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1. A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)
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A nurse is assessing an older adult client who is receiving VI therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? (select all that apply)
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Med Surg 11
Med surg Final
| Question | Answer |
|---|---|
| 1. A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) | Increased, blood pressure, increased heart rate , increased respiratory rate |
| A nurse is assessing an older adult client who is receiving VI therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? (select all that apply) | Bounding pulse, pitting edema, crackles upon aucultation |
| Patient with burning injuries, what happen with their fluids? | Dehydration due to cellular damage, shift of fluid from the intra cellular to extra cellular. |
| A nurse is in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which following interventions should the nurse perform first? | Administer IV Fluids |
| A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hr following a burn injury? | Lacted Ringer's |
| A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? | Heart rate |
| A nurse is caring for four hospitalized clients. Which of the following client should the nurse identify as being at risk for fluid volume deficit? | The client who has gastroenteris and is febrile |
| A nurse is assessing client who is 3 days postoperative following abdominal surgery and notes the abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect? | Paralytic ileus |
| A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolis (VTE). The nurse should instruct the client to avoid which of the following unsafe actions? | Massaging her legs |
| A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). the client tells the nurse, I" can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up " Which of the following actions sh | Encouraging the client to drink 2 to 3 L of water dialy. |
| A nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy of breast cancer. Which of the following findings should the nurse report of the provider? | WBC 2300 /mm3 |
| A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority? | CD4-T -cell count 180 cells/nim3 |
| A nurse is reviewing the diagnostic test results of an older adult female client who is preoperative for ankle arthroplasty. the nurse should notify the surgeon of which of the following results? | WBC count 20,000/mm3 |
| A nurse is reviewing the laboratory findings for a client who has idiopathic thrombocytopenic purpura (ITP) Which of the following findings should the nurse expect to be decreased? | Platelets |
| A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productie cough and is SOB. The nurse should anticipate which of the following assessment finding f | Increased ante posterior diameter to the chest |
| A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? | Dyspnea, Barrel chest, clubbing of the fingers |
| A nurse in a clinic sees a client who has an acute asthma exacerbation. Which of the following medications should reduce the symptoms? | Albuterol via jet nebulizer |
| A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse' s highest priority? | Administering a nebaulized beta-adrenergic |
| A nurse is caring for a child who is experiencing status asthmatics. Which of the following interventions is the priority fo the nurse to take? | Administer a shor-acting B2 agonist (SABA) |
| A nurse is caring for a client who has asthma and is taking fluticasone. The nurse should monitor the client for which of the following adverse effect? | Oral candidiasis |
| A nurse is admitting a client who having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications? | Propranolol |
| A nurse is teaching a client who has been taking prednisone to treat asthma an has a new prescription to discontinue the medication. the nurse should explain to the client to reduce the dose gradually to prevent which of the following adverse effects? | Adrenocortical insufficiency |
| A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to client ? | A cup canned black beans |
| A nurse is reviewing the laboratory results of a client who has acute leukemia and received an aggressive chemotherapy treatment 10 days ago. Which of the following hematologic laboratory values should the nurse expect? (select all that apply) | Decreased platelet count, Decreaed leukocyte count, Decreased erythrocyte count |
| A nurse is assigned to care or a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura (ITP). When receiving the client, the nurse should recognize that the priority concern in caring for a client is to monitor for | Bleeding |
| A patient with squamous cell carcinoma has been schedule for treatment of this malignancy. the nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention? | Surgical excision |
| While performing an initial assessment of a patient admitted with appendicitis, the nurse observes an elevated blue-black lesion on the patient's car. the nurse knows that this lesion is consistent with what type of skin cancer> | Malignant melanoma |
| A nurse is assessing a client who has systemic lupus erythematosus (SLE). which of the following findings should the nurse expect? | Facial rash |
| A nurse is preparing a presentation at a community center about systemic lupus erythematous (SLE).The nurse should plan to include which of the following findings as a manifestation of SLE? | A raised rash |
| A 65 year-old man presents at the clinic complaining of nodules on both legs. The man tells the nurse that his son, who is medical school encouraged him to seel prompt care and told him that the nodules are realted to the fact that he is Jewish. What heal | Classikc Kaposi sarcoma |
