Adult Medical Surgical
A home health nurse is reinforcing teaching about preventing asthma attacks
with a client who has asthma. Which of the following instructions should the
nurse include in the teaching?
"Cover the floor of your bedroom with carpet."
"Do not allow visitors to smoke cigarettes in your home."
"Breathe cold air to ease feelings of shortness of breath."
"Open the windows in your home during the spring to increase air flow." - ANS
"Do not allow visitors to smoke cigarettes in your home."
A home health nurse is reinforcing teaching with a client about preventing
complications of peripheral vascular disease. Which of the following statements
indicates that the client is adhering to the nurse's instructions? - ANS I don't
cross my legs anymore.
It can impede circulation.
Have decreased sensation of the affected extremities. Therefore, they are unable
to detect the temperature of the water bottle, which increases the risk for burns.
Wool socks can result in perspiration, which puts the client at risk for developing
a fungal infection.
A nurse enters the room of a client whose transfusion of packed RBCs was
initiated 15 min ago by the RN. The client reports dyspnea and urticaria. After
stopping the infusion, which of the following actions should the nurse take next?
Collect a urine sample.
Take the client's vital signs.
Return the blood to the laboratory.
Administer an antihistamine. - ANS Take the client's vital signs.
A nurse in a long-term care facility is collecting data from a client who reports
fullness in the rectum and abdominal cramping. Which of the following findings
should indicate to the nurse that the client might have a fecal impaction? - ANS
Small liquid stools
,Halitosis: bad breath
Rebound tenderness: indication of appendicitis
A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a
client who has skin cancer. Which of the following information should the nurse
include in the teaching? - ANS Mohs surgery is a horizontal shaving of thin
layers of the tumor.
Treat basal and squamous cell carcinoma. The procedure, which involves a
horizontal shaving of thin layers of a tumor, has a high success rate.
Cryosurgery: uses liquid nitrogen to destroy cancerous tissue.
Melanoma: wide, full thickness surgical excision.
Radiation: used as a palliative treatment for metastatic skin cancer.
A nurse is assisting a client who reports difficulty falling asleep. Which of the
following activities should the nurse recommend to promote sleep?
Get out of bed if unable to fall asleep within 60 min.
Take a brisk walk before sleeping.
Listen to soft music before sleeping.
Drink adequate amounts of uids before sleeping. - ANS Listen to soft music
before sleeping.
A nurse is assisting in the care of a client who has manifestations of sepsis.
Which of the following provider prescriptions should the nurse implement first? -
ANS Initiate oxygen at 4 L/min via nasal cannula.
Clients who have manifestations of sepsis are often hypoxic, tachypneic, or have
a PaCO2 level less than 32 mm Hg. The nurse should provide supplemental
oxygen to keep the client's oxygen saturation levels at 95% or greater, which will
maximize the ability of the hemoglobin to support the oxygen needs of the body.
A broad spectrum antibiotic, such as ceftriaxone, is administered when sepsis is
suspected because it treats both gram-positive and gram-negative bacteria.
A nurse is assisting in the plan of care for a client who had a recent left
hemispheric stroke. Which of the following actions should the nurse include in
the plan? - ANS Use simple verbal cues when directing tasks
, They manifest some degree of expressive and/or receptive aphasia. Using simple
verbal cues will assist the client in understanding spoken communication
Will display slow movement and cautious behavior. A client who has had a right
hemisphere stroke, in contrast, will exhibit impulsive and unsafe behavior.
Might have deficits, such as impaired vision on the right side of the body. The
nurse should approach the client from the unaffected, or left side, of their body.
Place the client in high-Fowler's position when eating, drinking, or taking
medications to facilitate swallowing.
A nurse is assisting in the plan of care regarding bowel retraining for a client who
has a cervical spinal cord injury. Which of the following interventions should the
nurse plan to implement first?
Determine the client's daily elimination habits.
Administer a suppository to the client 30 min prior to defecation time.
Offer the client 4 oz of warm prune juice to promote elimination.
Provide dietary bulk to the client to ease the passage of stool. - ANS Determine
the client's daily elimination habits.
A nurse is assisting the charge nurse with developing an in-service about caring
for clients who have internal sealed radiation implants. Which of the following
information should the nurse include?
Restrict the time pregnant women are allowed in the client's room to 15 min.
Pick up a radiation implant with a double-gloved hand if it becomes dislodged.
Limit time spent in the client's room to 2 hr during an 8 hr shift.
Dispose of radiation implants in a lead container. - ANS Dispose of radiation
implants in a lead container.
A nurse is assisting with the care of a client who had a cardiac catheterization via
the right femoral artery. Which of the following actions should the nurse take to
prevent postprocedure complications?
