Medical-Surgical Nursing Assessment 1 Rated A+
The nurse is caring for a client who has as a son with a streptococcus throat
infection. Which nurse recommendation would be best to advise the client to do in
order to prevent acquiring the infection? - ANSWER-Frequently wash her hands and
surfaces of the home.
The nurse is caring for a client infected with Rocky Mountain spotted fever. The
nurse should ask if the client has experienced which of the following? - ANSWER-
Was bitten by a tick
The nurse is caring for a client with a protozoa infection. Which is the most likely
mode of transmission? - ANSWER-Ingestion of contaminated food or water
The nurse is caring for a client who is recovering from an allergic reaction. Which
leukocyte level would the nurse expect to be the most elevated? - ANSWER-
Eosinophils
The nurse is caring for a client who has an infected wound on the great toe that is
red with a purulent exudate. The nurse expects that this client has which type of
infection? - ANSWER-Localized
The client experienced a fall. Nursing assessment reveals that the client is
experiencing tachycardia, hypotension, confusion, tachypnea, and flat jugular veins.
What should be the nurse's first response? - ANSWER-Administer oxygen.
The family wants to know why the nurse is putting a urinary catheter in a client
experiencing shock. What is the nurse's best response? - ANSWER-"It will help
monitor how much urine the kidneys are able to produce."
A client experiencing shock has had a urinary output of 250 mL in the last 10 hours.
What is the nurse's most appropriate response? - ANSWER-Notify the physician.
Which client is most likely to be experiencing hypovolemic shock? - ANSWER-A
client who had surgery 24 hours ago and who also has a nasogastric tube
The physician has ordered arterial blood gases for a client experiencing shock. The
nurse knows that which value indicates shock? - ANSWER-pH 7.32
A 63-year-old Arab American male states his left leg is "hot." What is the nurse's
best first response? - ANSWER-Assess for pain
The client is complaining of excruciating pain in a foot that has been amputated.
The family tells the nurse that the client is just addicted to pain medications. What
is the nurse's best response? - ANSWER-"He is experiencing phantom limb pain."
, A client has had abdominal surgery and has orders to be ambulated three times a
day. Oral pain medication has been ordered for the client. What should the nurse
do to facilitate ambulation? - ANSWER-Mediate 1 hour prior to ambulating the
client.
The client reports frequent use of acetaminophen. How should the nurse best
respond? - ANSWER-"Do you drink alcohol?"
A client with chronic pain has been admitted with a fever. The nursing assessment
reveals that the client has a decreased level of consciousness. What should the
nurse ask the family about? - ANSWER-What medications the client has taken
The practical nurse is reviewing the social history from a client diagnosed with small
cell carcinoma of the lung. Which information is significant for this disease? -
ANSWER-The client has smoked two (2) packs of cigarettes a day for 20 years
The practical nurse and an unlicensed assistive personnel (UAP) are caring for a
group of clients on a medical unit. Which information provided by the UAP warrants
immediate intervention by the practical nurse? - ANSWER-The client receiving
Procrit (epoetin alfa) has a T 99.2˚F, P 68, R 24, and BP of 198/102
The client diagnosed with lung cancer has been told the cancer has metastasized to
the brain. Which intervention should the practical nurse expect to implement? -
ANSWER-Discuss implementing an advance directive
The client diagnosed with lung cancer is being discharged. Which statement made
by the client indicates a reiteration of information is required? - ANSWER-"It doesn't
matter if I smoke now. I already have cancer."
The practical nurse is interviewing clients at the clinic. Which information provided
by a client warrants further investigation? - ANSWER-The client has been coughing
up blood in the mornings
The male client had abdominal surgery and the practical nurse suspects the client
has peritonitis. Which information support the diagnosis of peritonitis? - ANSWER-
Hard, rigid abdomen and white blood cell count 22,000/mm3
The client who had abdominal surgery tells the practical nurse, "I felt something
give way in my stomach." Which intervention should the practical nurse implement
first? - ANSWER-Inspect the abdominal wound incision
The client is one (1) day postoperative major abdominal surgery. Which client
problem is a priority? - ANSWER-Fluid and electrolyte imbalance
The client has an eviscerated abdominal wound. Which intervention should the
practical nurse implement? - ANSWER-Apply sterile normal saline dressing
The client is diagnosed with peritonitis. Which information indicates to the practical
The nurse is caring for a client who has as a son with a streptococcus throat
infection. Which nurse recommendation would be best to advise the client to do in
order to prevent acquiring the infection? - ANSWER-Frequently wash her hands and
surfaces of the home.
