Med Surg A
A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted
to the hospital with pneumonia. Which of the following assessment findings is the nurse's
priority?
A. Temperature 38.4º C (101.1º F)
B. Increased respiratory secretions
C. Fluid intake of 200 mL in the prior 8 hr
D. Limited range of motion - ANS B. Increased respiratory secretions
Using the airway, breathing, circulation approach to client care, the nurse should determine that
the priority assessment finding is increased respiratory secretions. These secretions place the
client at risk for aspiration pneumonia due to respiratory muscle weakness caused by the ALS
and the pneumonia.
A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV
contrast agent. The nurse should identify which of the following findings requires further
assessment?
A. History of asthma
B. Appendectomy 1 year ago
C. Penicillin allergy
D. Total knee arthroplasty 6 months ago - ANS A. History of asthma
A client who has a history of asthma has a greater risk of reacting to the contrast dye used
during the procedure. Other conditions that can result in a reaction to contrast media include
allergies to foods, such as shellfish, eggs, milk, and chocolate
A nurse is providing discharge instructions to a client who has a partial-thickness burn on the
hand. Which of the following instructions should the nurse include?
A. Change the dressing every 72 hr.
B. Immobilize the hand with a pressure dressing.
C. Take pain medication 30 min after changing the dressing.
D. Wrap fingers with individual dressings. - ANS D. Wrap fingers with individual dressings.
The nurse should instruct the client to wrap the fingers individually to allow for functional use of
the hand while healing occurs. The nurse should also instruct the client to perform
range-of-motion exercises to each finger every hour while awake to promote function of the
injured hand.
,A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client has
dyspnea with a productive cough and is using accessory muscles to breathe. Which of the
following actions should the nurse take first?
A. Obtain a prescription for ABGs.
B. Administer IV antibiotics to the client.
C. Instruct the client to use the incentive spirometer.
D. Place the client in high-Fowler's position. - ANS D. Place the client in high-Fowler's position.
The greatest risk to this client is injury from airway obstruction. Therefore, the priority
intervention the nurse should take is to move the client into high-Fowler's position. High-Fowler's
position facilitates lung expansion and improves ventilation and gas exchange.
A nurse is providing teaching for a female client who has recurrent urinary tract infections.
Which of the following information should the nurse include in the teaching?
A. Take tub baths daily.
B. Drink at least 1 L of fluid daily.
C. Wear underwear made of nylon.
D. Void before and after intercourse. - ANS D. Void before and after intercourse.
The nurse should instruct the client to empty her bladder before and after intercourse, which
flushes bacteria out of the urinary tract and prevents the occurrence of infection.
A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The
nurse should postpone the testing and report to the provider which of the following findings?
A. Disease processes
B. Laboratory findings
C. Current medications
D. Family history - ANS C. Current medications
The nurse should review the client's medication record and identify medications, including ACE
inhibitors, beta blockers, theophylline, nifedipine, and glucocorticoids, such as prednisone, that
can alter the allergy skin test results. These medications can diminish the client's reaction to the
allergens. The nurse should notify the provider and instruct the client to discontinue prednisone
for 2 weeks before allergy skin testing.
A nurse in an emergency department is reviewing the provider's prescriptions for a client who
sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the
nurse expect?
A. Apply ice to the client's puncture wounds.
, B. Initiate corticosteroid therapy for the client.
C. Keep the client's leg above heart level.
D. Administer an opioid analgesic to the client. - ANS D. Administer an opioid analgesic to the
client.
The nurse should expect a prescription for an opioid analgesic to promote comfort following a
rattlesnake bite.
A nurse is planning to provider discharge teaching for the family of an older adult client who has
hemianopsia and is at risk for falls. Which of the following instructions should the nurse include?
A. Keep the client's personal care items in the bathroom.
B. Keep the overhead lights on in the client's bedroom while the client is sleeping.
C. Remind the client to scan their complete range of vision during ambulation.
D. Secure the client's extension cords under carpeting. - ANS C. Remind the client to scan their
complete range of vision during ambulation.
The nurse should instruct the family to remind a client who has hemianopsia, or blindness in half
of the visual field, to use visual scanning to look over their complete range of vision during
ambulation. This practice can accommodate for the loss of vision and help to reduce the risk for
falls.
A nurse is caring for a group of clients. The nurse should plan to make a referral to physical
therapy for which of the following clients?
A. A client who is receiving preoperative teaching for a right knee arthroplasty
B. A client who states they will have difficulty obtaining a walker for home use
C. A client who reports an increase in pain following a left hip arthroplasty
D. A client who is having emotional difficulty accepting that they have a prosthetic leg - ANS A.
A client who is receiving preoperative teaching for a right knee arthroplasty
The nurse should make a referral to physical therapy for a client who is receiving preoperative
teaching for a knee arthroplasty so the client can begin understanding postoperative exercises
and physical restrictions.
A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which
of the following actions should the nurse take?
A. Maintain adduction of the client's legs.
B. Encourage range of motion of the hip up to a 120° angle.
C. Place a pillow between the client's legs.
D. Keep the client's hip internally rotated. - ANS C. Place a pillow between the client's legs.
The nurse should place a pillow between the client's legs to prevent hip dislocation.