| A nurse is caring for a client who has a history o exposure to TB and symptoms of night sweats and hemoptysis. Which of the following test should the nurse realize is the most reliable to confirm the diagnosis of actie pulmonary TB? | Sputum culture for acid-fast bacillus |
| A nurse is caring for a client who has a mild traumatic brain injury TBI. Which of the following manifestations should the nurse immediately report to the provider? | A change in the Glasgow Coma Scale score for 13 to 1 |
| A nurse is receiving a transfer report for a client who has a head injury the client has a Glasgow Coma Scale (GCS) score of 3 for eye opening. 5 for best verbal response, and 5 for best motor reponse .Which of the following is an appropiate conclusion ba | .The client opens his eyes when spoken to |
| A nurse is assessing a client who has menigitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. which of the following conditions is the client displaying? | Brudzinki's sign |
| A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following action should the nurses take? | Notify emergency management services |
| A nurse who is of duty finds a woman who has collapsed an has right, sided weakness and slurred speech. Which of the following actions should the nurse take? | Call emergency services |
| A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. which of the following actions should the nurse take first? | Evaluate the clinet's neurological status |
| A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect? | Severe headache |
| A nurse in the emergency department is caring for a client who has myasthenia gravis and is in crisis. Which of the following factors should the nurse identify as a possible cause of myasthenic crisis? | Developing a respiratory infection |
| A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestation should the nurse monitor? | weakness |
| A nurse is assessing a client who has a suspected diagnosis of Guillain-Barr'e syndrome (GBS) Which of the following questions should the nurse ask the client? | Have you had a recent influeza infection? |
| A nurse is planning care for a client who is being teated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. the nurses should include which of the following restrictions in the client plan of care? | Fresh flower and poted plants in the rooom |
| A nurse is preparing a client who has AIDS for discharge. Which of the following statements should the nurse include in the discharge istruction? | Prevent the spread of infectio with good household cleaning practices |
| A nurse is caring for a client who has aT-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client at risk for experiencing autonomic dysreflexia? | The client's bladder becomes distended. |
| A nurse is providing dischage teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatietn radiation therapy the next day. Which of the following instruction about maintaning skin integrity should the nurse i | Do not apply heart to the area of irradiation |
| A nurse is assessing a client 15 min after administering morphine sulfate 2mg via VI push. The nurse should identify which of the following finds as an adeverse effect of the medication? | Resperiatory rate 8 min. |
| A nurse is administering morphine 2 mg VI every 2 to 4 hr. to a client who has an abdominal incision. The nurse should monitor the client for which of the following adverse effects? | Orthostatic hypotension |
| A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which following actions should the nurse take? | Auscultate bowel sounds |
| A nurse is planning a diet for a client who is iron deficient. Which of the following foods high in iron should the nurse include in the plan? | Red meat |
| A nurse is assignee to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura(ITP). When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for the | Bleeding |
| A nurse is planning care for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following manisfestations most appropriate for the nurse to monitor? | Eccymosis |
| A nurse is reviewing the laboratory findings for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following findings should findings should the nurse expect to be decreased? | Platelets |
| A nurse is reviewing a client's CBC findings and dicovers that the client's platelet count is 9,0000/mm3. The nurse should monitor the client for which of the following? | Spontaneous bleeding |
| A nurse is planning care for a client sho is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should inclued which of the following restrictions in the client' plan of care? | Fresh flowers and potted plants in the room |
| A nurse is assessing a client who is postoperative following a vaginal hysterectomy. which of the following findings is a manifestion of deep-vein thrombosis (DVT)? | Uniteral leg edema |
| A nurse is caring for a client is postoperative following vascular surgery. Which of the following signs and symptoms indicates that the patient had developed a thrombus? | dull, aching calf pain |
| A nurse is providing discharge instructions to a client who developed deep-vein thrombosis (DVT) postoperatively and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include? | Flexing her knees and feet frequently |
| A nurse is planning care for a client who has deep- vein thrombositis (DVT) and is receiving anticoagulation therapy. Which of the following interventions should the nurse include in the plan of care? | Encourage the client to walk. |
| A nurse is planning care for a client who has deep vein thrombosis of the lower leg. Which of the following interventions should the nurse include in the plan of care? | Keep the client's affected leg elevated while in bed |
| A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions? | Massaging her legs |
