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Medical surgical practice exam
Terms in this set (131)
An adult client who is hospitalized after surgery reports sudden onset of chest pain and dyspnea. the client appears anxious, restless, and mildly cyanotic. the nurse should further assess the client for which condition?
which information should the nurse obtain when performing an initial assessment of a client who presents to the emergency department with a painful ankle injury? (select all that apply)
Quality of the pain
Signs of inflammation
Ankle range of motion
Visible deformities of the joint
Which description of pain is consistent with a diagnosis of rheumatoid arthritis?
Joint pain is worse in the morning and involves symmetric joints
Which physical assessment finding should the nurse anticipate in a client with long-term gastroesophagealreflux disease (GERD)?
A client presents with chronic venous insufficiency. Which assessment finding should the nurse anticipate?
Bilateral lower leg stasis dermatitis
A client has been hospitalized with a femur fracture and is being treated with traction. which action by the nurse is the priority when caring for this client?
Assess neurovascular status
Which statement made by a client with chronic pancreatitis indicates that further education is needed?
I will cut back on smoking cigarettes daily
The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply)
Do not leave the diaphragm in place longer than 8 hours after intercourse
Replace the old diaphragm every 3 months
A male client who smokes two packs of cigarettes a day states he understands that smoking cigarettes is contributing to the difficulty that he and his wife are having in getting pregnant and wants to know if other factors could be contributing to their difficulty. Which information is best for the nurse to provide? (Select all that apply).
Alcohol consumption can cause erectile dysfunction
Low testosterone levels affect sperm production
Cessation of smoking improves general health and fertility
Twenty four hours after a client returns from surgical gastric bypass, the registered nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister. Which assessment finding should the RN report as early signs of hypovolemic shock?
the registered nurse (RN) is assessing a male client who arrives at the clinic with severe abdominal cramping, pain, tenesmus, and dehydration. the RN discovers that the client has had 14 to 20 loose stools with rectal bleeding. When taking the client's medical history, which information is most for the nurse to obtain?
A client is newly diagnosed with diverticulosis. The registered nurse (RN) is assessing the client's basic knowledge about the disease process. Which statement by the client conveys an understanding of the etiology of diverticula?
Chronic constipation causes weakening of colon wall which results in out pouching sacs
The registered nurse (RN) is assessing a client who was discharged home after management of chronic hypertension. Which equipment should the RN instruct the client to use at home?
A young adult mail is diagnosed with stage 4 Hodgkin's lymphoma in the abdominopelvic region and is scheduled for radiation therapy (RT). The client expresses concern about becoming infertile. How should the nurse respond?
Propose sperm banking before RT then artificial insemination is an option
A client's susceptibility to ulcerative colitis is most likely due to which aspect in the client's history?
Jewish European ancestry
Small bowl obstruction is a condition characterized by which finding?
Severe fluid and electrolyte imbalances
Which client should the nurse recognize as most likely to experience sleep apnea?
Obese older male client with a short, thick neck
Which milestone indicates to the nurse successful achievement of young adulthood?
Completes education and becomes self-supporting
A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement?
Initiate continuous cardiac monitoring
Which postmenopausal client's complaint should the nurse refer to the HCP?
episodes of vaginal bleeding
The nurse is teaching a female client about the best time to plan sexual intercourse in order to conceive. Which information should the nurse provide?
Two weeks before menstruation
A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. Which response is best for the nurse to provide?
Estrogen deficiency causes the vaginal tissue to become dry and thinner
Which discharge instruction is most important for a client after a kidney transplant?
Use daily reminders to take immunosuppressants
The nurse is assessing a client with chronic kidney disease (CKD). Which finding is most important for the nurse to respond to first?
Potassium 6.0 mEq
Which finding should the nurse identify as most significant for a client diagnosed with polycystic kidney disease (PKD)?
3+ bacteria in urine
The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session?
Willingness of the client to learn the injections sites
When providing discharge teaching for a client with osteoporosis, the nurse should reinforce which home care activity?
Elimination of hazards to home safety
A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client?
Raising the head of the bed on blocks
An older adult female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. the client states that she lives alone and denies problems or concerns. Which action should the nurse implement?
Collect further data to determine whether self-neglect is occuring
The nurse is assisting a client out of bed for the first time after surgery. Which action should the nurse do first?
Allow the client to sit with the bed in a high Fowler's position
After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented?
Report the findings to the surgeon
A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority?