A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted
to the hospital with pneumonia. Which of the following assessment findings is the nurse's
priority?
A. Temperature 38.4º C (101.1º F)
B. Increased respiratory secretions
C. Fluid intake of 200 mL in the prior 8 hr
D. Limited range of motion - ANS B. Increased respiratory secretions
Using the airway, breathing, circulation approach to client care, the nurse should determine that
the priority assessment finding is increased respiratory secretions. These secretions place the
client at risk for aspiration pneumonia due to respiratory muscle weakness caused by the ALS
and the pneumonia.
A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV
contrast agent. The nurse should identify which of the following findings requires further
assessment?
A. History of asthma
B. Appendectomy 1 year ago
C. Penicillin allergy
D. Total knee arthroplasty 6 months ago - ANS A. History of asthma
A client who has a history of asthma has a greater risk of reacting to the contrast dye used
during the procedure. Other conditions that can result in a reaction to contrast media include
allergies to foods, such as shellfish, eggs, milk, and chocolate
A nurse is providing discharge instructions to a client who has a partial-thickness burn on the
hand. Which of the following instructions should the nurse include?
A. Change the dressing every 72 hr.
B. Immobilize the hand with a pressure dressing.
C. Take pain medication 30 min after changing the dressing.
D. Wrap fingers with individual dressings. - ANS D. Wrap fingers with individual dressings.
The nurse should instruct the client to wrap the fingers individually to allow for functional use of
the hand while healing occurs. The nurse should also instruct the client to perform
range-of-motion exercises to each finger every hour while awake to promote function of the
injured hand.
,A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client has
dyspnea with a productive cough and is using accessory muscles to breathe. Which of the
following actions should the nurse take first?
A. Obtain a prescription for ABGs.
B. Administer IV antibiotics to the client.
C. Instruct the client to use the incentive spirometer.
D. Place the client in high-Fowler's position. - ANS D. Place the client in high-Fowler's position.
The greatest risk to this client is injury from airway obstruction. Therefore, the priority
intervention the nurse should take is to move the client into high-Fowler's position. High-Fowler's
position facilitates lung expansion and improves ventilation and gas exchange.
A nurse is providing teaching for a female client who has recurrent urinary tract infections.
Which of the following information should the nurse include in the teaching?
A. Take tub baths daily.
B. Drink at least 1 L of fluid daily.
C. Wear underwear made of nylon.
D. Void before and after intercourse. - ANS D. Void before and after intercourse.
The nurse should instruct the client to empty her bladder before and after intercourse, which
flushes bacteria out of the urinary tract and prevents the occurrence of infection.
A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The
nurse should postpone the testing and report to the provider which of the following findings?
A. Disease processes
B. Laboratory findings
C. Current medications
D. Family history - ANS C. Current medications
The nurse should review the client's medication record and identify medications, including ACE
inhibitors, beta blockers, theophylline, nifedipine, and glucocorticoids, such as prednisone, that
can alter the allergy skin test results. These medications can diminish the client's reaction to the
allergens. The nurse should notify the provider and instruct the client to discontinue prednisone
for 2 weeks before allergy skin testing.
A nurse in an emergency department is reviewing the provider's prescriptions for a client who
sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the
nurse expect?
A. Apply ice to the client's puncture wounds.
, B. Initiate corticosteroid therapy for the client.
C. Keep the client's leg above heart level.
D. Administer an opioid analgesic to the client. - ANS D. Administer an opioid analgesic to the
client.
The nurse should expect a prescription for an opioid analgesic to promote comfort following a
rattlesnake bite.
A nurse is planning to provider discharge teaching for the family of an older adult client who has
hemianopsia and is at risk for falls. Which of the following instructions should the nurse include?
A. Keep the client's personal care items in the bathroom.
B. Keep the overhead lights on in the client's bedroom while the client is sleeping.
C. Remind the client to scan their complete range of vision during ambulation.
D. Secure the client's extension cords under carpeting. - ANS C. Remind the client to scan their
complete range of vision during ambulation.
The nurse should instruct the family to remind a client who has hemianopsia, or blindness in half
of the visual field, to use visual scanning to look over their complete range of vision during
ambulation. This practice can accommodate for the loss of vision and help to reduce the risk for
falls.
A nurse is caring for a group of clients. The nurse should plan to make a referral to physical
therapy for which of the following clients?
A. A client who is receiving preoperative teaching for a right knee arthroplasty
B. A client who states they will have difficulty obtaining a walker for home use
C. A client who reports an increase in pain following a left hip arthroplasty
D. A client who is having emotional difficulty accepting that they have a prosthetic leg - ANS A.
A client who is receiving preoperative teaching for a right knee arthroplasty
The nurse should make a referral to physical therapy for a client who is receiving preoperative
teaching for a knee arthroplasty so the client can begin understanding postoperative exercises
and physical restrictions.
A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which
of the following actions should the nurse take?
A. Maintain adduction of the client's legs.
B. Encourage range of motion of the hip up to a 120° angle.
C. Place a pillow between the client's legs.
D. Keep the client's hip internally rotated. - ANS C. Place a pillow between the client's legs.
The nurse should place a pillow between the client's legs to prevent hip dislocation.
