MedSurge EAQ Questions
Respiratory rate: 14 Blood pressure: 110/70 Oxygen saturation: 92%
A 50-year-old client with a 30-year history of smoking reports a chronic cough and shortness of breath related to chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100, a blood pressure of 138/82, a respiratory rate of 32, a tympanic temperature 36.8 °C, and an oxygen saturation of 80%. Which vital signs obtained by the nurse during the therapy indicates a positive outcome? Select all that apply.
Fresh orange wedges
A client is receiving a 2-gram sodium diet. The family members ask whether they can bring snacks from home. Which food item will the nurse suggest?
Paresthesias
A nurse assesses for hypocalcemia in a postoperative client. What is one of the initial signs that might be present?
Decrease in serum potassium level
A nurse gave a client the prescribed sodium polystyrene sulfonate. What assessment finding indicates that the drug has been effective?
metabolic acidosis
An arterial blood gas report indicates the client's pH is 7.25, PCO 2 is 35 mm Hg, and HCO 3 is 20 mEq/L. Which disturbance should the nurse identify based on these results?
"There will be an indwelling urinary catheter and a continuous bladder irrigation in place."
Before a transurethral resection of the prostate (TURP), a client asks about what to expect postoperatively. Which response by the nurse is most appropriate?
Obtain the client's vital signs.
On the third postoperative day after a subtotal gastrectomy, a client reports having severe abdominal pain. The nurse palpates the client's abdomen and determines rigidity. What should be the nurse's firstaction?
"Continue with long-term follow-up care."
What is the most important information the nurse can share with a client who is just diagnosed with hypertension?
Distention of the lower abdomen
When admitting a client with benign prostatic hyperplasia, which assessment made by the nurse is most relevant?
Dependent rubor Ulcers on the toes Delayed capillary refill
When assessing the client with peripheral arterial disease, the nurse anticipates the presence of which clinical manifestations? Select all that apply.
Kidney failure
A client is admitted to the hospital with a long history of hypertension. The nurse should assess the client for which complication?
Digoxin toxicity occurs rapidly in the presence of hypokalemia.
A client has been given a prescription for furosemide 40 mg every day in conjunction with digoxin. What would prompt the nurse to ask the provider about potassium supplements?
Last serum potassium level Patency of the intravenous access Urinary output
A client is scheduled to receive an intravenous (IV) infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours. Before administering this IV medication, it is a priority for the nurse to assess which of the following? Select all that apply.
Use disposable tissues
A client newly diagnosed with tuberculosis has a productive cough. Which is the most appropriate nursing intervention to teach the client?
0.9% sodium chloride
A client with a history of severe diarrhea for the past 3 days is admitted for dehydration. The nurse anticipates that which intravenous (IV) solution will be prescribed initially?
"My urine may become discolored." "I will lose weight while on this medication." "The medication should be taken between meals." "When I'm feeling better, I can stop taking this medication."
A client with chronic obstructive pulmonary disease will be taking long-term oral corticosteroid therapy. After the nurse conducts a teaching session, which statements by the client indicates that the nurse should follow up? Select all that apply .
Determine blood glucose level
A client with type 1 diabetes complains of hunger, thirst, tiredness, and frequent urination. Based on these findings, the nurse should take what action?
Check blood glucose for hypoglycemia.
A client with type 2 diabetes has been receiving insulin in the hospital while being treated for sepsis. The client's infection is resolving and the primary healthcare provider writes a prescription to discontinue the 7:00 AM dose of insulin and to administer glyburide 5 mg twice daily (8:00 AM and 8:00 PM). The nurse on the day shift (8:00 AM to 4:00 PM) administers the glyburide at 8:30 AM. When recording its administration in the client's record, the nurse sees that the insulin had already been administered at 7:00 AM. What initial action should the nurse take?
Muscle weakness Irregular heart rate Vomiting
A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? Select all that apply.
Oxygenation Drowsiness Mental confusion
A nurse administers oxygen at 2 L/min via nasal cannula to a client with emphysema. Which clinical indicators should the nurse closely observe in the client? Select all that apply.
fluid and electrolyte balance
A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what client data or assessment finding?
Cardiac problems
A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). What complications are associated mostcommonly with COPD?
