Brunner & Suddarth's Textbook of Medical-Surgical Nursing
1. The nurse in the oncology clinic is caring for a 42-year-old female client
receiving chemotherapy with fludarabine for acute myeloid leukemia who has
developed petechiae, epistaxis, and ecchymosis.
client has developed ______________ that the laboratory results will reveal
__________: client has developed hemorrhage that the laboratory results will
reveal thrombocytopenia.
2. The nurse provides care for a client, with a history of atherosclerosis,
who is hospitalized for the initiation of pharmacotherapy for the treatment of
hypothyroidism.
The client is at highest risk for developing _______________ as evidenced
by _______________.: The client is at highest risk for developing cardiac
dysfunction as evidenced by angina.
3. The nurse is caring for a 24-year-old female client with a right tibial
fracture treated with a cast 2 hours ago. The client now reports unrelenting
pain, rated as 7/10, despite taking oxycodone, and decreased sensation in the
right foot. A nursing assessment reveals the right foot is cooler and paler than
the left foot, with delayed capillary refill and a weak pulse.
Based on the nursing assessment, the priority action the nurse should
take is to _________________________ and prepare the client for
_________________.: Based on the nursing assessment, the priority action the
nurse should take is to notify the orthopedic health care provider immediately and
prepare the client for bivalving of the cast.
4. The nurse assesses a client who has a nasogastric tube for long-term
nutritional needs for complications associated with the medical device.
The nurse monitors the client for ___________ , a finding indicative of
_____________.: The nurse monitors the client for purulent nasal drainage, a
finding indicative of rhinosinusitis.
5. The office nurse is reviewing an 80-year-old female client's reports
related to the onset of a severe headache, rated at 9 out of 10 on the pain
scale, with recent onset. The client denies any visual changes. During a prior
visit to the office a few months ago, the client had reported a ground-level fall
as a result of falling off a chair and hitting the back of their head. The client
, Brunner & Suddarth's Textbook of Medical-Surgical Nursing
had been taken to the emergency department, where imaging was performed
with negative results.
The nurse anticipates that the client has developed __________ and that
__________ will be ordered.: The nurse anticipates that the client has developed
chronic subdural hematoma and that computed tomography (CT) imaging of the
brain will be ordered.
6. A client will undergo abdominal surgery. The nurse provides
preoperative education regarding the importance of diaphragmatic breathing
exercises to prevent postoperative complications.
The nurse will educate the client about the risk for developing _________,
____________, and ____________, if the client does not implement
diaphragmatic breathing exercises in the postoperative period of care.: The
nurse will educate the client about the risk for developing pneumonia,
bronchospasm, and atelectasis, if the client does not implement diaphragmatic
breathing exercises in the postoperative period of care.
7. A nurse is caring for a client who was admitted for an asthma
exacerbation. In the past year, the client has been admitted for three asthma
events. What will the nurse include in the client teaching about preventing
repeat hospitalizations?
The nurse should teach about __________ followed by ___________.: The
nurse should teach about triggers to avoid followed by knowing medications.
8. A 47-year-old male client presented to the medical unit and the health
care team suspects tuberculosis (TB). The nurse is admitting the client to a
reverse isolation room. QuantiFERON testing and chest x-ray are pending.
Urinalysis results are negative. No other testing was performed prior to
admission to isolation. The client denies any chest pain, shortness of breath
(SOB), or respiratory difficulty. The client presents with productive yellow
sputum.
Based on the provided assessment status, the nurse should utilize
__________ to prevent exposure and __________ to collect specimens for
additional testing.: Based on the provided assessment status, the nurse should
utilize airborne precautions to prevent exposure and sputum to collect specimens
for additional testing.
, Brunner & Suddarth's Textbook of Medical-Surgical Nursing
9. The nurse has documented an assessment on a 45-year-old male client
on the third postoperative day following an open abdominal appendectomy.
Client has 3 in (7.6 cm) right lower abdominal incision. Proximal 2 in (5
cm) of incision edges are red and well-approximated. Distal portion of
incision has separated and has yellow drainage on dressing. Bulb drain
has serosanguinous drainage and clumps of yellow pus. Oxygen
saturation on room air 97%. Blood pressure, 112/60 mm Hg; heart rate, 102
beats/min; respiratory rate, 22 breaths/min; temperature, 101.2F (38.4C)
orally. Denies chills. Bowel sounds hypoactive in all 4 quadrants. Client
reports passing flatus, no Abdomen firm and slightly distended bowel
movement. Lungs clear to auscultation bilaterally. Client reports incisional
pain level of 3/10 red blood cell count 4.2 million/mcl, thirty (30) minutes
following oxycodone 5 mg orally. Reports an increased, but tolerable,
level of pain while performing cough and deep-breathing exercises while
splinting incision. Reports minimal pain on abdominal palpation. White
blood count 12.9 x 103 cells/mm3 (12.9 x 109 /l), hemoglobin 14 g/dl (140
g/l), blood glucose level 130 mg/dl (7.21 mmol/l).
What the assessment findings that will require follow up: -has separated and
has yellow drainage on dressing
-clumps of yellow pus
-102 beats/min; respiratory rate, 22 breaths/min; temperature, 101.2°F
(38.4°C) orally
-White blood count 12.9 x 103 cells/mm3 (12.9 x 109 /l) -
blood glucose level 130 mg/dl (7.21 mmol/l).
10. The nurse monitors a client for side effects associated with furosemide,
which is newly prescribed for the treatment of heart failure.
Due to the client's high risk for developing _________ as a result of the
prescribed medication, the nurse focuses on monitoring the client for
__________.: Due to the client's high risk for developing hypokalemia as a result
of the prescribed medication, the nurse focuses on monitoring the client for
ventricular arrhythmia.