Monitor the insertion site for bleeding
Position the affected extremity at a 45º
Restrict the client's fluid intake
Maintain the pressure dressing
A home health nurse is reinforcing teaching about preventing asthma attacks
with a client who has asthma. Which of the following instructions should the
nurse include in the teaching?
"Cover the floor of your bedroom with carpet."
"Do not allow visitors to smoke cigarettes in your home."
"Breathe cold air to ease feelings of shortness of breath."
"Open the windows in your home during the spring to increase air flow." - ANS
"Do not allow visitors to smoke cigarettes in your home."
A home health nurse is reinforcing teaching with a client about preventing
complications of peripheral vascular disease. Which of the following statements
indicates that the client is adhering to the nurse's instructions? - ANS I don't
cross my legs anymore.
It can impede circulation.
Have decreased sensation of the affected extremities. Therefore, they are unable
to detect the temperature of the water bottle, which increases the risk for burns.
Wool socks can result in perspiration, which puts the client at risk for developing
a fungal infection.
A nurse enters the room of a client whose transfusion of packed RBCs was
initiated 15 min ago by the RN. The client reports dyspnea and urticaria. After
stopping the infusion, which of the following actions should the nurse take next?
Collect a urine sample.
Take the client's vital signs.
Return the blood to the laboratory.
Administer an antihistamine. - ANS Take the client's vital signs.
A nurse in a long-term care facility is collecting data from a client who reports
fullness in the rectum and abdominal cramping. Which of the following findings
should indicate to the nurse that the client might have a fecal impaction? - ANS
Small liquid stools
,Halitosis: bad breath
Rebound tenderness: indication of appendicitis
A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a
client who has skin cancer. Which of the following information should the nurse
include in the teaching? - ANS Mohs surgery is a horizontal shaving of thin
layers of the tumor.
Treat basal and squamous cell carcinoma. The procedure, which involves a
horizontal shaving of thin layers of a tumor, has a high success rate.
Cryosurgery: uses liquid nitrogen to destroy cancerous tissue.
Melanoma: wide, full thickness surgical excision.
Radiation: used as a palliative treatment for metastatic skin cancer.
A nurse is assisting a client who reports difficulty falling asleep. Which of the
following activities should the nurse recommend to promote sleep?
Get out of bed if unable to fall asleep within 60 min.
Take a brisk walk before sleeping.
Listen to soft music before sleeping.
Drink adequate amounts of uids before sleeping. - ANS Listen to soft music
before sleeping.
A nurse is assisting in the care of a client who has manifestations of sepsis.
Which of the following provider prescriptions should the nurse implement first? -
ANS Initiate oxygen at 4 L/min via nasal cannula.
Clients who have manifestations of sepsis are often hypoxic, tachypneic, or have
a PaCO2 level less than 32 mm Hg. The nurse should provide supplemental
oxygen to keep the client's oxygen saturation levels at 95% or greater, which will
maximize the ability of the hemoglobin to support the oxygen needs of the body.
A broad spectrum antibiotic, such as ceftriaxone, is administered when sepsis is
suspected because it treats both gram-positive and gram-negative bacteria.
A nurse is assisting in the plan of care for a client who had a recent left
hemispheric stroke. Which of the following actions should the nurse include in
the plan? - ANS Use simple verbal cues when directing tasks
, They manifest some degree of expressive and/or receptive aphasia. Using simple
verbal cues will assist the client in understanding spoken communication
Will display slow movement and cautious behavior. A client who has had a right
hemisphere stroke, in contrast, will exhibit impulsive and unsafe behavior.
Might have deficits, such as impaired vision on the right side of the body. The
nurse should approach the client from the unaffected, or left side, of their body.
Place the client in high-Fowler's position when eating, drinking, or taking
medications to facilitate swallowing.
A nurse is assisting in the plan of care regarding bowel retraining for a client who
has a cervical spinal cord injury. Which of the following interventions should the
nurse plan to implement first?
Determine the client's daily elimination habits.
Administer a suppository to the client 30 min prior to defecation time.
Offer the client 4 oz of warm prune juice to promote elimination.
Provide dietary bulk to the client to ease the passage of stool. - ANS Determine
the client's daily elimination habits.
A nurse is assisting the charge nurse with developing an in-service about caring
for clients who have internal sealed radiation implants. Which of the following
information should the nurse include?
Restrict the time pregnant women are allowed in the client's room to 15 min.
Pick up a radiation implant with a double-gloved hand if it becomes dislodged.
Limit time spent in the client's room to 2 hr during an 8 hr shift.
Dispose of radiation implants in a lead container. - ANS Dispose of radiation
implants in a lead container.
A nurse is assisting with the care of a client who had a cardiac catheterization via
the right femoral artery. Which of the following actions should the nurse take to
prevent postprocedure complications?
Monitor the insertion site for bleeding
Position the affected extremity at a 45º
Restrict the client's fluid intake
Maintain the pressure dressing
