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Medical Surgical Assessment A/
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A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure? A) Sodium 136 mEq/L B) Potassium 4.8 mEq/L C) Creatinine 1.9 mg/dL D) Calcium 10 mg/dL - C) Creatinine 1.9 mg/dL Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse should report the finding to the provider before the client has a CT scan with an IV contrast agent. This finding places the client at risk for developing contrast-induced nephropathy. A nurse is monitoring a client who is taking acarbose. Which of the following findings should the nurse identify as an adverse effect of the medication? A) Polyuria B) Abdominal cramps C) Renal insufficiency D) Insomnia - B) Abdominal cramps Acarbose affects the gastrointestinal system. Therefore, the nurse should monitor the client for abdominal cramping, rumbling bowel sounds, and diarrhea as adverse effects of this medication. A nurse is assisting with the care of a client who had a cardiac catheterization via the right femoral artery. Which of the following actions should the nurse take to prevent postprocedure complications? (Select all) A) Monitor the insertion site for bleeding B) Position the affected extremity at a 45 degree angle
C) Restrict the client's fluid intake D) Maintain the pressure dressing E) Check the client's peripheral pulses - A) Monitor the insertion site for bleeding The nurse should monitor the client's insertion site for manifestations of hemorrhaging. D) Maintain the pressure dressing. The nurse should maintain the client's pressure dressing to prevent hemorrhaging and allow for the cannulation site to heal. E) Check the client's peripheral pulses. The nurse should assess the client's peripheral pulses to help identify signs of arterial occlusion. A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary disease (COPD) and is dyspneic. Which of the following interventions should the nurse include in the plan? A) Encourage abdominal breathing B) Direct the client to inhale with pursed lips C) Set the oxygen therapy at 5L/min D) Instruct the client to lean back while coughing - A) Encourage abdominal breathing The nurse should encourage abdominal breathing, which reduces the workload on the accessory muscles of respiration during dyspneic episodes. A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an INR of
- Available is phytonadione 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero is it applies. Do not use a trailing zero. - 7mg/10 mg *1mL= 0.7 mL A nurse is examining a client's IV site and notes a red line up his arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy?
A) Lower the side rails of the client's bed B) Apply wrist restraints to the client C) Position the client in the semi-Fowler's position D) Loosen clothing around the client's neck - D) Loosen clothing around the client's neck The nurse should loosen clothing around the client's neck to maintain an open airway and prevent aspiration. A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should the nurse include? A) Apply hot packs to the client's muscles B) Schedule physical therapy in the afternoon C) Encourage the client to complete ADLs D) Administer valerian to promote sleep - C) Encourage the client to complete ADLs The nurse should encourage the client to complete ADLs and provide assistance as needed. Performing self-care increases the client's independence, strength, and level of functioning. A nurse is reinforcing discharge teaching to prevent dumping syndrome for a client following a partial gastrectomy for ulcers. Which of the following information should the nurse include in the teaching? A) Avoid liquids at mealtimes B) Exclude eating starchy vegetables C) Avoid eating high-protein meals D) Plan to increase intake of sweetened fruits - A) Avoid liquids at mealtimes The nurse should remind the client to avoid drinking liquids at mealtimes to prevent the food from emptying into the small bowel too quickly.
A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect? A) Increased weight B) Increased heart rate C) Decreased urinary output D) Decreased shortness of breath - D) Decreased shortness of breath The nurse should expect the client to have decreased shortness of breath. Digoxin increases the contractility of the heart, which decreases pulmonary congestion. A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take with communicating with the client? A) Rephrase client instructions when not understood B) Cup hands around the mouth and direct speech toward the client C) Accentuate vowel sounds by using a higher pitch when speaking D) Sit to the side of the client and speak instructions into her best eat - A) Rephrase client instructions when not understood When communicating with a client who has hearing loss, the nurse should rephrase, rather than repeat, discharge instructions when they are not understood. A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk of aspiration? A) Instill 10mL of air through the NG tube B) Place the client in supine position C) Irrigate the NG tube D) Pinch the NG tube - D) Pinch the NG tube The nurse should pinch the NG tube to prevent secretions from draining into the client's throat, which can cause aspiration.
