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MEDSURG Q & A.
1. A nurse is caring for a client who has a central venous access device and notes the tubing has become disconnected. The client develops dyspnea and tachycardia. Which of the following actions should the nurse take first? a. Obtain ABG values b. Perform an ECG c. Turn the client to his left side d. Clamp the catheter 2. A nurse is providing discharge teaching to a client who has impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching? a. Wash your perineal area 2 times each day with antimicrobial soap b. Change the water in your drinking glass every 4 hours c. Wash your toothbrush in the dishwasher once each month d. Change your pet litter box daily 3. A nurse is caring for a client who has advanced liver disease. Which of the following laboratory results should the nurse monitor when assessing the client? a. Serum Ammonia b. Glucose level c. Phosphate level d. Serum troponin 4. A nurse is caring for a client who has admitted with nausea, vomiting, and a possible bowel obstruction. An NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider? a. The client reports being extremely thirsty with a sore throat b. The amount of drainage is gradually decreasing c. The clients abdomen becomes distended and firm d. The drainage is bright green in color with brown fecal material 5. A nurse is caring for a client who takes Lisinopril for HTN. Which of the following client statements indicates an adverse effect of the medication?
a. I have a heightened sense of taste
d. PD manifestations worse due to the clients decreased production of acetylcholine.
10. A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin? a. Thrombocytopenia b. Thalassemia c. Rheumatoid arthritis d. COPD 11. A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are testing on the floor. Which of the following actions should the nurse take? a. Pull the client up in bed b. Tie knots in the ropes near the pulleys to shorten them c. Increase the elevation of the affected extremity d. Remove one of the weights 12. A nurse is reviewing a medical record of a client who has acute gout. The nurse expects an increase in which of the following laboratory results? a. Intrinsic factor b. Chloride level c. Uric acid d. Creatinine kinase 13. A nurse is providing teaching to a client who is to start furosemide therapy for heart failure. Which of the following statements indicates that the client understands a potential adverse effect of this medication? a. “I will check my pulse before I take this medication.” b. “I’ll check my blood pressure so it doesn’t get too high.” c. “I’m going to include more cantaloupe in my diet.” d. “I will try to limit foods that contain salt.” 14. A nurse is assessing a client who is 12hr postoperative following a colon resection. Which of the following findings should the nurse report to the surgeon? a. Heart rate 90/min
b. Absent bowel sounds c. Hgb 8.2 g/dl d. Gastric pH of 3.
15. A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the nurse plan to administer? a. Desmopressin b. Regular insulin c. Furosemide d. Lithium carbonate 16. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following test should the nurse monitor? a. Fasting blood glucose b. Stool for occult blood c. Urine for white blood cells d. Serum calcium 17. A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.) a. Obtain a sputum sample for culture b. Prepare the client for a chest x-ray c. Initiate airborne precautions d. Administer ondansetron. 18. A nurse is contacting the provider for a client who has cancer and is experiencing breakthrough pain. Which of the following prescriptions should the nurse anticipate? a. Transmucosal fentanyl
d. Blood pressure 90/50 mm Hg
23. A nurse is reviewing a client’s ABG results pH 7.42, PaC02 30 mm Hg, and HCO3 21 mEq/L. The nurse should recognize these findings as indication of which of the following conditions? a. Metabolic acidosis b. Metabolic alkalosis c. Compensated respiratory alkalosis d. Uncompensated respiratory acidosis 24. A nurse is caring for a client who has a deep partial thickness burns over 15% of her body which of the following labs should the nurse expect during the first 24 hours a. Decreased BUN b. Hypoglycemia c. Hypoalbuminemia d. Decreased Hematocrit 25. A nurse is caring for a client who has dumping syndrome following a gastrectomy, which of the following actions should the nurse takes? a. Offer the client high carbohydrate meal options b. Provide the client with four full meals a day c. Encourage the client to drink at least 360 ml of fluids with meals d. Have the client lie down for 30 minutes after meals 26. A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which of the following factors should the nurse include in the teaching? SATA a. Born with a high weight b. Chronic infections of the middle ear c. Use a loop diuretic such as furosemide and antibiotics like aminoglycoside and gentamicin d. Perforation of the ear drum e. Frequent exposure to low volume noise 27. A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take?