| During a routine physical examination, a nurse observes a 1 cm (0.4 in)Lesion on a client's chest . The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this findings is suggestive of which of the following typ | Basal cell carcinoma |
| A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include? | Basal cell carcinoma has a low incidence of metastatis. |
| A nurse is assessing a client who has basal cell carcinoma on her nose. The nurse should expect which of the following findings? | A small, translucent papule with rolled borders. |
| A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values shoud give the nurse the best indication of the client's renal function? | Serum Creatinine |
| A nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants risks of basal cell carcinoma (BCC)? | Teaching particpants to limit their sun exposure. |
| A nurse is teaching a client about risk factor for skin cancer. Which of the following statements by the client indicates an understading of the teaching? | "I should apply sunscreen prior to going outside, even in the winter months" |
| A nurse is planning care for client who is confined to bed. Which of the following action should the nurse include in the pain? | Reposition the client every 2 hr |
| A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider? | Difficulty swallowing |
| A nurse in an emergency room is caring the client who sustained partial-thickness burns to both lower legs, chest face, and both forearms. Which of the following is the priority action the nurse should take? | Inspect the mouth for signs of inhalation injuries |
| A nurse is caring for a client who has herpes zoster. Which of the following findings should the nurse expect? | Painful lesions following a nerve pathway. |
| A nurse is assessing a client at a dermatology clinic. Which of following findings places the client at risk for developing malignant melanoma? | History of chronic skin irritation |
| A nurse is caring for an adult client who has atopic dermatitis Which of the following findings should the nurse expect? | Chronic rash with thick skin |
| A nurse is planning care for an older adult client who has herpes zoster. Which of the following interventions should the nurse include in the plan? | Administer analgesics for pain |
| A nurse is caring for a client who has herpes zoster.which of the following action should the nurse take? | Prepare to administer acyclovir |
| A nurse is formulating a teaching plan about herpes zoster for a group of older adults at a community center. The nurse should include which of the following information in the plan? | " Many clients experencience pain in the affected are for weeks after the lesion have resolved |
| Findings when you assess a patient with psoriasis. A nurse in the outpatient clinic is assessing a client who has psoriasis. The nurse should expect which of the following findings? | Silvery, white scales |
| A nurse is developing a teaching plan for a client who has psoriasis. Which of the following actions should the nurse include in the plan? | Identify effective stress reduction techniques |
| A nurse is providing teaching to a client who has psoriasis and a new prescription for the topical corticosteroid cream betamethasone valerate. Which of the following information should then nurse include in the teaching? | Wrappiing plastic around the site can increase the medication's effectiveness |
| A nurse is developing a teaching plan for a client who has psoriasis. Which of the following information should the nurse include in the plan? | Use bath oils to soften and soothe the skin. |
| A nurse is assessing a client who reports a nevus that has increased in size and an irregularly shaped lesion that varies in color. These findings are consistent with which of the following medical diagnoses? | Malignant melanoma |
| A nurse is assessing a client who presents to the provider's office for evaluation of multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy? | Irregular borders |
| A nurse is caring for a client who has malignant melanoma. Which of the following findings should the nurse expect when assessing the lesion? | Purplish in color |
| A nurse is providing teaching to a client who has superficial lesion and had a biopsy indicates malignant melanoma. The nurse should include which of the follwoing options as the treatment of choice? | Surgical excision |
| While performing an initial assessment of patient admitted with appendicitis, the nurse observes an elevated blu-black lesion on the patient ear. The nurse knows that this lesion consistent with what type of skin cancer? | Malignant meloma |
| A patient with a suspected malignant melanoma is referred to the dermatology clinic. The nurse know to facilitate what diagnostic test to rule out a skin malignancy? | skin biopsy |
| A nurse is assessing a client who has viral rhinitis and a history of herpes simplex virus type 1 (HSV-1 lesions. The nurse should assess which of the following areas of the body for the recurrence of HSV-1 lesions? | Mouth |
| A nurse is teaching a cliet who has herpes simples virus type 2 disease transmission. Which of the following statements by the client indicates understanding of the teaching? | Itching or tingling occurs at the site where a blister forms |
| A nurse in a provider's office is assessing a client who has AIDS. The nurse notes that the client has multiple and widespread raised, purplish brownskin lesions. The nurse should recognize that these findings indicate which of the following condition? | Kaposi's sarcoma |
| A nurse is teaching a client who has a new prescription for topical betamethasone to treat contract dermatitis.. Which of the following instructions hould the nurse include? | Use the cream for a few days after the area has healed |
| A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following actions should the nurse plan to take? | Administer an antiemetic prior to the procedure |