Check the client's gag and swallow reflexes
During an interview with a client planning elective surgery, the client asks the nurse, "What is the advantage of having a preferred provider organization insurance plan?" Which response is best for the nurse to provide?
An individual may select healthcare providers from outside of the PPO network
The nurse is providing dietary instructions to a 69 year old client who is at high risk for development of coronary heart disease (CHD). Which information should the nurse include?
Increase intake of soluble fiber to 10 to 25 grams per day
A male client receives a local anesthetic during surgery. During the post-operative assessment, the nurse notices the client is slurring his speech. Which action should the nurse take?
Evaluate his blood pressure, pulse, and respiratory status
A client who is sexually active with several partners requests an intrauterine device (IUD) as a contraceptive method. Which information should the nurse provide?
Using an IUD offers no protection against sexually transmitted disease (STD), which increase the risk for pelvic inflammatory disease (PID).
A female client requests information about using the calendar method of contraception. Which assessment is most important for the nurse to obtain?
An accurate menstrual cycle diary for the past 6 to 12 months
A 32 year old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints?
Inability to get pregnant
A 20 year old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide?
Most lumps are benign, but it is always best to come in form an examination.
The nurse is working with a 71-year-old obese client with bilateral osteoarthritis (OA) of the hips. What recommendation should the nurse make that is most beneficial in protecting the client's joints?
Initiate a weight-reduction diet to achieve a health body weight
A 58 year old client who has been post menopausal for five years is concerned about the risk of osteoporosis because her mother has the condition. Which information should the nurse offer?
Calcium loss from bones can be slowed by increasing calcium intake and exercise
During assessment of a client with amyotrophic lateral sclerosis (ALS), which finding should the nurse identify when planning care for this client?
The nurse formulates the nursing problem of urinary retention related to sensorimotor deficit for a client with multiple sclerosis. Which nursing intervention should the nurse implement?
Teach the client techniques of intermittent self-catheterization
The nurse is caring for a client with a stroke resulting in right-sided paresis and aphasia. The client attempts to use the left hand for feeding and other self-care activities. The spouse becomes frustrated and insists on doing everything for the client. Based on this data, which nursing problem should the nurse document for this client?
Disabled family coping related to dissonant coping style of significant person
A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement?
Give an antihypertensive medication
A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency?
The nurse is caring for a client with a continuous feeding through a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse include in the plan of care?
Check for tube placement and residual volume q4 hours
The nurse is planning care to prevent complications for a client with multiple myeloma. Which intervention is most important for the nurse to include?
Maintain a fluid intake of 3 to 4 L per day
When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide?
Place a small book or magazine on the abdomen and make it rise while inhaling deeply
During suctioning, a client with an uncuffed tracheostomy tube begins to cough violently and dislodges the tracheostomy tube. Which action should the nurse implement first?
Attempt to reinsert the tracheostomy tube
A client is admitted for further testing to confirm sarcoidosis Which diagnostic test provides definitive information that the nurse should report to the HCP?
Lung tissue biopsy
How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring?
Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line
A 57 year old male client is scheduled to have a stress thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client?
The test you are having tomorrow requires that you have nothing by mouth tonight
The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia (VT). The client has an implanted automatic defibrillator. What action should the nurse implement?
Shock the client with 200 joules per hospital policy
In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing intervention? (Select all that apply.)
Set the infusion pump to infuse the albumin within four hours
Administer through a large gauge catheter
Monitor hemoglobin and hematocrit levels
Assess for increased bleeding after administration
The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema?
She sustained an insect bite to her left arm yesterday
Which intervention should the nurse implement for a female client diagnosed with pelvic relaxation disorder?
Encourage the client to perform Kegel exercises 10 times daily
Despite several eye surgeries, a 78-year-old client who lives alone has persistent vision problems. The visiting nurse is discussing painting the house with the client. The nurse suggests that the edge of the steps should be painted which color?
What types of medication should the nurse expect to administer to a client during an acute respiratory distress episode?
Bronchodilators and steroids
A 46 year old female client is admitted for acute renal failure secondary to diabetes and hypertension. Which test is the best indicator of adequate glomerular filtration?
Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. What intervention should be most helpful to this client?
Advise the client to remain in bed with the leg elevated
Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation?
Wear gloves when coming in contact with the blood or body fluids of any client
A 51 year old truck driver who smokes two packs of cigarettes a day and is 30 pounds overweight is diagnosed with having a gastric ulcer. Which content is most important for the nurse to include in the discharge teaching for this client?
