MedSurge
A nurse is providing discharge instructions to a client who developed deep-vein thrombosis (VT) postoperatively and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include?
Flexing her knees and feet frequently
A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?
Movement of the trachea toward the unaffected side
A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following information should the nurse include in the teaching?
"You may experience a small amount of bleeding around the stoma."
A nurse is providing instructions to a client who has a new prescription for sublingual nitroglycerin (Nitrostat) to treat angina pectoris. Which of the following instructions should the nurse include?
"Avoid taking the medication prior to exercising.
A nurse is caring for a client following the surgical placement of a colostomy. What statement by the client indicates understanding of the dietary teaching?
"Eating yogurt can help decrease the amount of gas that I have" Rationale: The client who has a colostomy can include yogurt into his diet to help reduce odors and intestinal gas.
A nurse is reinforcing teaching about ileostomy care with a client. The nurse should recognize which of the following statements by the client indicates a need for further teaching?
"I will be certain to take enteric-coated medications."
A nurse is providing teaching about the Mediterranean diet to a client who has a new diagnosis of hypertension. Which of the following statements by the client indicates a need for further teaching?
"I will limit my intake of red meat to twice weekly."
A nurse is caring for a client who is scheduled for an exercise stress test. Which of the following comments made by the client should indicate to the nurse that the client requires further teaching?
"I'll take my heart medications the morning of my test.'
A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching?
"Increasing my intake of foods containing trans-fatty acids can lower my risk."
A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching?
"Increasing my intake of foods containing trans-fatty acids can lower my risk.'
A nurse is preparing a client for magnetic resonance imaging (MRI) of the heart and great vessels. Which of the following instructions should the nurse include about this test?
"It requires removing metal objects like jewelry.'
A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity?
"My vision seems yellow."
A nurse is providing information regarding transmission-based precautions for a client who has Clostridium difficile to assistive personnel (AP). Which of the following instructions should the nurse include? (SATA)
"Provide the client with disposable utensils and dishes for meals." "Leave blood pressure equipment in the client's room" "Clean contaminated surfaces with a bleach solution"
A nurse is providing teaching to a client who has a new colostomy. What information should the nurse include in the teaching?
"You may experience a small amount of bleeding around the stoma" Rationale: A small amount of bleeding around the stoma and its stem can occur. However, the client should report an increase in bleeding to the surgeon
A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder?
A. Hypertension B. Obesity C.Smoking
A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia
A. Abnormally prominent U wave
A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply.)
A. Count your pulse for 1 min each morning. C. Do not wear tight clothing over the insertion area. D. Request to be scanned with a handheld metal detector when in the airport.
A nurse is reinforcing teaching with a client that reports having constipation. Which of the following should the nurse discuss as causes of constipation? Select all that apply?
A. Excessive laxative use B. Ignoring the urge to defecate C. Inadequate fluid intake
A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?
A. Febrile
A nurse in an emergency department is assessing a client who 1s having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select all that apply.)
A. Orthopnea C. Nausea E. Diaphoresis
A nurse is caring for a male client who has peripheral vascular disease (PVD), is taking dietary supplements and has a new prescription for warfarin. The nurse should instruct the client to stop which of the following supplements prior to starting the warfarin? (Select all that apply.)
A. Saw palmetto C. Glucosamine E. Gingko biloba
A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds?
A. The fourth heart sound (S4)
A nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave?
Atrial depolarization
A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia!
Atropine
A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?
Atropine
A nurse is caring for a client who has ulcerative colitis and is teaching the client about common link with Crohn's disease. What information should the nurse include?
Both are inflammatory diseases Rationale: The nurse should inform the client that both disease processes are an inflammatory process of the GI tract
A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis?
C. Hip arthroplasty
A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first?
Attach the leads for a 12-lead ECG.
A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching?
Avoid medications in capsule or enteric form.
A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe?
B-type natriuretic peptide (BNP)
A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?
B. Different apical and radial pulses.
A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?
B. Massaging her legs
A nurse is caring for a client who is postoperative following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus?
B. Positive Homan's sign
A charge nurse is reinforcing teaching with a newly licensed nurse about the common link between ulcerative colitis and Crohn's disease. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
Both illnesses are inflammatory in nature
A nurse is caring for a client who has valvular heart disease and is at risk for developing left- sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition?
Breathlessness
A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification?
Bumetanide 1 mg IV bolus every 12 hr
A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?.
C. "DIC is caused by abnormal coagulation involving fibrinogen."
A nurse is reviewing a client's laboratory results and finds the hemoglobin is 10 g/dL and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following?
Cellular hypoxia
A nurse is reinforcing discharge teaching with a client who has a new diagnosis of gastroesophageal disease (GERD). Which of the following foods should the nurse include in the list of foods the client should avoid?
Chocolate
A nurse is caring for a client who has a history of chronic ulcerative colitis and has a new diagnosis of anemia. The nurse should explain to the client that which of the following manifestations of colitis can result from anemia?
Chronic blood loss
nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip
Pacemaker spikes after each QRS complex
A nurse is caring for a client who is postoperative and has a Jackson-Pratt drain. Which of the following actions should the nurse take?
Compress the bulb reservoir and then close the drainage valve.
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
D. Increased clotting factors
A nurse is caring for a client who has infective endocarditis. Which of the following manifestations is the priority for the nurse to monitor for?
Fever
A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication?
Decreased potassium
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?
Dependent edema
A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect?
Dependent edema
A nurse is caring for an older adult client who has right-sided heart failure. Which of the following assessment findings should the nurse expect?
