Obtain serial ABGs every 8 hours. b. Perform coughing and deep breathing exercises every 8 hours. c. Place client in high Fowler's position. d. Place client in the reverse trendelenberg position.
c. Place client in high Fowler's position. Placing the client with dyspnea in a high Fowler's position will maximize chest expansion and improve oxygenation.
A nurse is caring for a client with newly diagnosed diabetes mellitus. Which of the following client statements demonstrates understanding of self-blood glucose monitoring? Select one: a. "I can use my wife's blood glucose meter as long as I use my test strips." b. "I will check my blood sugar before dinner each day." c. "I only need to check my blood sugar when I feel dizzy." d. "I will check my blood sugar at the same times each day."
d. "I will check my blood sugar at the same times each day." While frequency of testing varies with prescribed drug therapy and blood glucose goals, checking the blood glucose at the same times each day will yield the most accurate information.
A client is having an exercise electrocardiography (stress test) performed. The nurse recognizes the need to stop the test if which of the following occurs? Select one: a. The client begins to breathe harder b. The client experiences an increase in heart rate. c. QRS complexes begin to occur more frequently. d. An ST segment depression or T wave inversion on the EKG.
d. An ST segment depression or T wave inversion on the EKG. Significant ST segment depression or T wave inversion are indications of myocardial ischemia and the stress test should be stopped
A nurse is caring for a client who underwent a right below the knee amputation yesterday. Which of the following findings should the nurse report to the provider immediately? Select one: a. Quarter size spot of blood on dressing b. White blood cell count of 10,000 mm3 c. Redness of the incision site d. Blood glucose 200 mg/dL
d. Blood glucose 200 mg/dL Hyperglycemia impairs healing and can increase risk of infection.
A client experiencing intermittent chest pain has been admitted to the hospital. Which of the following laboratory values should the nurse report to the health care provider immediately? Select one: a. Creatine kinase (CK) 90 units/L b. C-reactive protein (CRP) 0.2 mg/dL c. Total myoglobin 60 mcg/L d. Cardiac troponin T 1.2 ng/mL
d. Cardiac troponin T 1.2 ng/mL Normal range for cardiac troponin T is < 0.20 ng/mL. The value listed in choice C is significantly elevated and indicates myocardial injury or infarction and should be reported to the provider immediately.
A nurse is caring for a post-operative client who underwent thoracic surgery 7 hours prior, and now has in place a chest tube for drainage. What finding would require the nurse to contact the provider immediately? Select one: a. Chest tube and tubing become disconnected during client transfer. b. Diminished breath sounds auscultated in left lower lobe. c. Client complains of left-sided chest pain of 7 on pain scale when performing incentive spirometry. d. Chest tube drainage measures 80 mls an hour of red blood.
d. Chest tube drainage measures 80 mls an hour of red blood. The client is 7 hours post-operative the drainage should be tapering off at approximately 30 mls an hour. This is an indication of hemorrhage and the provider needs to be contacted immediately.
A nurse is caring for a client with severe peripheral arterial disease of the right lower extremity. Which intervention is appropriate? Select one: a. Apply cold compresses to the affected extremity. b. Apply warm compresses to the affected extremity. c. Keep the affected extremity above the level of the heart. d. Keep the affected extremity below the level of the heart.
d. Keep the affected extremity below the level of the heart. The affected extremity should be kept lower than the level of the heart to enhance arterial blood flow to the feet.
Physiological Integrity: COPD, Oxygen Therapy A client diagnosed with chronic obstructive pulmonary disease (COPD) is reporting shortness of breath upon exertion. The client is prescribed oxygen at 3 L/min and his oxygen saturation level is measuring 86%. The nurse understands which of the following is the priority intervention? Select one: a. Teach the client to eat several small meals a day. b. Encourage the client to stop smoking. c. Increase oxygen from 3L/min to 6 L/min. d. Position the client in the high-Fowlers.
d. Position the client in the high-Fowlers. Clients with COPD should be positioned in the high-Fowler's position in order to maximize ventilation. High-Fowler's is 90º.
A client is receiving chemotherapy for the treatment of breast cancer. Which of the following findings should be reported to the provider immediately? Select one: a. Mucositis b. Alopecia c. Absolute neutrophil count 8,000/mm3 d. Temperature 38.1°C
d. Temperature 38.1°C
A client is admitted to the inpatient care unit with a diagnosis of diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect? Select one: a. Serum pH 7.40 b. Serum glucose 200 mg/dL c. Low serum osmolality d. Urine ketones positive
d. Urine ketones positive DKA is an acute, life-threatening condition characterized by hyperglycemia (greater than 300 mg/dL) resulting in the breakdown of body fat for energy and an accumulation of ketones in the blood and urine.