| A nurse is instructing a client how to decrease the nausea associated with chemotherapy and radiation. Which of the following statements indicates an understanding of the teaching? | I will eat foods that are served at room temperature |
| A nurse is teaching a client about the side effects of chemotherapy medication. Which of the following nursing statements shluld th enurse include in the teaching? | Hair loss is common and includes eyeslashes. |
| A patient arrives in the emergency department after being burned in a house fire. The patients burn cover the face and the left forearm. What extent of burns does the patient most likely have? | 18% |
| A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines, the nurse should document burns to which percentage of client total body surface area (TBSA)? | 54 percent |
| A nurse in a emergency department is caring for a client who has deep partial and full thickness burns to his chest, abdomen, and upper arms. What is the nurse 's priority intervention for this client during the resuscitation of phase of injury? | Maintain the airway. |
| A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect? | Hyperkalemia |
| A nurse is caring for a group of clients in a infectious disease unit. The nurse should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases? | Tuberculosis |
| A nurse is caring for a client who has active pulmonary tuberculosis(TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the cliient safely to the radiolog | Have the client wear mask. |
| A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client? | Airbone |
| A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client 's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82 min, r | Hemorrhagic stroke |
| A nurse is caring for a client who had hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect? | Manifestations preceed by a severe headache WORSE |
| If you are in certain place, and you are out of duty, and you find a person that suddenly has a stroke and collapsed, What are you going to do? | Call 911 |
| A nurse is receiving a transfer repotr for a client who has a head injury. The client has Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response and 5 for best motor response. Which of the following is an appropriate conclusion b | The client opens his eyes when spoken to |
| A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first? | Evaluate the client's neurological status |
| A nurse in the emergency in the emergency department is caring for a client who has maysthenia gravis and is in crisis. Which of the following factor should the nurse identify as a possible cause of myathenic crisis? | Developing a respiratory infection |
| A nurse is assesing a client who has socre of 6 on the Glasgow Coma Scale. the nurse should expect which of the following outcomes based on this score? | The client needs total nursing care. |
| A nurse is caring for a young female adult client who reports weakness, fatigue, and heavy menstrual periods. The client has a hemoglobin level of 8 g/dl and a hematocrict level of 28 g/dl. The nurse suspect wihich of the following types of anemia? | Iron-deficiency anemia |
| A nurse is caring for a client who has a T-4 signal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for expleriencing autonomic dysreflexia? | The client's bladder becomes distended. |
| A nurse is caring for client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 m Hmg and suspects the client is experiencing autonomic dysreflexia. Which of the follo | Place the client in a high-Flower's position |
| A nurse in a provider's office is caring for a client who has a new diagnosis of tinea pedis. Which of the following findings should the nurse expect? | Scaling and redness between client's toes. |
| A nurse is teaching a client who has a new diagnosis of atopic dermatitis. Which of the follwoing statement should the nurse include in the teaching? | " Your provider may recommend a daily anthistamine to help control your symptoms" |
| A nurse is planning care for a client who requires airborne precaution. Which of the following actions should the nurse take? | Wear an N95 respirator mask |
| A nurse is caring for a client who had total hip arthroplasty 1day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take? | Auscultate bowel sounds |
| scale A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level? | a self report paint rating scale |
| A client is admitted to the emergency room with a respiratory rate of 7/ min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Satura | Respiratory Acidosis |
| A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip? | Pacemaker spikes before each QRS complex |
| A nurse is teaching an older adult client who is postoperative following insertion of a permanent pacemaker. The nurse should instruct the client to notify the provider about which of the following manifestations? | Fatigue |
| When the patient has a pacemaker, when do you know that the pacemaker is functioning at the level of the atrium and ventricle? | Spike before atrium contraction before P, Packemaker will do the SA nod job, AV node before QRS: problem contraction of the ventricle is before QRS |
| A nurse is caring for a client who has a serum potassium level of 5.5 mEq/ L. The provider prescribes polystyrene sulfonate. If this medication is effective, the nurse should expect which of the following changes on the client’s ECG? | Reduction of T-wave a,mplitude |
| A nurse is caring for a client 1 day postoperative who has developed atelectasis. Which of the following manifestations is an expected finding for this condition? | Hypoxemia |
| A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication? | Output of brugundy colored urine |
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