Dependent edema
A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?
Different apical and radial pulses.
A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?
Elevated central venous pressure (CVP).
A nurse is reviewing the medical record of a client who has acute pancreatitis. Which of the following findings should the nurse anticipate?
Elevated serum amylase level
A nurse is demonstrating colostomy care to a client who has a new colostomy. Which of the following actions should the nurse teach the client to perform? (Select all that apply).
Empty the bag when it is one-third to one-half full Cut the skin barrier opening a little larger than the ostomy Wash the peristomal skin with mild soap and water
A patient in asystole is likely to receive which drug treatment?
Epinephrine and atropine
A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following actions is the priority?
Evaluate fluid and electrolyte levels.
A nurse is collecting date from a client who has manifestations of appendicitis. Where should the nurse palpate to monitor for pain at McBurney's point?
Found between the navel and the anterior iliac crest
A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?
Have the client lie flat in bed.
A nurse in a provider's office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions?
Heart failure
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
Increased clotting factors
A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective?
Increased heart rate
A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect?
Irregular
A nurse is assessing a male client who has advanced peripheral artery disease (PAD). Which of the following findings should the nurse expect?
Leg pain at rest
A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarity!
MRI of the chest
A nurse in an emergency department is planning care for a client who 1s having an acute myocardial infarction (MI). The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety?
Nitroglycerin
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mFq/L Which of the following actions should the nurse take?
Obtain a 12-lead ECG.
A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action?
Obtain a stool specimen with gloves
A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding?
Obtain a venous duplex ultrasound.
A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take?
Obtain an EKG.
A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting. Which of the following medications should the nurse administer prior to chemotherapy?
Ondansetron
A nurse is planning care for a client who has a peptic ulcer and a new prescription for sucralfate 2 gm administrated twice daily. Which of the following times should the nurse plan to administer the medication?
One hour before breakfast and the evening meal
A nurse is planning care for a client who has a peptic ulcer and a new prescription for sucralfate 2 gm administrated twice daily. Which of the following times should the nurse plan to administer the medication?
One hour before breakfast and the evening meal.
A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?
Pacemaker spikes after each QRS complex
A nurse is providing teaching to a client with a colostomy about appropriate food choices. What foods should the nurse include in the teaching?
Pasta Rationale: Pasta may thicken stool and is an appropriate food choice for a client with a colostomy.
A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?
Perform a 12-lead ECG
A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time?
Place the client on his left side in Trendelenburg position.
A nurse is reviewing the serum laboratory findings for a client who has hypertension and is prescribed hydrochlorothiazide. Which of the following findings should the nurse report to the provider?
Potassium 2.3 mEq/L
A nurse is assisting with the plan of care for a client who has viral hepatitis. Which of the following actions should the nurse include in the plan?
Provide periods of rest.
A nurse is collecting data from a client who is 12 hr postoperative following a colectomy with colostomy placement. Which of the following findings should the nurse report to the provider?
Purplish colored stoma
A nurse in a PACU is assessing a client who has a newly created colostomy. What finding should the nurse report to the provider?
Purplish-colored stoma Rationale: A stoma that is purplish in color indicates ischemia. The nurse should notify the provider immediately.
A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. If this medication is effective, the nurse should expect which of the following changes on the client's ECG?
Reduction of T-wave amplitude
Which of the following food choices would be allowed for a patient with celiac disease?
Rice Rationale: because rice is naturally gluten-free, it is an acceptable food choice for a child who has celiac disease
A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point.
Right lower quadrantRationale: McBurney's point is located by drawing a line from the navel to the right iliac crest.
Suspected stomach perforation due to a peptic ulcer s/s:
Rigid abdomen Tachycardia Rebound tenderness
A client with peptic ulcer disease has a new NG tube in place with orders for NG tube monitoring for the nurse. What is an expected finding?
Scant blood may be seen for the first 12-24 hrs
A nurse is collecting data from a client who has peptic ulcer disease. Which of the following findings is a manifestation of gastrointestinal perforation?
Severe upper abdominal pain
A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?
The P wave falls before the QRS complex.
A nurse is monitoring the cardiac output of a client who has left-sided heart failure using pulse pressure analysis. Which of the following findings can compromise the readings?
The client is experiencing premature atrial contractions.
A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include?
The client should hold his cell phone on the side opposite the ICD.
A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include?
The client should hold his cell phone on the side opposite the ICD.
A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds?
The fourth heart sound (S4)
A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?
The laboratory values are prolonged.
A nurse is assessing a client who has a colostomy. What findings should the nurse report to the provider?
The stoma is pale in color Rationale: The stoma should be pinkish to cherry red in color, which indicates an adequate blood supply. If the stoma becomes, pale, bluish, or dark, the nurse should report this finding to the provider immediately.
A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzyme studies?
These tests help determine the degree of damage to the heart tissues."
A nurse is reinforcing teaching with a community group about the prevention of viral hepatitis. Which of the following information should the nurse include in the teaching?
Thoroughly cook foods prepared with tap water.
A nurse is caring for a client who has Crohn's disease. What food choices would follow the recommended diet for clients who have Crohn's disease?
Toast with jelly Rationale: Toast with jelly is an appropriate food choice by the client. It does not contain large amounts of lactose, fat, or fiber.
A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client?
Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart.
A nurse is providing discharge teaching to a client who has peripheral arterial disease (PAD).Which of the following instructions should the nurse include in the teaching?
Wear antiembolic stockings during the day.
A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication?
antiplatelet aggregate
