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med surg

QuestionAnswer
An adult woman with primary Raynaud’s phenomenon develops pallor and then redness with burning in fingers. What action should the nurse take? Continue to monitor until color normalizes (avoid cold; do NOT apply cold).
While completing a health assessment, a young adult female thinks she may be pregnant and is scheduled for surgery. What action should the nurse implement immediately? Perform a bedside pregnancy test.
Client with Pneumocystis jirovecii pneumonia, HIV+, CD4 443, febrile, tachycardic, worsening symptoms. Which prescriptions should the nurse anticipate? Increase IV fluids; administer antiemetic; monitor for adverse reactions to antibiotics.
When assessing a client for possible lung cancer, which finding is most significant? Hemoptysis
Streptomycin 300 mg IM prescribed. Supply: Streptomycin 1 g / 2.5 mL. How many mL? 0.8 mL.
Client with urolithiasis and severe flank pain. What should the nurse implement? Strain all urine.
Client with atopic dermatitis receiving teaching. Which intervention should be included? Instruct to keep fingernails trimmed short
Five months after shingles, an older adult has pain where a rash occurred. What action should the nurse take?  Complete a pain assessment (suspect postherpetic neuralgia).
Client in diuretic phase of acute kidney injury. Which parameters are monitored? Hypovolemia and electrolyte changes.
Client with arterial ischemic leg injury. What should be included in discharge teaching? Wear shoes and socks while awake.
Nurse assessing an arteriovenous fistula. What finding requires intervention? Pulselessness
Client with microcytic, hypochromic anemia. Which meal to suggest? Beef steak with steamed broccoli.
Post-cholecystectomy POD2: fever, chills, productive cough, pain on right side. Which condition most likely? Pneumonia
Client with metastatic cancer reports pain 10/10 despite analgesic. Best POC intervention? Administer analgesics on fixed, continuous schedule.
Client after appendectomy. Which finding requires immediate intervention? Redness and edema at incision site.
Client allergic to iodine arrives for surgery. Which pre-op action? Avoid iodine-containing skin prep solution.
Older adult with COPD sitting upright leaning forward. Which action? Instruct in pursed-lip breathing.
Client with cirrhosis and 4+ edema and ascites. Which mechanism contributes? Hypoalbuminemia causing decreased oncotic pressure.
Older adult with poorly controlled DM seen at follow-up. Priority intervention? Review HbA1c level.
Client with acute pancreatitis. Which action is priority? Monitor glucose levels.
Client with STI tests positive. Which response is correct? Discuss that partners without symptoms can still transmit infection.
Client with full-thickness burns 40%. Before reporting decreased wound healing, which lab to check? Drainage - neutrophil count Serum albumin
OSA client refuses CPAP due to discomfort. Which recommendation? Begin a weight loss program.
Post-paracentesis, continued drainage of straw-colored fluid. What action? Continue monitoring output.
Client with newly diagnosed Crohn’s disease asks about diet. Best instruction? Describe elimination diet to identify triggers.
Client ANC 500. What is most important? Place the client in protective isolation.
Ciprofloxacin 400 mg in 200 mL D5W administered over 1 hour. What rate? 200 mL/hr.
Client admitted with symptoms of right-sided heart failure. Which symptom to further assess? Breathlessness.
Client post–cataract surgery discharge teaching. Which instruction? Light housekeeping is safe; avoid heavy lifting.
Type 2 DM client with infected toe. Which instruction emphasized? Check the insides of shoes before wearing.
Post-bariatric surgery client with nausea/vomiting. What intervention? Keep client NPO.
Client with C7 spinal cord injury at risk for autonomic dysreflexia. Which precipitating factor? An acutely distended bladder.
Total thyroidectomy client. Which finding indicates a complication? Muscle twitching in hands/feet (hypocalcemia).
Client with chronic kidney disease selecting breakfast foods. Which apply? Slice of whole grain toast; bowl of cream of wheat.
A client who has developed acute kidney injury (AKI) due to aminoglycoside antibiotics 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 electrocardiographic (ECG) changes.
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?    1    Activity level of bowel sounds.     2    Eating patterns of dietary intake.     3    Level and amount of physical activity     4    Color and consistency of feces
Which action should the nurse implement to reduce the risk of vesicant extravasation in NJ the client who is receiving intravenous chemotherapy?   1    Monitor the client's intravenous site hourly during the treatment     2    Keep the head of the bed elevated until the treatment is completed.     3    Instruct the client to drink plenty of fluids during the treatment.
Created by: rballiao
 

 



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