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BSN 266 1.0
Meg Surg study
| Question | Answer |
|---|---|
| The nurse is evaluating a client’s understanding about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan? | Enjoys fat-free yogurt as an occasional snack food |
| A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse? Hematocrit (Reference Range: Male: 42% to 52% (0.42 to 0.52 volume fraction)] | Further decline in level of consciousness. |
| The nurse is caring for a client with a burn that is severely edematous with a wound bed that is brown and yellow in appearance. The client expresses feeling no pain. Which classification of burn depth should the nurse document? | Full thickness. |
| An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment includes a heart rate 128 beats/minute and irregular, respirations 38 breaths/minute, blood pressure 168/10 | Urinary output. Oxygen saturation. Lung sounds. |
| A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis? | Crohn's disease with colectomy. |
| The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis? | Hypoalbuminemia that results in a decreased colloidal oncotic pressure. |
| While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take? | Discuss approaches to chronic pain control with the client. |
| Which information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)? | Minimize symptoms by wearing loose, comfortable clothing. |
| The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review? | Platelet count. |
| The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheral neuropathy. Which information should the nurse provide? | Family members can help with regular foot exams. |
| The nurse is providing discharge teaching to an older adult client hospitalized for treatment of venous leg ulcers. Which instruction(s) should the nurse include in the teaching plan? (Select all that apply.) | Inspect ankles daily for areas of darkening skin. Keep legs elevated when sitting or lying down. Eat a diet that is high in protein and vitamins A and C |
| An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with possible anastomosis leakage. The client's abdomen is tender to touch, and the vital signs are: temperature 101° F (38.3° C), heart rate 130 beats/minute, respiratory rate 26 b | Strict intravenous (IV) fluid replacement. |
| A client arrives to the emergency department reporting an intermittent fever and night sweats for the past 3 weeks and has developed a productive cough containing small amounts of blood. Which intervention should the nurse prioritize? | Move into airborne isolation. |
| A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider? | Morphine. |
| The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assess | Notify the healthcare provider of the client's medication history. |
| The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the lef | Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy. |
| The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for the healthcare provider? | Lumbar puncture |
| The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain? | Eating patterns of dietary intake. |
| A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor? | Hypovolemia and electrocardiogram (ECG) changes. |
| The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL about preventing complications related to diabetes mellitus. Which information stated by the client indicates understanding? Reference Range Glucose [Reference Ra | Include no more than 1-2 alcoholic beverages in diet per day. |
| After falling down the basement steps, a client is brought to the emergency room. X-rays confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse? | Right foot pale with sluggish capillary refill. |
| A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care? | Teach the client techniques for performing intermittent catheterization. |
| The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about huff coughing to clear secretions. During the client's return demonstration, the client uses pursed lips during exhalation. Which action should the nurse do next? | Instruct the client after inhaling deeply to quickly and forcefully exhale 2 to 3 times. |
| A client with a history of asthma reports having episodes of bronchoconstriction and increased mucous production while exercising. Which action should the nurse implement? | Determine if the client is using an inhaler before exercising. |
| An overweight, young adult client who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The client reports feeling very weak and jittery. Which action(s) should the nurse implement? (Select all that apply.) | Assess skin temperature and moisture. Measure pulse and blood pressure. Check fingerstick glucose level. |
| A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide? | Wearing gloves when handling cold items guards against painful spasms. |
| A client arrives at the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing, and the nurse observes dark, pink-tinged outflow with blood cl | Monitor catheter drainage. |
| The nurse is preparing a client for discharge who was recently diagnosed with Addison's disease. Which instruction is most important for the nurse to include in this client's discharge teaching plan? | Take prescribed cortisone accurately. |
| The parent of an adolescent tells the clinic nurse, "My child has athlete's foot. I have been applying triple antibiotic ointment for two days, but there has been no improvement." Which instruction should the nurse provide? | Stop using the ointment and encourage complete drying of feet and wearing clean socks. |
| A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider? | Lower back pain and hypotension. |
| The nurse is caring for a client in the post-anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mm Hg. | Medicate for pain and monitor vital signs according to protocol. |
| An adult who was recently diagnosed with glaucoma tells the nurse, "it feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client? | Maintain prescribed eye drop regimen. |
| The healthcare provider prescribes diagnostic tests for a client whose chest X-ray indicates pneumonia. Which diagnostic test should the nurse review for implementation in the most therapeutic treatment of the pneumonia? | Sputum culture and sensitivity. |
| A young adult client with osteoarthritis of both knees tells the nurse the desire to continue daily walks in the park with friends. How should the nurse respond? | Encourage continued maintenance of the walking routine. |
| The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment? | Tenderness upon palpation and generalized erythema. |
| The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi? | Eats a vegetarian diet with cheese 2 to 3 times a day. |
| A nurse is assessing a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access. The nurse auscultates a bruit over the graft area. Which intervention should the nurse implement? | Document the findings. |
| A client who has small cell carcinoma of the lung is admit with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). client responds to treatment, the client's serum sodium level increases 120 mEq/L to 125 mEq/L. Based on this, ... | Maintain the prescribed fluid restriction. |
| A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement? | Administer opioid and non-opioid medication simultaneously |
| While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? | White blood cell (WBC) count. |
| A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Nurse teaching... | Drink at least 8 cups (1920 mL) of water per day. |
| An obese client with emphysema who smokes at least a pack of cigarettes daily is admitted after experiencing a sudden increase in dyspnea and activity intolerance. Oxygen therapy is initiated, and it is determined that the client will be discharged with o | Guidelines for oxygen use. |
| An older client is admitted with an acute onset of diverticulitis and intravenous antibiotic therapy is initiated. Which intervention should the nurse implement next? | Maintain the client's NPO status. |
| A client presents to the emergency department with nausea, vomiting, and diarrhea. While obtaining the history and physical assessment, the nurse discovers that the client's significant other is recovering from the coronavirus (COVID-19). After obtaining | Move the client to a private room, keep the door closed, and initiate droplet precautions. |
| A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. Which action should the nurse implement? | Prepare ice packs for placement in the client's axillary area. |
| Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy? | Monitor the client's intravenous site hourly during the treatment. |
| While caring for a client with Guillain-Barre syndrome, the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse? | Sensory loss at T-8. |
| A client with right hydronephrosis and a history of renal calculi is preparing for discharge following a retrograde pyelogram. Which instruction should the nurse include in the client's discharge instructions? | Monitor urinary stream for decreased output. |
| Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers? | Oatmeal, raisins, and fruit with skin. |
| Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan? | Clamp the catheter when taking a shower. |
Created by:
RachelKleinKatz1