D) "I will plan to fast before I have my HbA1c tested" - C) "I will have my HbA1c checked twice per year" An HbA1c test provides the client's average glucose level for the preceding 3 months. The nurse should instruct the client to have her HbA1c tested twice yearly to manage her glucose. A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include? A) Restrict the time pregnant women are allowed in the client's room to 15 min B) Pick up a radiation implant with a double-gloved hand if it becomes dislodged C) Limit time spent in the client's room to 2 hr during an 8 hr shift D) Dispose of radiation implants in a lead container - D) Dispose of radiation implants in a lead container Lead impairs the emission of radiation. Therefore, the nurse should dispose of radiation implants in a lead container in accordance with facility protocol. A nurse is caring for a client who had an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration? A) Allow for 30 min of rest before meals B) Provide a straw for drinking liquids C) Serve foods at room temperature D) Place 2 tsp of food in the client's mouth at a time - A) Allow for 30 min of rest before meals The nurse should allow the client to rest for 30 min before meals to prevent aspiration. A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate which of the following complications? A) Wound infection
B) Pulmonary embolism C) Thrombophlebitis D) Paralytic ileus - B) Pulmonary embolism Manifestations of a pulmonary embolism include hypotension, tachycardia, and tachypnea. A nurse is reinforcing teaching with a client who has gonorrhea. Which of the following information should the nurse include? A) "Your partner will not require treatment for this infection" B) "You can resume sexual activity as soon as you begin treatment" C) "You are at risk for infertility with this infection, regardless of treatment" D) "You will not be at further risk for this infection following treatment" - C) "You are at risk for infertility with this infection, regardless of treatment" The nurse should inform the client that there is a risk for infertility as a result of this infection. A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority? A) Encourage the client to participate in self-care B) Assist the client with active range-of-motion exercises C) Keep the client in a side-lying position D) Maintain the client's body alignment - C) Keep the client in a side-lying position The greatest risk to the client following a stroke is aspiration. The nurse should position the client in a lateral, or side-lying position, which will allow any secretions to drain out of the mouth, decreasing the risk for aspiration. Additionally, the nurse should have suction available in the event that any secretions are present in the oral cavity. A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first?
A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. Which of the following findings should the nurse expect related to hyperkalemia? A) Polyuria B) Constipation C) Anorexia D) Bradycardia - D) Bradycardia The client who has hyperkalemia can have an irregular, slow heart rate, known as bradycardia. A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. Which of the following actions should the nurse perform first? A) Count the client's respiratory rate B) Ask the client if chest pain is present C) Stop the infusion D) Administer an antihistamine - C) Stop the infusion Evidence-based practice indicates the nurse should stop the infusion of the blood product as soon as manifestations occur because they can indicate a transfusion reaction. A nurse is collecting data from a 55 yr old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT? A) 5 yr history of menopause manifestations B) History of treatment for blood clots C) Topiramate use for migraine headaches D) Increased serum cholesterol levels - B) History of treatment for blood clots
Estrogen increases the risk of blood clots. Therefore, a woman who has a history of blood clots should not receive HRT. A nurse is reinforcing teaching with the family of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching? A) Clean the pin sites every 72 hr B) Use the halo ring to reposition the client when in bed C) Change the sheepskin liner weekly D) Tighten the traction bar as needed - C) Change the sheepskin liner weekly The nurse should provide instruction regarding the care and maintenance of the vest. The instruction should include changing the sheepskin liner when soiled, or at least once per week, to prevent skin irritation. A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority? A) Muscle weakness B) Dysrhythmia C) Abdominal pain D) Lethargy - B) Dysrhythmia When using the airway, breathing, circulation approach to client care, the nurse should identify that the priority finding for a client who has hypokalemia is dysrhythmia. A nurse in a long-term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. Which of the following findings should indicate to the nurse that the client might have a fecal impaction? A) Halitosis B) Hemorrhoids C) Rebound tenderness D) Small liquid stools - D) Small liquid stools
C) "Avoid bending your hips more than 90 degrees" D) You may sleep on a soft mattress" - C) "Avoid bending your hips more than 90 degrees" The nurse should instruct the client to avoid bending her hips more than 90° to prevent dislocation of the replacement hip. A nurse is reinforcing teaching with an adolescent client regarding testicular self-examination. Which of the following statements by the client demonstrates an understanding of the teaching? A) "I will perform the exam before I shower" B) "I will check my testicles every 6 months" C) "I understand that testicular cancer is painless" D) "I understand that pea-sized lumps are normal" - C) "I understand that testicular cancer is painless" Clients should report a lump that is not painful because testicular cancer is typically painless. A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of which of the following? A) Cirrhosis of the liver B) Hypermotility of the bowel C) Intra-abdominal bleeding D) Acute cholecystitis - C) Intra-abdominal bleeding Ecchymosis around the umbilicus is a sign of intra-abdominal bleeding, which is a finding consistent with pancreatitis. A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care? A) Store the CPM machine on the floor when it is not in use
B) Keep a sheepskin pad between the client's extremity and the CPM C) Check the cycle and range-of-motion settings at least every 12 hr D) Align the frame joint of the CPM with the middle of the client's calf - B) Keep a sheepskin pad between the client's extremity and the CPM The nurse should plan to keep a sheepskin pad between the client's extremity and the CPM machine to protect the client's skin. The nurse should check the client's skin condition frequently while the client is using the CPM. A nurse is monitoring a client who recently has a cast placed on the right lower extremity for a bone fracture. Which of the following findings should the nurse recognize as abnormal? A) Report of a dull, throbbing pain B) Extremities that are cool bilaterally C) Capillary refill of 3 seconds in the nail beds of the toes D) Lack of sensation between the first and second toes - D) Lack of sensation between the first and second toes Lack of sensation between the toes indicates peripheral nerve impairment and is an abnormal finding that can indicate the client has compartment syndrome. The nurse should notify the provider immediately. A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process? A) "I should call my doctor if I get a headache" B) "I may develop gastric reflux" C) "I may develop excessive bruising" D) "I should call my doctor if my ankles swell" - D) "I should call my doctor if my ankles swell" Swelling of the ankles can indicate heart failure. The client should report this finding to the provider. A nurse is providing discharge teaching for the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?
