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Capstone Med Surg Assessment
- A nurse is teaching a client about using a continuous positive airway pressure (CPAP) device to treat obstructive sleep apnea. Which of the following information should the nurse include in the teaching? It delivers a present amount of airway pressure throughout the breathing cycle
- A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching? Shortness of breath might be an indication of transplant rejection
- A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and is receiving 3 % sodium chloride via continuous IV. Which of the following laboratory finding should the nurse identify as an indication that the SIADH is resolving? Urine specific gravity 1.
- A nurse is teaching a client about fecal occult blood testing (FOBT) for the screening of colorectal cancer. Which of the following statements should the nurse include in the teaching? You should avoid taking corticosteroids prior to testing
- A nurse is preparing a client for a colonoscopy. Which of the following medications should the nurse anticipate the provider to prescribe as an anesthetic for the procedure? Propofol
- A nurse is planning care for a client who has acute pancreatitis. Which of the following interventions should the nurse include in the clients plan? Select all that apply. Monitor blood glucose levels Maintain NPO status until pain-free Manage acute pain
- A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as the client to include in their diet? 3 oz of chicken breast
- A nurse is reviewing the medical record of a client who has unstable angina. Which of the findings should the nurse report to the provider? Breath Sounds
- A nurse is providing discharge instructions to a client who has GERD. Which of the following statements by the client demonstrates an understanding of the teaching? I will limit activities that require bending at the waist. 10.A nurse at a provide office is interviewing a client who has multiple sclerosis and has been taking dantrolone for several months. Which of the following client statements should the nurse identify as an indication that the medication is effective? I don’t have muscle spasms as frequently 11.A nurse is assessing a client who reports a possible exposure to HIV. Which of the following finding should the nurse identify as an early manifestation of HIV infection? Fatigue 12.A nurse is teaching a client who has type 1 diabetes mellitus about hypoglycemia .which of the following statements by the client indicates an understanding of the teaching? I can drink 4 ounces of soda if my blood sugar is low 13.A nurse is providing discharge teaching to a client who has heart failure and a prescription for furosemide 20 mg PO two times daily. Which of the following instructions should the nurse include in the teaching? Increase intake of high-potassium foods
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. The nurse
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.
35.A nurse is teaching strategies to prevent carpal tunnel syndrome to a group of oce workers. Which of the following instructions should the nurse include? (Select all that apply.) "Raise your chair height so that you lean over to type." "Use a wrist rest when working at a computer station." "Stretch your ngers and wrists periodically while working." "Position your keyboard at shoulder height." "Take breaks from the repetitive activity." 36.A nurse is assessing a client who has a tension pneumothorax following blunt chest trauma. Which of the following findings should the nurse expect? Tracheal deviation to the unaffected side Pleural friction rub Frothy, pink-tinged sputum Increased breath sounds on the affected side 37.A nurse is caring for an adult client who asks about vaccinations against communicable diseases. The nurse should inform the client that which of the following vaccines are available? (Select all that apply) Hepatitis A vaccine Hepatitis B vaccine Pneumococcal vaccine Hepatitis C vaccine Helicobacter pylori vaccine 38.A nurse is teaching a client who has angina pectoris about nitroglycerin sublingual tablets. Which of the following statements should indicate to the nurse that the client understands the teaching? "I will keep the tablets in the original container." "I should keep the container in my shirt or pants pocket." "I should begin to feel relief within 20 minutes of taking the medication." "I will drive myself to the emergency room if three nitroglycerin tablets do not relieve my pain."
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."
- "You will lie on your back during the procedure." "You will receive general anesthesia for the procedure." "Take acetaminophen as prescribed for pain relief after the procedure." 46.A nurse is providing discharge instructions to a client who has a peptic ulcer. Which of the following dietary modications should the nurse include? Provide a snack at bedtime. • Choose decaeinated coee. Restrict intake of fried foods. Avoid drinking liquids with meals 47.A nurse is assessing a client following a hypophysectomy. Which of the following findings indicates the client might be developing diabetes insipidus? Urine ketones Hyperglycemia • Halo or ring-shaped dressing drainage Low urine specic gravity
48.A nurse is assessing a client who has a history of migraine headaches with aura and reports feeling "a migraine coming on." The nurse should expect the client to report which of the following manifestations? Visual disturbances
- Photophobia Nasal congestion Phonophobia 49.A nurse is reviewing laboratory values for a client who has Cushing's disease. Which of the following values should the nurse expect? Blood glucose 65 mg/dL • Serum calcium 12.2 mg/dL Potassium 5 mEq/L Sodium 150 mEq/L 50.A nurse is assessing a client who has had a left-hemisphere stroke. Which of the following findings should the nurse expect? Expressive aphasia • Poor impulse control Left hemiparesis Disorientation to place 51.A nurse is assessing a client who has a mild traumatic brain injury. The nurse should report which of the following findings as a complication of this injury? (Select all that apply.) Bradycardia Vomiting Drainage from the ear para mi Unequal pupils Pruritus 52.A nurse is providing discharge teaching to a client who has multiple sclerosis. Which of the following instructions should the nurse include in the teaching?
