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Capstone Med Surg Assessment 2025.Capstone Med Surg Assessment 2025.Capstone Med Surg Assessment 2025.
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Capstone Med Surg Assessment 2025.
Capstone Med Surg Assessment 2025.
Position the client on their side during a seizure. 20.A nurse is contributing to the plan of care for a client who has pyelonephritis. Which of the following interventions should the nurse include? Encourage the client to consume caffeinated beverages Avoid the use of acetaminophen for discomfort Monitor the clients the urine for color changes Begin antibiotic therapy after culture and sensitivity results are obtained 21.Nurse is assessing a client who has a herniated lumbar disc. Which of the following findings should the nurse expect? The client reports relief from pain when lying in the prone position. The client reports that her low-back pain radiates upward toward one scapula. The client reports tingling and a burning sensation in one foot. The client reports decreased pain when the affected leg is raised and straightened 22.A nurse is caring for a client who has acute gastritis and is NPO. The client has a new prescription to resume oral intake. Which of the following items should the nurse offered the client? Lemonade Tomato soup Gelatin Black coffee 23.A triage nurse nds a school-age child lying in the road following a school bus crash with multiple casualties. The child has a respiratory rate of 8/min, is unresponsive to verbal commands, and groans to painful stimuli. The nurse should assign the client which of the following triage tags?
Red Yellow Green Black 24.A nurse is teaching a client who has a new diagnosis of polycystic kidney disease. Which of the following statements should the nurse include in the teaching? "Take aspirin as needed to reduce your pain." "Reduce your dietary beer intake." "Apply dry heat to your abdomen when needed." "Check your weight once per week." 25.A nurse is assessing a client who has right lower lobe pneumonia. Which of the following findings should the nurse expect? Dull percussion sounds Increased anterior posterior chest diameter Distended neck veins Pitting edema 26.A nurse is providing teaching to the caregivers of a client who has Alzheimer's disease. Which of the following instructions should the nurse give? (Select all that apply.) Install safety locks and alarm systems. Place nightlights throughout the home. Replace carpeted flooring with tile. Establish a predictable daily routine for the client. Remind the client of scheduled activities 1 day in advance. 27.A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50, PaCO 29 mm Hg, and HCO 25 mEq/L.
should recognize that the client has which of the following acid-base imbalances? 2 3 – Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis 28.A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include? Eat three large meals daily. Consume high-calorie foods. Limit caffeinated drinks to two per day. Drink fluids during mealtime 29.A nurse is caring for a client who has a right-sided pneumothorax. Following chest tube insertion, which of the following findings indicates that the chest drainage system is functioning correctly? Gentle bubbling in the suction chamber Crepitus around the insertion site Constant bubbling in the water seal chamber Absence of breath sounds on the right side 30.A nurse is caring for client who has a new diagnosis of tuberculosis. Which of the following precautions should the nurse initiate to present transmission of the disease? Contact precautions Airborne precautions Droplet precautions Protective environment
31.A nurse is planning care for a client who has Ménière's disease and is experiencing episodes of vertigo. Which of the following interventions should the nurse include in the plan? Maintain strict bed rest. Restrict uid intake to the morning hours. Administer aspirin. Provide a low-sodium diet. 32.A nurse reviewing laboratory reports for client who is taking NSAISs for rheumatoid arthritis. Which of the following results should the nurse recognize as a possible adverse effect of NSAID therapy? Increased erythrocyte sedimentation rate Elevated creatinine clearance Increased serum potassium Positive fecal occult blood test 33.A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates the client might be experiencing a hemolytic transfusion reaction. Hypertension Report of urticarial Distended neck veins Report of chest pain 34.A nurse is caring for a client who had surgery 2 days ago and reports incisional pain. Which of the following actions should the nurse take first? Determine the time the last dose of pain medication was administered. Reposition the client to assist with reduction of pain. Ask the client to describe the pain and rate it on a scale of 0 to 10. Para mi Check the client's medical record for type of PRN pain medication.
