Medical Surgical Assessment A
st st st
Astnursestisstreviewingstthestlaboratorystresultsstofstastclientstwhostisstscheduledst
forstastCTstscanstwithstanstIVstcontraststagent.stWhichstofstthestfollowingstlaborat
orystfindingsstshouldstthestnursestreportsttostthestproviderstpriorsttostthestprocedu
re?
A)stSodiumst136stmEq/L
B)stPotassiumst4.8stmEq/L
C)stCreatininest1.9stmg/dL
D)stCalciumst10stmg/dLst-stcorrectstanswer✔ ✔
C)stCreatininest1.9stmg/dL
Creatininest1.9stmg/dLstisstnotstwithinstthestexpectedstreferencestrange.stTheref
ore,stthestnursestshouldstreportstthestfindingsttostthestproviderstbeforestthestclients
thasstastCTstscanstwithstanstIVstcontraststagent.stThisstfindingstplacesstthestclientst
atstriskstforstdevelopingstcontrast-inducedstnephropathy.
Astnursestisstmonitoringstastclientstwhostissttakingstacarbose.stWhichstofstthestfoll
owingstfindingsstshouldstthestnursestidentifystasstanstadversesteffectstofstthestme
dication?
A)stPolyuria
B)stAbdominalstcramps
,C)stRenalstinsufficiency
D)stInsomniast-stcorrectstanswer✔ ✔ B)stAbdominalstcramps
Acarbosestaffectsstthestgastrointestinalstsystem.stTherefore,stthestnursestshoul
dstmonitorstthestclientstforstabdominalstcramping,strumblingstbowelstsounds,sta
ndstdiarrheastasstadversesteffectsstofstthisstmedication.
Astnursestisstassistingstwithstthestcarestofstastclientstwhosthadstastcardiacstcatheteri
zationstviastthestrightstfemoralstartery.stWhichstofstthestfollowingstactionsstshou
ldstthestnursesttakesttostpreventstpostprocedurestcomplications?st(Selectstall)
A)stMonitorstthestinsertionstsitestforstbleeding
B)stPositionstthestaffectedstextremitystatstast45stdegreestangle
C)stRestrictstthestclient'sstfluidstintake
D)stMaintainstthestpressurestdressing
E)stCheckstthestclient'sstperipheralstpulsesst-stcorrectstanswer✔ ✔
A)stMonitorstthestinsertionstsitestforstbleeding
Thestnursestshouldstmonitorstthestclient'sstinsertionstsitestforstmanifestationsstof
sthemorrhaging.
D)stMaintainstthestpressurestdressing.
,Thestnursestshouldstmaintainstthestclient'sstpressurestdressingsttostpreventsthem
orrhagingstandstallowstforstthestcannulationstsitesttostheal.
E)stCheckstthestclient'sstperipheralstpulses.
Thestnursestshouldstassessstthestclient'sstperipheralstpulsessttosthelpstidentifystsi
gnsstofstarterialstocclusion.
Astnursestisstcontributingsttostthestplanstofstcarestforstastclientstwhosthasstchronicst
obstructivestpulmonarystdiseasest(COPD)standstisstdyspneic.stWhichstofstthestf
ollowingstinterventionsstshouldstthestnursestincludestinstthestplan?
A)stEncouragestabdominalstbreathing
B)stDirectstthestclientsttostinhalestwithstpursedstlips
C)stSetstthestoxygensttherapystatst5L/min
D)stInstructstthestclientsttostleanstbackstwhilestcoughingst-stcorrectstanswer✔
✔ A)stEncouragestabdominalstbreathing
Thestnursestshouldstencouragestabdominalstbreathing,stwhichstreducesstthestw
orkloadstonstthestaccessorystmusclesstofstrespirationstduringstdyspneicstepisod
es.
, Astnursestisstpreparingsttostadministerstphytonadionest7stmgstsubcutaneouslystt
ostastclientstwhosthasstanstINRstofst4.stAvailablestisstphytonadionest10stmg/mL.st
HowstmanystmLstshouldstthestnursestadminister?st(Roundstthestanswersttostthest
neareststtenth.stUsestastleadingstzerostisstitstapplies.stDostnotstusestasttrailingstzero
.st-stcorrectstanswer✔ ✔ 7mg/10stmgst*1mL=st0.7stmL
Astnursestisstexaminingstastclient'sstIVstsitestandstnotesstastredstlinestupsthisstarm.st
Thestclientstreportsstastthrobbing,stburningstpainstatstthestIVstsite.stThestnursestsh
ouldstidentifystthatstthestclient'sstmanifestationsstindicatestwhichstofstthestfollo
wingstcomplicationsstofstIVsttherapy?
A)stThrombophlebitis
B)stInfiltration
C)stHematoma
D)stVenousstspasmsst-stcorrectstanswer✔ ✔ A)stThrombophlebitis
Thestnursestshouldstidentifystpain,stwarmth,standstastredststreakstupstthestarmstasst
indicationsstofstthrombophlebitis.
Astnursestisstreinforcingstteachingstaboutstmanagementstofstconstipationstwithst
astclientstwhosthassthypothyroidism.stWhichstofstthestfollowingstshouldstthestnu
rsestincludestinstthestteaching?