The nurse is caring for a client infected with Rocky Mountain spotted fever. The
nurse should ask if the client has experienced which of the following? - ANSWER-
Was bitten by a tick
The nurse is caring for a client with a protozoa infection. Which is the most likely
mode of transmission? - ANSWER-Ingestion of contaminated food or water
The nurse is caring for a client who is recovering from an allergic reaction. Which
leukocyte level would the nurse expect to be the most elevated? - ANSWER-
Eosinophils
The nurse is caring for a client who has an infected wound on the great toe that is
red with a purulent exudate. The nurse expects that this client has which type of
infection? - ANSWER-Localized
The client experienced a fall. Nursing assessment reveals that the client is
experiencing tachycardia, hypotension, confusion, tachypnea, and flat jugular veins.
What should be the nurse's first response? - ANSWER-Administer oxygen.
The family wants to know why the nurse is putting a urinary catheter in a client
experiencing shock. What is the nurse's best response? - ANSWER-"It will help
monitor how much urine the kidneys are able to produce."
A client experiencing shock has had a urinary output of 250 mL in the last 10 hours.
What is the nurse's most appropriate response? - ANSWER-Notify the physician.
Which client is most likely to be experiencing hypovolemic shock? - ANSWER-A
client who had surgery 24 hours ago and who also has a nasogastric tube
The physician has ordered arterial blood gases for a client experiencing shock. The
nurse knows that which value indicates shock? - ANSWER-pH 7.32
A 63-year-old Arab American male states his left leg is "hot." What is the nurse's
best first response? - ANSWER-Assess for pain
The client is complaining of excruciating pain in a foot that has been amputated.
The family tells the nurse that the client is just addicted to pain medications. What
is the nurse's best response? - ANSWER-"He is experiencing phantom limb pain."
, A client has had abdominal surgery and has orders to be ambulated three times a
day. Oral pain medication has been ordered for the client. What should the nurse
do to facilitate ambulation? - ANSWER-Mediate 1 hour prior to ambulating the
client.
The client reports frequent use of acetaminophen. How should the nurse best
respond? - ANSWER-"Do you drink alcohol?"
A client with chronic pain has been admitted with a fever. The nursing assessment
reveals that the client has a decreased level of consciousness. What should the
nurse ask the family about? - ANSWER-What medications the client has taken
The practical nurse is reviewing the social history from a client diagnosed with small
cell carcinoma of the lung. Which information is significant for this disease? -
ANSWER-The client has smoked two (2) packs of cigarettes a day for 20 years
The practical nurse and an unlicensed assistive personnel (UAP) are caring for a
group of clients on a medical unit. Which information provided by the UAP warrants
immediate intervention by the practical nurse? - ANSWER-The client receiving
Procrit (epoetin alfa) has a T 99.2˚F, P 68, R 24, and BP of 198/102
The client diagnosed with lung cancer has been told the cancer has metastasized to
the brain. Which intervention should the practical nurse expect to implement? -
ANSWER-Discuss implementing an advance directive
The client diagnosed with lung cancer is being discharged. Which statement made
by the client indicates a reiteration of information is required? - ANSWER-"It doesn't
matter if I smoke now. I already have cancer."
The practical nurse is interviewing clients at the clinic. Which information provided
by a client warrants further investigation? - ANSWER-The client has been coughing
up blood in the mornings
The male client had abdominal surgery and the practical nurse suspects the client
has peritonitis. Which information support the diagnosis of peritonitis? - ANSWER-
Hard, rigid abdomen and white blood cell count 22,000/mm3
The client who had abdominal surgery tells the practical nurse, "I felt something
give way in my stomach." Which intervention should the practical nurse implement
first? - ANSWER-Inspect the abdominal wound incision
The client is one (1) day postoperative major abdominal surgery. Which client
problem is a priority? - ANSWER-Fluid and electrolyte imbalance
The client has an eviscerated abdominal wound. Which intervention should the
practical nurse implement? - ANSWER-Apply sterile normal saline dressing
The client is diagnosed with peritonitis. Which information indicates to the practical
