Download NUR 155 MED-SURG FINAL EXAM|2025-2026|ACTUAL 155QS&AS|A+GRADE and more Exams Nursing in PDF only on Docsity!
NUR 155 MED-SURG FINAL EXAM|2025-
2026|ACTUAL 155QS&AS|A+GRADE
The Client is 4 hours post-op TURP for BPH and reports hematuria. What is the nurse's next action? Inform the client this is an expected outcome for up to 12 hours postop. The nurse is preparing to administer benztropine for a client. The nurse knows this medication is used to treat what disease? Parkinson’s disease Risk factors for PVD? HTN, HLP, smoking, family history What discharge education should be reviewed with the client with hypocalcemia? Compliance with calcium and vit. D replacements, eats foods high in calcium. The nurse knows enalapril is prescribed to treat this condition. Cardiac afterload in clients with heart failure.
The nurse is caring for a client with liver cirrhosis and an elevated ammonia level. What should the nurse assess? Mental status changes. A priority nursing concern for a client with a fractured tibia would be this. Compromised circulation A client is admitted with a BP of 88/56, HR 115, and dry mucous membranes. Which lab value should the nurse monitor to support a diagnosis of dehydration? Increased sodium level. The nurse is preparing to send a client for dialysis treatment. What should the nurse assess prior to sending the patient? Assess AV fistula site for thrill and bruit, obtain weight, and vital signs. The nurse is caring for a patient at risk for fluid imbalance. What should the nurse include on the patient's plan of care? Monitor intake and output, daily weights, monitor electrolyte levels, assess lung sounds.
The nurse is providing education to a client newly diagnosed with diabetes insipidus. What should the nurse include in the teaching plan? Encourage adequate oral intake. The NG tube is accidentally removed in a client who is post-op whipple procedure. What should be the nurse's next action? Notify the HCP/surgeon. These are considered complications of restraint use. Impaired circulation, aspiration, anxiety, impaired skin integrity, respiratory distress. Post thyroidectomy, the patient is complaining of tingling in the lips. What should the nurse's next action be? Check for Chvostek's sign. These can lead to macrovascular complications of diabetes mellitus. smoking , elevated glucose levels, obesity.
The client is having an acute exacerbation of asthma. What medication can be used to treat this exacerbation? Albuterol These are expected lab values in a client with HIV. Decreased CD4 count and increased viral load. When should the nurse question the administration of NS IV fluids? If the client has severe hypernatremia, CHF, or Renal failure. When caring for a client with acute exacerbation of gout, the nurse should provide this education regarding dietary modifications diet low in purine, limited alcohol use The nurse is providing medication education to a client with post acute asthma attack. The nurse knows the education is effective if the client states the medication will prevent asthma exacerbations. montelukast This should be included in the teaching plan for a client that is newly started on carbidopa-levodopa
The nurse recognizes these as risk factors for seizure activity CVA, hypoxemia, childhood fever, head injury, sodium imbalance, HTN, genetic or metabolic conditions, brain tumor and drug withdrawal This nursing intervention is aimed at reducing muscle weakness in a patient with Myasthenia Gravis Assisting with patients ADL's The nurse should expect to see these assessment findings in a patient with Bell's Palsy weakness/paralysis of one side of the face, inability to puff up cheek, or close eye on affected side of face, difficulty with speech or eating Bell's palsy affects Cranial Nerve 7 These nursing interventions are appropriate for a patient with right sided hemiplegia and dysphagia after a stroke allow plenty of time to eat, proper positioning for eating, assist with ADL A patient that reports calf pain that gets better with rest peripheral arterial disease (PAD)
What is a priority nursing intervention for a patient in sickle cell crisis apply ordered O2 therapy to maintain sat >90% The nurse recognizes these as common side effects as thiazide diuretics dehydration, hypokalemia, hyponatremia, hypercalcemia, hypomagnesemia, muscle cramps A patient with a suspected PE will likely report the following signs or symptoms SOB, dyspnea, anxiety, tachypnea, chest/pleuritic pain, diaphoresis, apprehension A nurse is admitting a client diagnosed with pneumonia. What assessment findings should the nurse anticipate? cough, elevated WBCs, dyspnea, tachypnea, adventitious lung sounds, chest pain, fatigue, sputum, fever, chills, non/productive cough, myalgia A patient diagnosed with Meniere's disease should be educated on this dietary modification limit sodium intake
A client reports to the ED with complaints of a rash on arms and chest area. What info should the nurse obtain from the client? assess for food/medication/environmental allergies, when rash began, any travel outside of the country This is a priority nursing diagnosis for a patient with an acute exacerbation of Meniere's disease Risk for injury related to impaired balance A patient has been diagnosed with osteoarthritis and is started on a new NSAID. What should the nurse include in the teaching plan regarding this medication? take with food to reduce gastric irritation, avoid alcohol, discontinue use 5-7 days prior to surgery The nurse is providing education to a client diagnosed with scleroderma. What should the nurse include in the teaching plan? maintain skin integrity, assistance with mobility and ADLs, maintain comfort, pain management during Raynaud's exacerbation The nurse is admitting a new client to the unit with heart failure. What task can the nurse delegate to the UAP to help monitor for early signs of HF? Obtain daily weights
The nurse is admitting a client with influenza to the med surg unit. The nurse should expect to implement these types of precautions. Standard and droplet precautions The nurse is preparing to administer the following meds: digoxin, warfarin, metoprolol, lisinopril and spironolactone. The UAP reports the following VS: BP 146/82, HR 50, temp. 99.2. Which meds should the nurse hold? digoxin and metoprolol A client cannot elicit a gag reflex is likely to have a deficit of which cranial nerve? The vagus nerve A client with pernicious anemia is given a B12 injection rather than orally d/t what factor? An inability of the stomach to secrete intrinsic factor necessary for B12 to be absorbed orally The nurse walks in and finds the client with SOB, anxiety, and lying supine in bed. The nurse knows to place the patient in this position to assist w/ lung expansion.