39.A nurse is preparing to administer epoetin to a client who has anemia due to chemotherapy. Which of the following actions should the nurse plan to take? Review the client's Hgb level prior to administration. Use the Z-tract method when administering the medication. Shake the vial for 30 seconds prior to withdrawing the medication. Ensure the client is not taking iron supplements while on this medication. 40.A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse report to the provider immediately? Decreasing leg strength Decreasing voice volume Decreased deep tendon reflexes Decreased sensation in the arm 41.A nurse is assessing a client who has Addison's disease. Which of the following manifestations should indicate to the nurse that the client is experiencing an Addisonian crisis? Hypothermia Increased deep tendon reflexes Hypotension Erythema of the neck and chest 42.A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is the nurse's priority? Provide assistance with ambulation. Facilitate retention of facts by repeating instructions. Place the client in a darkened room. Speak slowly and clearly. 43.A nurse is providing teaching to a newly licensed nurse about caring for a client who is receiving a ealed radioactive implant. Which of the following information should the nurse include in the teaching? Place soiled linens in a lead container. • Allow children who are over 10 years old to visit.
Limit visitors to 1 hr per day. Wear a lead apron during care 44.A nurse is assessing a client who is postoperative following a kidney transplant. Which of the following findings indicates the client is experiencing a transplant rejection? Polyuria • Hypothermia Hypertension Hypovolemia 45.A nurse is providing teaching to a client who is scheduled for a bone marrow biopsy taken from the iliac crest. Which of the following information should the nurse include? "Avoid taking warm baths following the procedure."
"It is important to engage in a strenuous aerobic exercise program to build strength and endurance." "It is important with this disease to relax muscles in a hot tub or spa." "It is important to engage in social activity, and volunteering to read to schoolchildren will keep you active." "It is important to develop a daily schedule that reduces fatigue and conserves energy." 53.A nurse is caring for a client who is postoperative immediately following a pheochromocytoma removal. Which of the following actions is the nurse's priority? Increase hydration. Monitor blood pressure. • Measure urine output. Provide a calm environment. 54.A nurse is teaching a client who has glaucoma and is to start taking timolol. Which of the following information should the nurse include? "Notify the provider if you experience a stinging sensation following administration." Para mi "Watch for a decreased heart rate while using this medication." "You can expect to develop a harmless darkening of the iris." • "This medication can cause the lashes of the affected eye to lengthen." 55.A nurse is providing teaching to a client who has a new onset of genital herpes. Which of the following statements should the nurse include in the teaching? "You are not contagious when lesions are healed." "This infection is spread through the air." "Stress can activate an outbreak." "Antiviral drugs will cure the infection." 56.A nurse is instructing a client's caregiver on how to position the client before administering tube feedings in the home. Which of the following
statements by the caregiver demonstrates an understanding of the teaching?
Tuck the top bedsheet tightly around the client's torso. Monitor for cerebrospinal fluid leakage 61.A nurse is caring for a client who is using a ventilator when the low- pressure ventilator alarm sounds. Which of the following actions should the nurse take? Suction secretions from the endotracheal tube. Check the ventilator tubing connections. Administer intravenous sedation and analgesia. Reassure the client and instruct them not to bite on the tube. 62.A nurse is caring for a client who has renal calculi. Which of the following prescriptions by the provider is the priority action for the nurse to take? Strain all urine. Schedule a retrograde pyelography. Monitor intake and output. Schedule a kidney ultrasound. 63.A nurse is providing discharge teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements by the client indicates an understanding of the teaching? "When I'm exercising, I'll include bent-leg raises." "I'll use my reaching device to help me pick up objects I drop on the oor." "I can stop physical therapy when I quit using my walker." • "I'll sleep on my back with my knees close together." 64.A nurse is providing teaching for a client who has Parkinson's disease and a new prescription for selegiline. Which of the following statements should the nurse include? "You might experience joint pain while taking this medication." "The medication cannot be combined with other antiparkinsonian agents." "Avoid eating aged cheeses or smoked meats while taking this medication." "It will take up to 2 weeks for the medication to work."