b. I should increase my intake of canned salmon to three times per week c. I will season my food with lemon pepper rather than salt d. I should limit my intake of hard cheese to 3 ounces each day
32. A nurse is caring for a client who has a peripherally inserted central catheter. The client is receiving an antibiotic via intermittent IV bolus. Which of the following actions should the nurse take? a. Administer 20 ml of 0.9 sodium chloride after each dose of medication b. Flush the catheter using a 5 ml syringe c. Verify the placement with an x-ray prior to the initial dose d. Change the transparent membranes dressing daily 33. A nurse is teaching a client using a metered dose rescue inhaler. Which of the following statements should the nurse include in the teaching? a. Do not shake your inhaler before use. b. Exhale fully before bringing the inhaler to your lips c. Depress the canister after you inhale d. Use peroxide to clean the mouthpiece if your inhaler 34. A nurse is assessing the pain status of a group of clients. Which of the following findings indicate a client is experiencing referred pain? a. A client who has angina reports substernal chest pain b. A client who has pancreatitis reports pain in the left shoulder c. A client who is postoperative reports incisional pain d. A client who has peritonitis reports generalized abdominal pain 35. A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessments findings requires immediate intervention by the nurse? a. The client reports a pain level of 7 on a scale from 0 -10 at the operative site. b. The client’s capillary refill in the left toe is 6 c. The client has an oral temperature of 38.3 (100.9 F) d. The client has 100 ml of blood in the closed suction drained. 36. A nurse is assessing a client who has acute pancreatitis and has been receiving total parenteral nutrition for the past 72 hours. Which of the following findings requires the nurse to intervene?
d. Monitor for hypokalemia as a manifestation of acute rejection
41. A nurse is obtaining a medication history from a client who is to start therapy with naproxen for rheumatoid arthritis. Which of the following medications places the client at risk for bleeding? a. Captopril b. Ibuprofen c. Digoxin d. Phenytoin 42. A nurse is assessing the extremities of a client who has Raynaud’s disease. Which of the following findings should the nurse expect? a. Blanching of the hands b. Hyperactive reflexes c. Calf pain with foot dorsiflexion d. Vitiligo on affected extremities 43. A nurse is caring for a group of clients. The nurse should obtain a blood pressure reading using only the left extremity from which of the following clients? a. A client who has a peripherally inserted central catheter in the left arm b. A client who has left-sided Bell’s palsy c. A client who has a right upper extremity arteriovenous fistula d. A client who has right-sided weakness due to Parkinson’s disease 44. A nurse is providing teaching to a client who has DVT. Which of the following findings should the nurse identify as a risk factor for the development of DVTs? a. Hypertension b. Cirrhosis c. NSAIDS use d. Oral Contraceptive Use 45. A nurse is caring for client who has Cushing’s disease. Which of the following actions should the nurse take first? (Click Exhibit button for additional information)
b. Verify the client’s understanding of sodium restriction. c. Auscultate the client’s lung sound d. Determine the need for further glucose monitoring.
46. A nurse is assessing a client who has nephrotic syndrome. Which of the findings should the nurse expect? a. Proteinuria b. Flank pain c. Hyperalbuminemia d. Hypotension 47. A nurse is assessing a client who has right-sided heart failure. Which of the following assessment findings should the nurse expect to find? a. Oliguria b. S3/S4 galloping heart sounds c. Poor skin turgor d. Pitting edema 48. A nurse is caring for a client who has newly inserted chest tube. The nurse should clarify which of the following prescriptions with the provider? a. Notify the provider when tidaling ceases. b. Assisting the client out of bed three times daily. c. Vigorously strip the chest tube twice daily. d. Administer morphine 2 mg IV bolus every 3 hr PRN for pain. 49. A nurse is teaching a client who is taking an ACE inhibitor for heart failure. Which of the following instructions should the nurse include for home management of heart failure? a. Obtain daily weight. b. Use of salt substitute. c. Monitor Intake and Output d. Limit daily activity. 50. A nurse is providing discharge teaching to a client who has a permanent pacemaker. Which of the following statements by the client indicates an
understanding of the teaching?
b. May operate a motor vehicle when no longer taking analgesics
c. Take tub baths instead of showers d. May place a small pillow under the head when sleeping
55. A nurse is assessing for elderly signs of compartment syndrome for a client who has a short leg fiberglass cast. Which of the following findings should the nurse expect? a. Bounding distal pulses b. Capillary refill less than 2 seconds c. Erythema of the toes d. Intense pain with movement 56. A nurse is caring for a client who is postoperative following coronary artery bypass surgery and reports shortness of breath. The nurse administers oxygen at 3L/min and obtains arterial blood gases 60 min later. Which of the following lab findings indicates a positive response to the oxygen therapy? a. PaCO2 34 mmHg b. Bicarbonate 20 mEq/L c. PaO2 90 mmHg d. ph 7. 57. A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear (VIII)? a. Loss of the peripheral vision b. Disequilibrium with movement c. Deviation of the tongue from midline d. Inability to smell 58. A nurse is caring for a client admitted with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse? a. Glasgow coma scale score changes from 14 to 9 b. Bilateral pupil diameter changes from 4 to 2 mm c. Pulse pressure changes from 30 to 20 mm Hg d. WBC count changes from 9000 to 16,000 mm