1. The nurse in the oncology clinic is caring for a 42-year-old female client
receiving chemotherapy with fludarabine for acute myeloid leukemia who has
developed petechiae, epistaxis, and ecchymosis.
client has developed ______________ that the laboratory results will reveal
__________: client has developed hemorrhage that the laboratory results will
reveal thrombocytopenia.
2. The nurse provides care for a client, with a history of atherosclerosis,
who is hospitalized for the initiation of pharmacotherapy for the treatment of
hypothyroidism.
The client is at highest risk for developing _______________ as evidenced
by _______________.: The client is at highest risk for developing cardiac
dysfunction as evidenced by angina.
3. The nurse is caring for a 24-year-old female client with a right tibial
fracture treated with a cast 2 hours ago. The client now reports unrelenting
pain, rated as 7/10, despite taking oxycodone, and decreased sensation in the
right foot. A nursing assessment reveals the right foot is cooler and paler than
the left foot, with delayed capillary refill and a weak pulse.
Based on the nursing assessment, the priority action the nurse should
take is to _________________________ and prepare the client for
_________________.: Based on the nursing assessment, the priority action the
nurse should take is to notify the orthopedic health care provider immediately and
prepare the client for bivalving of the cast.
4. The nurse assesses a client who has a nasogastric tube for long-term
nutritional needs for complications associated with the medical device.
The nurse monitors the client for ___________ , a finding indicative of
_____________.: The nurse monitors the client for purulent nasal drainage, a
finding indicative of rhinosinusitis.
5. The office nurse is reviewing an 80-year-old female client's reports
related to the onset of a severe headache, rated at 9 out of 10 on the pain
scale, with recent onset. The client denies any visual changes. During a prior
visit to the office a few months ago, the client had reported a ground-level fall
as a result of falling off a chair and hitting the back of their head. The client
, Brunner & Suddarth's Textbook of Medical-Surgical Nursing
had been taken to the emergency department, where imaging was performed
with negative results.
The nurse anticipates that the client has developed __________ and that
__________ will be ordered.: The nurse anticipates that the client has developed
chronic subdural hematoma and that computed tomography (CT) imaging of the
brain will be ordered.
6. A client will undergo abdominal surgery. The nurse provides
preoperative education regarding the importance of diaphragmatic breathing
exercises to prevent postoperative complications.
The nurse will educate the client about the risk for developing _________,
____________, and ____________, if the client does not implement
diaphragmatic breathing exercises in the postoperative period of care.: The
nurse will educate the client about the risk for developing pneumonia,
bronchospasm, and atelectasis, if the client does not implement diaphragmatic
breathing exercises in the postoperative period of care.
7. A nurse is caring for a client who was admitted for an asthma
exacerbation. In the past year, the client has been admitted for three asthma
events. What will the nurse include in the client teaching about preventing
repeat hospitalizations?
The nurse should teach about __________ followed by ___________.: The
nurse should teach about triggers to avoid followed by knowing medications.
8. A 47-year-old male client presented to the medical unit and the health
care team suspects tuberculosis (TB). The nurse is admitting the client to a
reverse isolation room. QuantiFERON testing and chest x-ray are pending.
Urinalysis results are negative. No other testing was performed prior to
admission to isolation. The client denies any chest pain, shortness of breath
(SOB), or respiratory difficulty. The client presents with productive yellow
sputum.
Based on the provided assessment status, the nurse should utilize
__________ to prevent exposure and __________ to collect specimens for
additional testing.: Based on the provided assessment status, the nurse should
utilize airborne precautions to prevent exposure and sputum to collect specimens
for additional testing.
, Brunner & Suddarth's Textbook of Medical-Surgical Nursing
9. The nurse has documented an assessment on a 45-year-old male client
on the third postoperative day following an open abdominal appendectomy.
Client has 3 in (7.6 cm) right lower abdominal incision. Proximal 2 in (5
cm) of incision edges are red and well-approximated. Distal portion of
incision has separated and has yellow drainage on dressing. Bulb drain
has serosanguinous drainage and clumps of yellow pus. Oxygen
saturation on room air 97%. Blood pressure, 112/60 mm Hg; heart rate, 102
beats/min; respiratory rate, 22 breaths/min; temperature, 101.2F (38.4C)
orally. Denies chills. Bowel sounds hypoactive in all 4 quadrants. Client
reports passing flatus, no Abdomen firm and slightly distended bowel
movement. Lungs clear to auscultation bilaterally. Client reports incisional
pain level of 3/10 red blood cell count 4.2 million/mcl, thirty (30) minutes
following oxycodone 5 mg orally. Reports an increased, but tolerable,
level of pain while performing cough and deep-breathing exercises while
splinting incision. Reports minimal pain on abdominal palpation. White
blood count 12.9 x 103 cells/mm3 (12.9 x 109 /l), hemoglobin 14 g/dl (140
g/l), blood glucose level 130 mg/dl (7.21 mmol/l).
What the assessment findings that will require follow up: -has separated and
has yellow drainage on dressing
-clumps of yellow pus
-102 beats/min; respiratory rate, 22 breaths/min; temperature, 101.2°F
(38.4°C) orally
-White blood count 12.9 x 103 cells/mm3 (12.9 x 109 /l) -
blood glucose level 130 mg/dl (7.21 mmol/l).
10. The nurse monitors a client for side effects associated with furosemide,
which is newly prescribed for the treatment of heart failure.
Due to the client's high risk for developing _________ as a result of the
prescribed medication, the nurse focuses on monitoring the client for
__________.: Due to the client's high risk for developing hypokalemia as a result
of the prescribed medication, the nurse focuses on monitoring the client for
ventricular arrhythmia.