These are considered risk factors for developing pneumonia age, respiratory conditions, compromised immune system, environmental exposure, swallowing im,pairment and lifestyle habits The nurses are caring for a client diagnosed with pneumonia. what interventions can the nurse anticipate implementing. pulmonary hygiene, encourage incentive spirometry use, aspiration precautions, proper positioning, oxygen therapy if ordered to keep sats >90%, encourage fluid and adequate nutrition, ABX therapy as ordered, monitor sputum for color/consistency To prevent shoulder subluxation in a patient with L sided hemiplegia after a CVA, the nurse should implement these interventions move affected side gently and slowly, encourage use of sling on affected side if indicated, use pillow to maintain proper body alignment if needed These are considered risk factors for developing end-stage renal disease (ESRD). 8 things
- Obesity · Diabetes Mellitus · Hypertension · Sickle Cell Disease
· Lupus · chronic Glomerulonephritis · Polycystic Kidney Disease · nephrotoxic drugs The nurse is preparing to obtain a wound culture of a wound with purulent drainage. What should the nurse do prior to swabbing the wound? Cleanse/irrigate the wound with normal saline. This would be a therapeutic effect of Omeprazole. ( - prazole, PPI, blocks production of gastric acid) Relief of burning sensation in the chest after eating a meal What education should be reviewed with the client to reduce exacerbations of Gastritis? · smoking cessation · avoid spicy foods · No alcohol · No caffeine · No coffee ·avoid NSAIDs
· dry/itchy skin · decreased urine output · blood in urine · shortness of breath These laboratory values are consistent with a diagnosis of Liver Disease. · increased ALT/AST · decreased albumin · increased bilirubin · increased ammonia · increased PT/INR These are considered "independent" nursing interventions for a client with a bleeding gastric ulcer. · complete a physical assessment · assess for bleeding · monitor I&Os A client is post op Whipple procedure. What intervention can the nurse anticipate to implement related to loss of endocrine function after this procedure?
monitor blood sugars A client who has a primary IV now has a secondary antibiotic to be infused. What action(s) should the nurse take?
- lower the primary IV bag
- program the volume and time for the secondary IV 3.swab the access port on the primary tubing with alcohol prior to connecting the secondary tubing What instructions should the nurse give to a client with a hiatal hernia complaining for abdominal/sternal pain after eating and when lying down? · avoid caffeine/spicy foods · follow a low-fat diet · maintain normal body weight The nurse is caring for a client with a diagnosis of Nephrolithiasis. What interventions can the nurse expect to implement? · strain all urine · assess urine for color/clarity/odor · increase oral fluid intake · monitor I&Os
exposure to recent triggers such as... o injury o stress o infection o cold weather ocertain foods/medications These are appropriate nursing interventions for a client with ascites · monitor daily weights · low sodium diet · measure abdominal girth ·administer diuretics as ordered To obtain accurate intake and output for a client receiving continuous bladder irrigation (CBI), the nurse knows he/she must do this. subtract the volume of irrigation solution infused from the total output These are considered risk factors for non-viral hepatitis. · alcohol abuse · Type I DM
· Lupus · toxins · certain medications such as Tylenol, Augmentin The nurse is preparing to administer the following medications at 0900: Colace, clopidogrel, calcium acetate, Estrogen, omeprazole, and epoetin alfa. Which medications are used to manage symptoms of ESRD. calcium acetate and epoetin alfa These assessment findings can be expected in a client with Vitamin K deficiency due to Liver Cirrhosis. petechiae, purpura and bruising These topics should be included in the teaching plan for a client with Peptic Ulcer Disease (PUD). · smoking cessation · avoid spicy foods · avoid alcohol, caffeine, coffee · avoid foods that produce pain · avoid extreme temperature of food/beverages · avoid NSAIDs
