Quiz: Med-Surg Final

A nurse is reinforcing teaching with a client who has a new diagnosis of multiple sclerosis (MS). The client asks the nurse about the usual course of MS. Which of the following responses should the nurse make?

"Acute episodes are usually followed by remissions, which can last varying lengths of time."

A nurse is working with an assistive personnel (AP) who is assigned to bathe a client who has herpes zoster. The AP asks the nurse if herpes zoster is contagious. which of the following responses should the nurse make?

"Herpes zoster is contagious to people who have never had chickenpox"

A nurse is reinforcing discharge teaching with a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching? "I should check my heart rate at the same time each day." "I don't have to take my antihypertensive medications now that I have a pacemaker." "I should keep a pressure dressing over the generator until the incision is healed." "I cannot stand in front of our new microwave oven when it is on."

"I should check my heart rate each day."

A nurse is reinforcing discharge teaching with a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teachings?

"I should take ibuprofen for my joint pain."

A nurse is reinforcing teaching with a client who has stomatitis due to chemotherapy. which of the following statements by the client indicates a need for further instructions?

"I will cleanse my mouth after meals with an alcohol-based mouthwash." "I will use lemon and glycerine swabs after meals."

A nurse is reinforcing discharge teaching with a client who has infective endocarditis about how to prevent recurrence. Which of the following statements by the client indicates an understanding of the teaching?

"I will notify my doctor before I have dental procedures"

A nurse is reinforcing teaching with a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching?

"My diet will have to change to a soft diet after surgery."

A nurse is obtaining a weekly weight for a client who has obesity and osteoarthritis and is on weight management program. The nurse determines that the client gained 1.36 kg (3lb) in the past week. Which of the following statements should the nurse make?

"Were there any issues last week that kept you from focusing on your diet?"

A nurse is reinforcing discharge teaching with a client who has AIDS. Which of the following statements should the nurse include?

"You should clean bathroom surfaces with a bleach and water solution."

A nurse is reinforcing teaching with a client who has tuberculosis (TB) and a prescription for isoniazid. Which of the following instructions should the nurse include?

"Your provider will monitor your liver function while you are taking this medication"

A nurse is assisting with the care of a client who is to receive a transfusion of packed red blood cells (RBCs). Which of the following actions should the nurse take? (Select all that apply.) Assess and document the client's vital signs. Restart the IV with a 22-guage needle. Verify with another nurse the blood type and Rh of the packed RBCs. Hang a bag of lactated Ringer's IV solution. Change IV tubing to a set that has a filter.

- Check and document the client's vital signs - Verify that the blood type and Rh of the packed RBCs are checked by two other nurses - Provide the RN with IV tubing that has a filter

A nurse is reinforcing teaching with a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse make? (select all that apply) Take allopurinol as prescribed. Exercise several times a week. Limit intake of foods high in purine. Decrease daily fluid intake. Avoid citrus juices.

- Exercise several times a week - Take allopurinol as prescribed - Limit intake of foods high in purine

A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. which of the following personal protective equipment (PPE) should the nurse don prior to providing client care? Gown Gloves Mask Hair cover Goggles

- Gown - Gloves

A nurse is collecting data from a client who has encephalitis due to West Nile virus. Which of the following findings should the nurse expect?

- Stiff neck - Lethargy - Photophobia

A nurse is preparing to care for a group of clients after receiving change-of-shift report. From which of the following clients should the nurse collect data first?

A client who has emphysema and reports dyspnea

A nurse is reinforcing teaching with a client about how to perform a breast self exam (BSE). The nurse should identify which of the following findings as an indication of breast cancer? Lumps that are mobile and tender upon palpation prior to a menstrual period Multiple round masses that are tender and found in both breasts Bilaterally darkened areolas A nontender, hard lump that is palpated in one breast

A nontender, hard lump that is palpated in one breast typically hard, fixed, irregular in shape, and nontender to palpation.

A nurse is contributing to the plan of care for a client during a sickle cell crisis. Which of the following interventions should the nurse recommend?

Administer oxygen via nasal cannula

A community health nurse is reinforcing teaching about melanoma with a group of clients. Which of the following characteristics of lesions associated with melanoma should the nurse include in the teaching?

An irregular border

A nurse is preparing to administer timolol eye drops for a client who has glaucoma. when instilling the medication, which of the following actions should the nurse take?

Apply pressure to the bridge of the nose after instillation of the medication.

A nurse is collecting data from a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first?

Ask the client to identify the specific food allergies.

A nurse is reinforcing dietary teaching with a client who has diabetes mellitus. Which of the following actions should the nurse take first?

Ask the client to identify the type of foods she prefers

A nurse is contributing to the plan of care for a client who is 72hr postoperative following an above-the-knee amputation. Which of the following actions should the nurse recommend? Elevate the residual limb on a soft pillow. Assist the client to a prone position every 4 hr. Reapply a bandage to the residual limb every 12 hr. Apply dressings to the site in a proximal-to-distal direction.

Assist the client to a prone position every 4 hr. for 20 to 30 min every 3 to 4 hr following an amputation because it reduces the risk of flexion contractures.

A nurse is caring for a client who is to have his chest tube removed. Which of the following actions should the nurse take?

