Med Surg Assessment

Med Surg Assessment 1 1. A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following actions should the nurse include in the plan? a. Provide the client with a means of communication i. Use electronic tablet, computer, programmable speech generating device, alphabet board, pencil and paper, etc. 2. A nurse is caring for a client who is receiving IV fluid replacement therapy for dehydration. Which of the following laboratory results indicates effectiveness of the treatment? a. Urine specific gravity 1.020 i. Within the expected range of 1.005 – 1.030 3. A nurse is monitoring the laboratory findings for a client who is postoperative following a total hip arthroplasty 6 hours ago. Which of the following values indicates that the client has an increased risk for bleeding? a. Platelets 80,000 i. Platelet range is 150,000 – 400,000 4. A nurse is admitting a client who has a cervical spinal cord injury following a motor vehicle accident. Which of the following interventions is the nurse’s priority while caring for this client? a. Assist the client with quad coughing i. The greatest risk to a client who has a cervical spinal cord injury is an obstructed airway; the priority is to ensure that the client can clear their airway. Apply abdominal pressure as the client coughs (quad coughing). 5. A nurse is caring for a client who is receiving a blood transfusion. Which of the following findings indicates that the client is experiencing transfusion-associated circulatory overload? a. Dyspnea i. Dyspnea is an indication of possible transfusion-associated circulatory overload, leading to hypertension, bounding pulses, and confusion. Dyspnea can also indicate transfusion related acute lung injury to an anaphylactic response, which also causes wheezing, chest tightness, cyanosis and low BP. 6. A nurse is assessing a client who has lung cancer and is undergoing radiation therapy to the chest. Which of the following indicates an adverse effect of the therapy? a. Altered taste sensations i. Altered taste is a result of the release of metabolites by dead cells 7. A nurse is preparing to administer a unit of packed RBCs to a client who has anemia. Which of the following actions should the nurse plan to take? SATA: a. Obtain pre-transfusion temperature i. Complete assessment prior to transfuion b. Verify the client’s blood type with a second nurse i. Verify ID, blood compatibility, and expiration of product with second nurse c. Use a 20-gauge-IV needle for venous access i. The nurse should use a large-bore needle to transfuse the PRBCs to reduce the risk of cell hemolysis and obstruction of flow 8. A nurse is reviewing the laboratory findings for a client who is dehydrated. Which of the following BUN levels should the nurse expect? a. 26 mg/dL i. Normal range is 10-20, and elevated levels indicate renal disease, dehydration, shock, excessive protein in the diet, sepsis, glucocorticoid use, GI bleeding, or other conditions in which blood is reabsorbed from injured tissues 9. A nurse is reviewing ECG strips for several clients. Which of the following images should the nurse identify as atrial fibrillation? a. Multiple irregular and variable waves at the baseline and irregular R to R waves 10. A nurse is preparing to admit a client who has a new tracheostomy from the operating room. Which of the following items is the priority for the nurse to have available in the client’s room upon admission? a. Obturator i. The obturator can be inserted in the stoma in the event of dislodgment or decannulation to maintain an airway until a trach tube can be placed. For the first 72 hours following the insertion of the trach, dislodgment or decannulation is considered an emergency. 11. A nurse is caring for a client who had a below-the-knee amputation due to a traumatic injury 2 days ago. Which of the following statements should the nurse use to assess how the client is coping with this change in their body image? a. “Tell me how the changes to your leg make you feel.” 12. A nurse is teaching a client how to administer a medication using an inhaler with a spacer. Which of the following instructions should the nurse include? a. “Shake the inhaler vigorously prior to use.” i. Thoroughly shake the inhaler to disperse the medication because the medication in the inhaler can separate easily 13. A nurse in an endoscopy clinic is providing teaching to a client who is to under go a colonoscopy for colon cancer screening. Which of the following information should the nurse provide? a. “You will need someone to drive you home after your procedure?” i. Do not drive for 12-18 hours following the procedure, because during a colonoscopy, the patient receives moderate sedation 14. A nurse is monitoring a client who is receiving moderate sedation with midazolam. Which of the following findings requires immediate intervention by the nurse? a. No response to verbal stimuli i. Using urgent vs non-urgent approach, this is the priority; during moderate sedation, the patient should be able to provide a response to questions and commands. No response to verbal stimuli can indicate a loss of consciousness or over sedation. 15. A nurse is reviewing the laboratory findings for a client who has heart failure and is taking furosemide. The nurse should identify which of the following findings as an adverse effect of the medication? a. Potassium 3.2 mEq/L i. Loop diuretics remove excessive extracellular fluid through the kidneys, causing an increased excretion of potassium; monitor for dysrhythmias 16. A nurse is caring for a client who is in Buck’s traction. Which of the following actions should the nurse take? SATA: a. Closely monitor the neurovascular integrity; circulation can be compromised from the fracture as well as the traction device b. Monitor skin integrity at least q8hrs c. Circulation can be compromised from the fracture as well as the traction device. Check and document color, temperature, distal pulses, capillary refill, movement, and sensation during neurovascular assessment. Monitor 6 P’s: pain, pallor, pulselessness, pressure, paresthesia, and paralysis 17. A nurse is reviewing safety measures with the caregiver of a client who has Alzheimer’s disease. Which of the following instructions should the nurse include in the teaching? a. Lock doors leading to stairways i. This patient is at an increased risk for falls due to difficulty with balance and an inability to recognize dangerous situations due to brain damage from the disease 18. A nurse is developing a plan of care for a client who has meningitis. Which of the following interventions should the nurse include in the plan? a. Keep the client’s room dark and quiet i. Meningitis often causes photophobia (sensitive to light) and phonophobia (sensitive to sound); reduce stimuli 19. A nurse is caring for a client who has a right subclavian central venous catheter. When reconnecting a new intravenous infusion ad