65.A nurse is caring for a client who has renal failure. Which of the following arterial blood gas (ABG) results should the nurse expect? pH 7.25, HCO3 20 mEq/L, PaCO 35 mm Hg - pH 7.30, HCO3 22 mEq/L, PaCO 50 mm Hg - 2 pH 7.50, HCO3 32 mEq/L, PaCO 45 mm Hg - 2 pH 7.55, HCO3 28 mEq/L, PaCO 31 mm Hg 66.A nurse is reviewing a client's medical record prior to administering furosemide via IV bolus to a client who has heart failure. For which of the following ndings should the nurse withhold the medication and notify the provider? Hypokalemia Hypernatremia Hypoglycemia Hypermagnesemia 67.A nurse is initiating a plan of care for a client who has COPD. Which of the following interventions should the nurse include? Request a prescription for an antibiotic. Educate the client on pursed-lip breathing. Place the client in airborne precautions. Initiate a referral for gene therapy. 68.A nurse is receiving report on a group of clients. Which of the following clients should the nurse assess first? A client who has a chest tube and reports a pain level of 6 on a scale of 0 to 10 A client who received parenteral cephalosporin and reports urticaria and edema A client who is being admitted with bilateral Stage 3 pressure injuries on both heels A client who has a systemic infection and an oral temperature of 39.1° C (102.4° F)
73.A nurse is creating a plan of care for a client who has meningitis. Which of the following interventions should the nurse include? Initiate contact isolation precautions. Keep the client's environment dark and quiet. Restrict the client's fluid intake. Perform neurovascular assessments once a day. 74.A nurse is a caring for client who is postoperative following a below- the- knee amputation. Which of the following actions should the nurse take? Maintain a loose bandage on the residual limb. Turn the client from side to side once every 4 hr. Request a soft mattress for the client. Place the client prone for 20 min every 3 hr. 75.A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig's sign? After stroking the lateral area of the foot, the client's toes contract and draw together. After hip exion, the client is unable to extend their leg completely without pain. Esta es la misma pregunta 17 The client's voluntary movement is not coordinated. The client reports pain and stiness when exing their neck 76.A nurse is caring for a client who has rheumatoid arthritis and has been taking prednisone. Which of the following findings should the nurse identify as an adverse effect of this medication? Weight loss Hypoglycemia Hypertension Hyperkalemia 77.A nurse is caring for a client who has increased intracranial pressure (ICP). Which of the following interventions should the nurse implement? Place several pillows behind the client's head.
Place the client in a Sims' position. Keep the client's neck in a midline position. Maintain exion of the client's hips at a 90° angle 78.A nurse in a rural community center is providing education to a group of clients about first aid interventions for snake bites to prevent further injury. Which of the following instructions should the nurse include in the teaching? Apply an ice pack directly to the affected area. Immobilize the affected extremity with a splint. Place a tourniquet above and below the affected area. Elevate the affected extremity 79.A nurse is providing discharge teaching to a client who is starting to take carbidopa/levodopa to treat Parkinson's disease. Which of the following instructions should the nurse include in the teaching? "This medication can cause your urine to turn a dark color." "Expect immediate relief after taking this medication." "Take the medication with a high-protein food." "Skip a dose of the medication if you experience dizziness." 80.A nurse is providing dietary teaching for a client who has chronic cholecystitis. Which of the following diets should the nurse recommend? Low-potassium diet High-ber diet Low-fat diet Low-sodium diet 81.A nurse is providing teaching to a client who is scheduled for an electroencephalogram (EEG). Which of the following statements by the client indicates an understanding of the teaching?