Information about smoking cessation
In assessing cancer risk, the nurse identifies which woman as being at greatest risk of developing breast cancer?
A 50 year old whose mother had unilateral breast cancer
An adult client is admitted to the hospital burn unit with partial-thickness and full-thickness burns over 40% of the body surface area. In assessing the potential for skin regeneration, what should the nurse remember about full-thickness burns?
Regenerative function of the skin is absent because the dermal layer has been destroyed
A client is admitted to the medical intensive care unit with a diagnosis of myocardial infarction. The client's history indicates the infarction occurred ten hours ago. Which lab test result would the nurse expect this client to exhibit?
The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which finding would the nurse expect this client to exhibit?
Normal skin coloring
A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints?
Prevention of deformities
A client who was in a motor vehicle collision was admitted to the hospital and the right knee was placed in skeletal traction. The nurse has documented this nursing diagnosis in the client's medical record: "Potential for impairment of skin integrity related to immobility from traction." Which nursing intervention is indicated based on this diagnosis statement?
Provide back and skin care while maintaining the traction
The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding would the nurse consider an indication of progressive hepatic encephalopathy?
Difficulty in handwriting
A client taking furosemide (Lasix), reports difficulty sleeping. What question is important for the nurse to ask the client?
At what time do you take your medication
A client taking a thiazide diuretic for the past six months has a serum potassium level of 3. The nurse anticipates which change in prescription for the client?
A potassium supplement will be prescribed
A client experiencing uncontrolled atrial fibrillation is admitted to the telemetry unit. What initial medication should the nurse anticipate administering to the client?
A client receiving cholestyramine (Questran) for hyperlipidemia should be evaluated for what vitamin deficiency?
A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair falling out each day?" Which response by the nurse best explains the reason for alopecia?
Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant
The nurse is preparing a teaching plan for a client who is newly diagnosed with type 1 diabetes mellitus. Which clinical cues should the nurse describe when teaching the client about hypoglycemia?
Sweating, trembling, tachycardia
A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What action should the nurse implement?
Advise the client to notify the HCP for immediate medication attention
The HCP prescribes aluminum and magnesium hydroxide, 1 tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of indigestion. which intervention should the nurse implement?
Question the HCP's prescription
A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse?
A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide?
Schedule extra rest periods
The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli?
Cyanosis of the fingertips
A 58 year old client, who has no health problems, asks the nurse about the Pneumovax vaccine. The nurse's response to the client should be based on which information?
The immunization is administered once to older adults or persons with a history of chronic illness
An elderly client is admitted with a diagnosis of bacterial pneumonia. When observing the client for the first signs of decreasing oxygenation, the nurse should assess for which clinical cues?
Confusion and tachycardia
An older adult male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain would further confirm this suspicion?
Pain in the calf upon exertion who is relieved by rest and elevating the extremity
An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that his tongue is somewhat cracked and his eyeballs are sunken into his head. What nursing intervention is indicated?
Help the client to determine ways to increase his fluid intake
A 77 year old female client is admitted to the hospital. She is confused, has no appetite, is nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43 beats per minute. It is most important for the nurse to assess for which finding?
The nurse knows that lab values sometimes vary for the older client. Which data would the nurse expect to find when reviewing lab values of an 80 year old male?
Increased protein in the urine, slightly increased serum glucose levels
The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group?
The usual activity patterns of each member of the group
While working in the emergency room, the nurse is exposed to a client with active tuberculosis. When should the nurse plan to obtain a tuberculin skin test?
Four to six weeks after the exposure
A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing function is of greatest importance to this client? Assess the client's
During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. What should be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope?
May indicate pneumonia
The nurse is performing an ophthalmoscopic examination on a hypertensive client. When assessing the client, which finding indicates the severity of hypertension?
Amount of retinal vessel damage that has occurred
The nurse is receiving report from surgery about a client with a penrose drain who is to be admitted to the postoperative unit. Before choosing a room for this client, which information is most important for the nurse to obtain?
If the client's wound is infected
The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in two hours is dated two years ago. The client reports that he has a history of "heart trouble," but has no problems at present. Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. What nursing action is best for the nurse to implement?
Call for an ECG to be performed immediately
The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk for developing a cerebral vascular accident (CVA)?
The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question provides information relevant to the client's plan of care?
Have you ever been 'frozen' in one spot, unable to move?
The nurse is assessing a client who has a history of Parkinson's disease for the past 5 years. Which symptoms would this client most likely exhibit?