Administering glucagon Administering IV glucose Administering oral hydrocortisone
A nurse is caring for a client with hypoglycemia. Which nursing intervention would be appropriate in managing the client's condition? Select all that apply.
Client B with Helicobacter pylori
A nurse is reviewing the laboratory reports of four clients. Which client may have peptic ulcer disease?
"Does walking for long periods of time increase your pain?"
A client presents with bilateral leg pain and cramping in the lower extremities. The client has a history of cardiovascular disease, diabetes, and varicose veins. To guide the assessment of the pain and cramping, the nurse should include which question when completing the initial assessment?
"Increase your fluid intake and urinate at regular intervals."
A client who has had a transurethral resection of the prostate (TURP) experiences dribbling after the indwelling catheter is removed. Which is an appropriate nursing response?
Oliguria is an indication for withholding intravenous (IV) potassium.
A client is admitted to the hospital with a diagnosis of dehydration and hypokalemia. Which statement/intervention is most accurate when administering potassium chloride intravenously to this client with hypokalemia?
Expected course of pneumonia
A client is admitted with a tentative diagnosis of pneumonia. On admission the client is not in respiratory distress, but later develops chest pain and a fever of 103° F (39.4° C). A productive cough produces rust-colored sputum. How should the nurse interpret these findings?
Wound drainage Diuretic therapy Gastrointestinal (GI) suction Inappropriate anti-diuretic hormone (ADH) secretion
A client is prone to hyponatremia. Which factors should the nurse identify that can precipitate hyponatremia? Select all that apply.
"I sometimes allow our children to sleep in our bed at night." "I know I also have tuberculosis because the skin test was positive." "I plan to attend a wine tasting event this evening."
Isoniazid (INH) is prescribed as a prophylactic measure for a client whose spouse has active tuberculosis (TB). Which statements made by the client indicate that there is a need for further teaching? Select all that apply.
aging and obesity
The nurse is caring for a 76-year-old obese client with a history of epigastric distress, esophageal burning, binge drinking, and frequent episodes of bronchitis. A diagnosis of hiatal hernia is made. Which health problems most likely contributed to the development of the hiatal hernia? Select all that apply.
Intracellular to intravascular because of hyperosmolarity
The nurse is caring for a client with diabetes mellitus. What is the primary fluid shift that occurs with this condition?
Lean beef Mushrooms Cooked broccoli
The nurse prepares a list of recommended foods for a client with hypertension who is starting a 2-gram sodium diet. Which foods should the nurse include in the list? Select all that apply.
Palpitations Tachycardia Nervousness
Which responses should a nurse expect a client experiencing hypoglycemia to exhibit? Select all that apply.
"I should drink at least six glasses of water every day." "I can include bran muffins in my breakfast daily." "I will walk every day as part of my exercise regimen."
A nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching is understood when the client makes which statements? Select all that apply.
Excessive emotional stress Running a fever with the flu
A nurse is collecting information about a client with type 1 diabetes who is being admitted because of diabetic ketoacidotic coma. Which factors can predispose a client to this condition? Select all that apply.
"I smoke one pack of cigarettes a day."
A nurse is obtaining a health history from a client with the diagnosis of peptic ulcer disease. Which client statement provides evidence to support the identification of a possible contributory factor?
A previous exposure to the organism
A client who is receiving a screening test for tuberculosis (TB) asks the nurse what a positive reaction will mean. What should the nurse explain that a positive reaction indicates?
To treat Helicobacter pylori infection
A client with gastric ulcer disease asks the nurse why the health care provider has prescribed metronidazole. What purpose does the nurse provide?
Fever Urinary retention abdominal muscle rigidity
The nurse is caring for a client with peritonitis who had surgery two hours ago due to a ruptured appendix. Which clinical findings should the nurse expect to observe when assessing this client? Select all that apply.
"Temperature of the client is 105° C." "I have administered intravenous fluids to the client."
The registered nurse (RN) and unlicensed assistive personnel (UAP) are caring for a client with diarrhea. After 2 hours, the RN communicates with the UAP and decides that the client needs immediate assessment. Which statements by the UAP led the nurse to this conclusion? Select all that apply.
Barrel chest
While a nurse is conducting an initial assessment on a client, which classic sign would alert the nurse that the client has chronic obstructive pulmonary disease (COPD)?
