Adult Medical Surgical Practice A+
GUARANTEED GUIDE
A charge nurse is instructing a newly licensed nurse about caring for a client who has MRSA which of the
following statements by the newly licensed nurse indicates an understanding of the teaching -CORRECT
ANSWERS-I will leave assessment equipment in the room to use on this client the nurse should follow
contact precautions and use dedicated equipment when assessing the client to prevent cross-
contamination with other clients
A client is admitted to the ER with anxiety loss of muscle coordination and skin is hot and dry the client
had been working on the yard prior to coming to the hospital which of the following actions should the
nurse anticipate taking first -CORRECT ANSWERS-Place the client on a cooling blanket because these
findings indicate the client is at greatest risk for hyperthermia
A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After
ensuring a patent Airway which of the following interventions is the priority -CORRECT ANSWERS-
applying oxygen via face mask because the priority intervention is for the nurse to apply oxygen using a
high-flow non-rebreather mask to deliver oxygen at 90 to 100%
A nurse in a provider's office is assessing a client who has migraine headaches and is taking Feverfew to
prevent her headaches the nurse should identify that which of the following client medications interact
with Feverfew -CORRECT ANSWERS-Naproxen because they both impaired platelet aggregation and
place the client at risk for bleeding
A nurse in a provider's office is caring for a client who requests sildenafil to treat erectile dysfunction.
Which of the following statements should the nurse make? -CORRECT ANSWERS-You will not be able to
use sildenafil if you are taking nitroglycerin. The client should not use sildenafil when taking nitroglycerin
because both medications can cause vasodilation and lead to significant hypotension
A nurse in an emergency department is admitting a client who reports dyspnea and shortness of breath.
Which of the following actions is the priority for the nurse to perform prior to administering oxygen? -
CORRECT ANSWERS-Determine if the client has a history of COPD. According to evidence based practice
the nurse should first assess if the client has COPD. Administering oxygen can worsen chronic
hypercarbia in a client who has COPD
A nurse in an emergency department is assessing an older adult client who has a fractured wrist
following a fall during the assessment the client states last week I crashed my car because my vision
suddenly became blurry which of the following actions is the nurses priority -CORRECT ANSWERS-Check
the clients neurologic status because the first action you should take is to assess the client
A nurse in an emergency department is caring for a client who has full thickness Burns over 20% of his
total body surface area after ensuring a patent Airway and administering oxygen which of the following
items should the nurse prepared to administer first -CORRECT ANSWERS-IV fluids to provide circulatory
support
, A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the
past 3 days which of the following findings should indicate to the nurse that the client is experiencing
fluid volume deficit -CORRECT ANSWERS-Heart rate of 110 per minute
A nurse in an emergency department is planning care for a client who has a flail chest on the right side
following a motor vehicle crash which of the following actions should the nurse plan to take -CORRECT
ANSWERS-Prepare the client for positive pressure ventilation to promote lung expansion and stabilize
the pressure within the client's chest then there should also administer analgesics to alleviate pain while
breathing to achieve optimal lung reexpansion
A nurse is assessing a client following the completion of hemodialysis which of the following findings is
the nurses priority to report to the provider -CORRECT ANSWERS-Restlessness because using the Urgent
vs. Non-virgin approach to client care the nurse to determine that the priority funding to report to the
provider is restlessness which can be an indication of the client is experiencing disequilibrium syndrome
which is caused by the rapid removal of electrolytes for the clients blood and can lead to dysrhythmias
or seizures other manifestations include nausea vomiting fatigue and headache
A nurse is assessing a client while suctioning the clients tracheostomy tube which of the following
findings should indicate to the nurse that the client is experiencing hypoxia -CORRECT ANSWERS-The
clients heart rate increases because hypoxia related to suctioning can cause the clients heart rate to
increase if this occurs the nurse should discontinue the sectioning and immediately oxygenate the client
with 100% oxygen the nurse should instruct the client to take three or four deep breaths prior to
suctioning to reduce the risk for hypoxia
A nurse is assessing a client who has Graves disease. Which of the following images should indicate to
the nurse that the client has exophthalmos? -CORRECT ANSWERS-The nurse should identify an outward
protrusion of the eyes is exophthalmos a common finding of graves disease. An overproduction of the
thyroid hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye
which results in the eyes protruding outward. Exophthalmos can cause the client to experience
problems with vision including focusing on objects as well as pressure on the optic nerve.