A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include? A) "You can take acetaminophen for pain" B) "Consume a diet high in animal protein" C) "Sleep lying flat on your back" D) "Consume foods low in sodium" - D) "Consume foods low in sodium" The nurse should instruct the client to consume foods low in sodium to reduce the development of edema and ascites. A nurse is reviewing the medical record of a client who has a prescription for morphine. Which of the following findings should the nurse report to the provider? A) Urinary retention B) Administration of celecoxib 24 hr ago C) History of immunosuppression D) Administration of levothyroxine 12 hr ago - A) Urinary retention The nurse should recognize that administering morphine to the client can cause urinary retention. Therefore, the nurse should report this finding to the provider. A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following actions should the nurse take? A) Position pillows between the bony prominences B) Check for incontinence every 3 hr C) Massage reddened areas of the skin D) Elevate the head of the bed to 45 degrees - A) Position pillows between the bony prominences The nurse should use positioning devices to keep bony prominences from being in direct contact with each other, which will prevent skin breakdown and pressure ulcer development.
A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include? A) "You should have a screening for glaucoma every 5 years" B) "You should have a physical examination every other year" C) "You should have your hearing checked every 2 years" D) "You should have a pneumococcal immunization every 10 years" - D) "You should have a pneumococcal immunization every 10 years" The nurse should remind the client to have a pneumococcal immunization at age 65 and every 10 years thereafter to protect her from acquiring pneumonia. A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching? A) Apply cold packs to the inflamed joints B) Participate in high impact exercise C) Carry a hand purse rather than a shoulder bag D) Sleep on a soft foam mattress - A) Apply cold packs to the inflamed joints The nurse should instruct the client to use both warm and cold packs on inflamed joints to decrease pain. A nurse is preparing to auscultate bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening in the left upper quadrant, the nurse should identify this sound as which of the following? A) Hyperactive bowel sounds B) Friction rub C) Normal bowel sounds D) Abdominal bruit - A) Hyperactive bowel sounds
D) Encourage the client to perform passive range-of-motion exercises. - C) Maintain abduction of the client's right leg while in bed. The nurse should maintain abduction of the client's right leg to prevent dislocation of the affected hip by placing an abductor pillow between the client's legs when resting in bed. A nurse is caring for a client who is 24 hr postoperative following abdominal surgery and has an NG tube. Which of the following actions should the nurse plan to take to decrease the risk of postoperative complications? A) Offer sips of water to the client following oral care. B) Massage the client's lower extremities with lotion every 2 hr. C) Encourage the client to use an incentive spirometer every hour while awake. D) Place one or two pillows beneath the client's knees while he is in bed. - C) Encourage the client to use an incentive spirometer every hour while awake. The nurse should assist the client to use the incentive spirometer in addition to coughing and deep breathing every hour while awake for the first 24 hr postoperatively and at least every 2 hr while awake thereafter. An incentive spirometer will inflate the client's alveoli and improve ventilation to prevent postoperative pneumonia. A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke. Which of the following interventions should the nurse plan to implement first? A) Collaborate with a dietitian. B) Provide nutritional supplements. C) Recommend a referral for a speech language pathologist. D) Inform assistive personnel about proper positioning. - C) Recommend a referral for a speech language pathologist. The greatest risk to the client following a stroke is injury from aspiration. Therefore, the first intervention the nurse should include in the plan of care is to recommend a referral for a speech language pathologist. A speech language pathologist can conduct a swallow study to determine the client's risk for aspiration, provide teaching to the client regarding swallowing techniques, and recommend the consistency of foods and liquids.
A nurse is caring for a client who is in Buck's traction. Which of the following interventions should the nurse perform to reduce skin breakdown? A) Keep the skin dry and free of perspiration. B) Use hot water and antibacterial soap to bathe the client. C) Massage the skin over bony prominences to promote circulation. D) Limit the use of moisturizers on the skin over bony prominences. - A) Keep the skin dry and free of perspiration. The nurse should not leave moisture on the skin for prolonged periods of time because it can cause skin breakdown. A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is receiving epoetin alfa. The nurse should identify that which of the following laboratory values indicates the treatment is effective? A) BUN 40 mg/dL B) Hgb 11 g/dL C) Urine specific gravity 1. D) Blood glucose 105 mg/dL - B) Hgb 11 g/dL Epoetin alfa stimulates the production of erythropoietin and red blood cells, resulting in increased hemoglobin levels. Therefore, a hemoglobin level of 11 g/dL indicates the epoetin alfa treatment is effective. A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? A) Consume a low-purine diet. B) Avoid stopping this medication suddenly. C) Use chamomile tea to alleviate insomnia. D) Take this medication on an empty stomach. - B) Avoid stopping this medication suddenly.