A)stIncreasestintakestofstfiber-richstfoods
st st st
Astnursestisstreviewingstthestlaboratorystresultsstofstastclientstwhostisstscheduledst
forstastCTstscanstwithstanstIVstcontraststagent.stWhichstofstthestfollowingstlaborat
orystfindingsstshouldstthestnursestreportsttostthestproviderstpriorsttostthestprocedu
re?
A)stSodiumst136stmEq/L
B)stPotassiumst4.8stmEq/L
C)stCreatininest1.9stmg/dL
D)stCalciumst10stmg/dLst-stcorrectstanswer✔ ✔
C)stCreatininest1.9stmg/dL
Creatininest1.9stmg/dLstisstnotstwithinstthestexpectedstreferencestrange.stTheref
ore,stthestnursestshouldstreportstthestfindingsttostthestproviderstbeforestthestclients
thasstastCTstscanstwithstanstIVstcontraststagent.stThisstfindingstplacesstthestclientst
atstriskstforstdevelopingstcontrast-inducedstnephropathy.
Astnursestisstmonitoringstastclientstwhostissttakingstacarbose.stWhichstofstthestfoll
owingstfindingsstshouldstthestnursestidentifystasstanstadversesteffectstofstthestme
dication?
A)stPolyuria
B)stAbdominalstcramps
,C)stRenalstinsufficiency
D)stInsomniast-stcorrectstanswer✔ ✔ B)stAbdominalstcramps
Acarbosestaffectsstthestgastrointestinalstsystem.stTherefore,stthestnursestshoul
dstmonitorstthestclientstforstabdominalstcramping,strumblingstbowelstsounds,sta
ndstdiarrheastasstadversesteffectsstofstthisstmedication.
Astnursestisstassistingstwithstthestcarestofstastclientstwhosthadstastcardiacstcatheteri
zationstviastthestrightstfemoralstartery.stWhichstofstthestfollowingstactionsstshou
ldstthestnursesttakesttostpreventstpostprocedurestcomplications?st(Selectstall)
A)stMonitorstthestinsertionstsitestforstbleeding
B)stPositionstthestaffectedstextremitystatstast45stdegreestangle
C)stRestrictstthestclient'sstfluidstintake
D)stMaintainstthestpressurestdressing
E)stCheckstthestclient'sstperipheralstpulsesst-stcorrectstanswer✔ ✔
A)stMonitorstthestinsertionstsitestforstbleeding
Thestnursestshouldstmonitorstthestclient'sstinsertionstsitestforstmanifestationsstof
sthemorrhaging.
D)stMaintainstthestpressurestdressing.
,Thestnursestshouldstmaintainstthestclient'sstpressurestdressingsttostpreventsthem
orrhagingstandstallowstforstthestcannulationstsitesttostheal.
E)stCheckstthestclient'sstperipheralstpulses.
Thestnursestshouldstassessstthestclient'sstperipheralstpulsessttosthelpstidentifystsi
gnsstofstarterialstocclusion.
Astnursestisstcontributingsttostthestplanstofstcarestforstastclientstwhosthasstchronicst
obstructivestpulmonarystdiseasest(COPD)standstisstdyspneic.stWhichstofstthestf
ollowingstinterventionsstshouldstthestnursestincludestinstthestplan?
A)stEncouragestabdominalstbreathing
B)stDirectstthestclientsttostinhalestwithstpursedstlips
C)stSetstthestoxygensttherapystatst5L/min
D)stInstructstthestclientsttostleanstbackstwhilestcoughingst-stcorrectstanswer✔
✔ A)stEncouragestabdominalstbreathing
Thestnursestshouldstencouragestabdominalstbreathing,stwhichstreducesstthestw
orkloadstonstthestaccessorystmusclesstofstrespirationstduringstdyspneicstepisod
es.
, Astnursestisstpreparingsttostadministerstphytonadionest7stmgstsubcutaneouslystt
ostastclientstwhosthasstanstINRstofst4.stAvailablestisstphytonadionest10stmg/mL.st
HowstmanystmLstshouldstthestnursestadminister?st(Roundstthestanswersttostthest
neareststtenth.stUsestastleadingstzerostisstitstapplies.stDostnotstusestasttrailingstzero
.st-stcorrectstanswer✔ ✔ 7mg/10stmgst*1mL=st0.7stmL
Astnursestisstexaminingstastclient'sstIVstsitestandstnotesstastredstlinestupsthisstarm.st
Thestclientstreportsstastthrobbing,stburningstpainstatstthestIVstsite.stThestnursestsh
ouldstidentifystthatstthestclient'sstmanifestationsstindicatestwhichstofstthestfollo
wingstcomplicationsstofstIVsttherapy?
A)stThrombophlebitis
B)stInfiltration
C)stHematoma
D)stVenousstspasmsst-stcorrectstanswer✔ ✔ A)stThrombophlebitis
Thestnursestshouldstidentifystpain,stwarmth,standstastredststreakstupstthestarmstasst
indicationsstofstthrombophlebitis.
Astnursestisstreinforcingstteachingstaboutstmanagementstofstconstipationstwithst
astclientstwhosthassthypothyroidism.stWhichstofstthestfollowingstshouldstthestnu
rsestincludestinstthestteaching?
A)stIncreasestintakestofstfiber-richstfoods