A nurse is assessing a client who has had a suspected cerebrovascular accident the nurse should place
the priority on which of the following findings -CORRECT ANSWERS-Dysphasia because it indicates that
the client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity
A nurse is assessing a client who has hypokalemia which of the following manifestations should the
nurse expect -CORRECT ANSWERS-Decreased peristalsis due to a decrease in gastrointestinal smooth
muscle contraction
A nurse is assessing a client who has peripheral artery disease which of the following findings should the
nurse expect -CORRECT ANSWERS-Hair loss on the lower legs the nurse should expect a client who is
Peripheral arterial disease to have hair loss on the lower legs as a result of impaired arterial circulation
affecting follicular growth
A nurse is assessing for compartment syndrome in a client who has a short leg cast which of the
following findings should the nurse identify as a manifestation of this condition -CORRECT ANSWERS-
Pain that increases with passive movement because compartment syndrome results from a decrease in
GUARANTEED GUIDE
A charge nurse is instructing a newly licensed nurse about caring for a client who has MRSA which of the
following statements by the newly licensed nurse indicates an understanding of the teaching -CORRECT
ANSWERS-I will leave assessment equipment in the room to use on this client the nurse should follow
contact precautions and use dedicated equipment when assessing the client to prevent cross-
contamination with other clients
A client is admitted to the ER with anxiety loss of muscle coordination and skin is hot and dry the client
had been working on the yard prior to coming to the hospital which of the following actions should the
nurse anticipate taking first -CORRECT ANSWERS-Place the client on a cooling blanket because these
findings indicate the client is at greatest risk for hyperthermia
A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After
ensuring a patent Airway which of the following interventions is the priority -CORRECT ANSWERS-
applying oxygen via face mask because the priority intervention is for the nurse to apply oxygen using a
high-flow non-rebreather mask to deliver oxygen at 90 to 100%
A nurse in a provider's office is assessing a client who has migraine headaches and is taking Feverfew to
prevent her headaches the nurse should identify that which of the following client medications interact
with Feverfew -CORRECT ANSWERS-Naproxen because they both impaired platelet aggregation and
place the client at risk for bleeding
A nurse in a provider's office is caring for a client who requests sildenafil to treat erectile dysfunction.
Which of the following statements should the nurse make? -CORRECT ANSWERS-You will not be able to
use sildenafil if you are taking nitroglycerin. The client should not use sildenafil when taking nitroglycerin
because both medications can cause vasodilation and lead to significant hypotension
A nurse in an emergency department is admitting a client who reports dyspnea and shortness of breath.
Which of the following actions is the priority for the nurse to perform prior to administering oxygen? -
CORRECT ANSWERS-Determine if the client has a history of COPD. According to evidence based practice
the nurse should first assess if the client has COPD. Administering oxygen can worsen chronic
hypercarbia in a client who has COPD
A nurse in an emergency department is assessing an older adult client who has a fractured wrist
following a fall during the assessment the client states last week I crashed my car because my vision
suddenly became blurry which of the following actions is the nurses priority -CORRECT ANSWERS-Check
the clients neurologic status because the first action you should take is to assess the client
A nurse in an emergency department is caring for a client who has full thickness Burns over 20% of his
total body surface area after ensuring a patent Airway and administering oxygen which of the following
items should the nurse prepared to administer first -CORRECT ANSWERS-IV fluids to provide circulatory
support
, A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the
past 3 days which of the following findings should indicate to the nurse that the client is experiencing
fluid volume deficit -CORRECT ANSWERS-Heart rate of 110 per minute
A nurse in an emergency department is planning care for a client who has a flail chest on the right side
following a motor vehicle crash which of the following actions should the nurse plan to take -CORRECT
ANSWERS-Prepare the client for positive pressure ventilation to promote lung expansion and stabilize
the pressure within the client's chest then there should also administer analgesics to alleviate pain while
breathing to achieve optimal lung reexpansion
A nurse is assessing a client following the completion of hemodialysis which of the following findings is
the nurses priority to report to the provider -CORRECT ANSWERS-Restlessness because using the Urgent
vs. Non-virgin approach to client care the nurse to determine that the priority funding to report to the
provider is restlessness which can be an indication of the client is experiencing disequilibrium syndrome
which is caused by the rapid removal of electrolytes for the clients blood and can lead to dysrhythmias
or seizures other manifestations include nausea vomiting fatigue and headache
A nurse is assessing a client while suctioning the clients tracheostomy tube which of the following
findings should indicate to the nurse that the client is experiencing hypoxia -CORRECT ANSWERS-The
clients heart rate increases because hypoxia related to suctioning can cause the clients heart rate to
increase if this occurs the nurse should discontinue the sectioning and immediately oxygenate the client
with 100% oxygen the nurse should instruct the client to take three or four deep breaths prior to
suctioning to reduce the risk for hypoxia
A nurse is assessing a client who has Graves disease. Which of the following images should indicate to
the nurse that the client has exophthalmos? -CORRECT ANSWERS-The nurse should identify an outward
protrusion of the eyes is exophthalmos a common finding of graves disease. An overproduction of the
thyroid hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye
which results in the eyes protruding outward. Exophthalmos can cause the client to experience
problems with vision including focusing on objects as well as pressure on the optic nerve.
A nurse is assessing a client who has had a suspected cerebrovascular accident the nurse should place
the priority on which of the following findings -CORRECT ANSWERS-Dysphasia because it indicates that
the client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity
A nurse is assessing a client who has hypokalemia which of the following manifestations should the
nurse expect -CORRECT ANSWERS-Decreased peristalsis due to a decrease in gastrointestinal smooth
muscle contraction
A nurse is assessing a client who has peripheral artery disease which of the following findings should the
nurse expect -CORRECT ANSWERS-Hair loss on the lower legs the nurse should expect a client who is
Peripheral arterial disease to have hair loss on the lower legs as a result of impaired arterial circulation
affecting follicular growth
A nurse is assessing for compartment syndrome in a client who has a short leg cast which of the
following findings should the nurse identify as a manifestation of this condition -CORRECT ANSWERS-
Pain that increases with passive movement because compartment syndrome results from a decrease in