"I will allow him to assume a position of comfort." "I will elevate the head of the bed 10 degrees." "I will place him in a left side-lying position." "I will sit him up in bed." 57.A nurse is teaching a client who has asthma about using a peak ow meter. When a yellow zone meter reading appears, the nurse should instruct the client to take which of the following actions? Take another peak ow meter reading in 15 min. Take prescribed relief medication. Call for emergency transport to a hospital. Inhale through pursed lips. 58.A nurse is caring for a client who is postoperative and reports frequent leakage of small amounts of urine. The nurse notes that the client's bladder is palpable upon examination. The nurse should identify these findings as which of the following forms of incontinence? Stress Urge Functional Overow 59.A nurse is assessing a client who has tuberculosis and is taking rifampin. Which of the following findings should the nurse report as an adverse effect of the medication? Alopecia Yellowing of the sclera Report of constipation Report of insomnia 60.A nurse is caring for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse include in the plan of care to prevent autonomic dyslexia? Monitor bowel movement regularity. Use a fan to promote air circulation in the client's room
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."
69.A nurse is discussing risk factors for hepatitis A with a newly licensed nurse. Which of the following clients should the nurse identify as being at an increased risk for hepatitis A? A client who is hepatitis B positive A client who had a kidney transplant in 1990 A client who has a history of intravenous street drug use A client who has recently done volunteer work in a developing country 70.A nurse is providing education regarding the prevention of urinary tract infections (UTIs) to a client who has a history of cystitis. Which of the following statements by the client indicates that the teaching has been effective? "I will limit my fluid intake to 1 liter per day to prevent frequency and urgency." "I will empty my bladder every 2 to 3 hours throughout the day." "I will use an antiseptic vaginal deodorant spray twice a day to reduce the bacterial growth." "I will take a hot bath after sexual intercourse." 71.A nurse is providing instructions to a newly licensed nurse about NG intubation for a client who is postoperative following a colectomy. Which of the following statements should the nurse include? "Tube drainage should be rust-colored." "Nutrition will be provided through the tube." Para mi "The tube decreases pressure within the stomach." "The tube should be irrigated with sterile water." 72.A nurse is caring for a client who has a history of tonic-clonic seizures. Which of the following precautions should the nurse take? (Select all that apply.) Keep a suction apparatus at the bedside. Keep a padded tongue blade next to the bed. Keep the bed in the lowest position. Keep oxygen equipment at the bedside. Keep safety restraints near the bedside.
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.
"I should not wash my hair prior to the procedure." "I will receive a sedative 1 hour before the procedure." "I should avoid eating prior to the procedure." "I will be exposed to ashes of light during the procedure." 82.A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching? Immunosuppressant medications need to be taken for up to 1 year. Shortness of breath might be an indication of transplant rejection. The surgical site will heal in 3 to 4 weeks after surgery. Begin 45 min of moderate aerobic exercise per day following discharge 83.A nurse is caring for a client who has been experiencing repeated tonic- clonic seizures over the course of 30 min. After maintaining the client's airway and turning the client on their side, which of the following medications should the nurse administer? Diazepam IV Lorazepam PO Diltiazem IV Clonazepam PO 84.A nurse is providing discharge instructions to a client who has GERD. Which of the following statements by the client demonstrates an understanding of the teaching? "I should take my medicine with orange juice." "A bedtime snack will prevent heartburn." "I will lie down after meals." "I will limit activities that require bending at the waist."
85.A nurse is caring for a client who is at high risk for iron deciency anemia. Which of the following foods should the nurse instruct the client to increase in their diet? Yogurt Apples Raisins Cheddar cheese 86.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 87.A nurse is planning care for a client who has acute post-streptococcal glomerulonephritis. Which of the following interventions should the nurse include in the client's plan? Encourage a high-protein diet for the client. Increase the client's fluid intake. Administer diuretics to the client. Weigh the client twice a week. 88.A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?