Auscultate the lungs after removal

A nurse is contributing to the plan of care for a client who has thrombocytopenia due to chemotherapy. Which of the following interventions should the nurse include?

Avoid IM injections

A nurse is collecting data from a client who develops a fruity breath odor, dry mouth, and extreme thirst. Which of the following additional data should the nurse collect? Blood glucose level Pupillary reaction to light Deep tendon reflexes Liver function tests

Blood glucose using a glucometer these findings are indications of hyperglycemia and diabetic ketoacidosis. The nurse should therefore check the client's blood glucose level. The nurse should also assess the client's respiratory status, vital signs, level of consciousness, and hydration status, including a laboratory assessment of his electrolyte levels.

A nurse is caring for a client who has a stage III pressure ulcer on his heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? Obtain the prescribed irrigation solution. Don personal protective equipment. Check the client's pain level. Place a waterproof pad under the client's extremity

Check the client's pain level.

A nurse is collecting data from a client who has a fractured left femur and is in skeletal tractions. Which of the following findings should the nurse identify as an indication of fat emboli to report to the provider?

Chest petechiae

A nurse in reinforcing teaching about a low-cholesterol diet with a client who has a myocardial infarction. which of the following meal selections by a client indicates an understanding of the teaching?

Chicken breast and corn of the cob

A nurse in an urgent care clinic is collection data from a client who sustained a fall. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? A depressed fracture of the forehead Clear fluid coming from the nares Motor loss on one side of the body Bleeding from the top of the scalp

Clear fluid coming from the nares

A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect? Kussmaul respirations Diaphoresis Decreased skin turgor Ketonuria

Diaphoresis blood glucose level below 70 mg/dL to exhibit manifestations of hypoglycemia. Expected findings associated with hypoglycemia include weakness, hunger, diaphoresis, nausea, shakiness, and confusion.

A nurse is caring for a male client who is undergoing screening tests for atherosclerosis. Which of the following laboratory findings should the nurse identify as an increased risk for this disorder?

Elevated LDL levels

A nurse is reinforcing teaching with a client about preventing the transmission of hepatitis A. The nurse should identify that hepatitis A is transmitted by which of the following routes?

Fecal-Oral contamination

A nurse in a provider's office is caring for a client who has blepharitis. Which of the following actions should the nurse take first?

Inspect the eye for drainage or redness

A nurse is monitoring a client following a thyroidectomy. Which of the following findings should the nurse identify as an indication of hypoparathyroidism?

Involuntary muscle spasms

A nurse is caring for a client who begins having a tonic-clonic seizures while sitting in a chair at the bedside. Which of the following actions should the nurse take first? Provide oxygen. Place the client in a side-lying position. Provide privacy. Lower the client to the floor.

Lower the client to the floor

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take?

Monitor the client's blood glucose level.

A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take?

Pinch the soft portion of the client's nose for 10 min.

A nurse is contributing to the plan of care for a client who has thrombophlebitis. Which of the following actions should the nurse recommend for the plan of care?

Place compression stockings on the lower extremities.

A nurse is contributing to the plan of care for a client who has cancer and is scheduled to receive internal radiation therapy. Which of the following actions should the nurse recommend?

Place the client in a private room.

A nurse is assisting with the care of a client who has a chest tube in place following a thoracotomy. Which of the following actions should the nurse take?

Place the drainage unit below the client's chest level.

A home health nurse enters a client's home and finds a used insulin syringe, without a cap, on the table. Which of the following actions should the nurse take?

Place the syringe in a puncture-proof disposal container

A nurse is caring for a client following a hip arthroplasty. The nurse should place an abduction pillow on the client for which of the following purposes? Raising the bed linens off the client's feet to prevent plantar flexion Keeping the client's heels off the bed to prevent pressure ulcers Positioning the client off of the operative site while in bed Preventing dislocation of the hip during position changes or movement

Preventing dislocation of the hip during position changes or movement

A nurse is reinforcing teaching with a client who has tuberculosis and a prescription for rifampin. The nurse should identify which of the following findings as a harmless and expected adverse effect of rifampin?

Red-Orange discoloration of Urine

A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following actions should the nurse take?

Report viscous drainage with clots to the provider.

A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances?

Respiratory Alkalosis

A nurse in an urgent care clinic is collecting data from a client who has extensive burns, including on her face. Which of the following data should the nurse collect first?

Respiratory rate

A nurse is reinforcing teaching with a client who has a history of tonic-clonic seizures and is scheduled for a standard electroencephalogram (EEG). Which of the following instructions should the nurse include in the teaching?

Thoroughly shampoo hair prior to the EEG.

A nurse is reinforcing discharge teaching about improving gas exchange with a client who has emphysema. which of the following information should the nurse include in the teaching? Use pursed-lip breathing during periods of dyspnea. Limit fluid intake to 1,500 mL per day. Practice chest breathing each day. Wear home oxygen to maintain an SaO2 of at least 94%.

Use pursed-lip breathing during periods of dyspnea increase airway pressure, and facilitate effective gas exchange

A nurse is caring for a client who is scheduled to receive intermittent peritoneal dialysis. Which of the following actions should the nurse take?

Weigh the client before and after each dialysis treatment

A nurse is contributing to the plan of care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following interventions should the nurse recommend?

offer the client a bedpan every 2 hr.