Shuffling gait, mask-like facial expression and tremors of the head
Which intervention should the nurse plan to implement when caring for a client who has just undergone a right above the knee amputation?
Place a large tourniquet at the client's bedside
Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)?
Sudden, stabbing, severe pain over the lip and chin
A client who is HIV positive asks the nurse, "How will I know when I have AIDS?" Which response is best for the nurse to provide?
AIDS is diagnosed when a specific opportunistic infection is found in an otherwise health individual.
A female client receiving IV vasopressin (Pitressin) for esophageal varice rupture reports to the nurse that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse initiate?
Start an IV nitroglycerin infusion
A client with cirrhosis develops increasing pedal edema and ascites. What dietary modification is most important for the nurse to teach this client?
Restrict salt and fluid intake
The nurse is taking a history of a newly diagnosed type 2 diabetic who is beginning treatment. Which subjective information is most important for the nurse to note?
An allergy to sulfa drugs
A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet?
He visits his diabetic brother who just had surgery to amputate an infected foot
In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance?
Which symptoms should the nurse expect a client to exhibit who is diagnosed with pheochromocytoma?
Headache, diaphoresis, and palpitations
A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's medication record. Which medication is most likely the cause of the bradycardia?
A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure." Which symptoms are most important to teach the client?
Feelings of dizziness
The nurse is initiating the client's fourth dose of gentamycin sulfate IV. The HCP has prescribed peak and trough levels. Which is the most important action for the nurse to implement next?
Draw the trough 5 minutes before and the peak 30 minutes after the next dose
The client is taking digoxin for congestive heart failure. The nurse would be correct in withholding a dose of digoxin based on which assessment?
Serum potassium level is 3
When preparing a client who has had a total laryngectomy for discharge, which instruction is most important for the nurse to include in the discharge teaching?
Tell the client to carry a medic alert card stating that he is a total neck breather
A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide 0.04 mg/kg q12 hours IV is prescribed. Which is the priority nursing diagnosis for this client?
impaired communication related to paralysis of skeletal muscles
A client is admitted to the hospital with a medical diagnosis of pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor. Which information relates most directly to the prognosis for gram negative pneumonias?
Gram negative organisms are more resistant to antibiotic therapy
During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first?
Reposition the head to validate that the head is in the proper position to open the airway
A client is admitted to the hospital with diagnosis of severe acute diverticulitis. Which assessment finding should the nurse expect this client to exhibit?
Lower left quadrant pain and a low-grade fever
The nurse is assessing a client's lab values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)?
Serum calcium of 5mg/dL
The RN assesses arterial blood gas results of a client that has emphysema. Which finding is consistent with respiratory acidosis?
pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L
The nurse is caring for a client who has been diagnosed with primary hyperaldosteronism. Which lab test result should the nurse expect an increase in the serum level?
Which condition should the nurse suspect when a client reports vaginal dryness during intercourse?
Obstructed Bartholin's glands
A client is admitted to the emergency department after falling from a high roof. Which finding should the nurse report immediately?
Clear, watery drainage from the ear
A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide?
The tumor's estrogen receptor guides treatment options
A client has a staging procedure for cancer of the breast and ask the nurse which type of breast cancer has the poorest prognosis. Which information should the nurse offer the client?
Inflammatory with peau d'orange
Which nail color alteration should the nurse expect to observe in a client with chronic kidney disease?
Horizontal white banding
Which instruction should the nurse give a client who is diagnosed with fibrocystic changes of the breast?
Perform a breast self-exam (BSE) procedure monthly
Which information about mammogram is most important to provide a post-menopausal female client?
Yearly mammogram should be done regardless of previous normal x-rays
A 49 year old female client arrives at the clinic for an annual exam and asks the nurse why she becomes excessively diaphoretic and feels warm during nighttime. What is the nurse's best response?
Discuss perimenopause and related comfort measures
Which assessment finding by the nurse during a client's clinical breast examination requires follow-up?
Newly retracted nipple
In preparing a discharge plan for a 22-year-old male client diagnosed with Buerger's disease (thromboangiitis obliterans), which referral is most important?
Smoking cessation program
A 67 year old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor probably led to the fracture in the proximal end of her femur?
Osteoporosis resulting from hormonal changes
During a health fair, a 72-year-old male client tells the nurse that he is experiencing shortness of breath. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic symptom should the nurse expect this client to have?
Productive cough with grayish-white sputum
A client with diabetes mellitus is experiencing polyphagia. Which outcome statement is the priority for this client?
Adequate cellular nourishment
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