CJE MED SURG I Questions And Verified Correct Answers
When the home health nurse visits a 90-year-old client after repair of a hip fracture, the client
states, "The back of my left leg sure does hurt. Can you rub it a bit for me?" Upon assessment
of the client's lower extremities, the nurse places a call to the health care provider.
What assessment findings prompted the call? Select all that apply.
A. There is warmth and redness to the client's left leg.
D. Left leg appears larger than the right.
The catheter-associated urinary tract infection (CAUTI) rate is up in the hospital and the
quality committee is meeting to devise a plan aimed at decreasing the rate. Nurses are
assessing all clients in the hospital with urinary drainage catheters to determine which
catheters can be discontinued.
Which client should have the catheter removed?
C. The client with generalized weakness who is incontinent of bowel and bladder.
A client is in the observation unit of the emergency department with lightheadedness upon
standing, dry mouth, and a headache. The client reports running a marathon two days ago
and has been feeling unwell since then.
Blood pressure is 92/60, temperature 101.1 °F (38.3 °C), respiratory rate 22, heart rate 112,
and oxygen saturation 94%. Serum laboratory tests reveal hyponatremia and hyperkalemia.
The client is asked to give a urine sample for urinalysis and is only able to urinate 30 mL of
very dark urine.
What does the nurse anticipate will be in the client's immediate plan of care? Select all that
apply.
A. Monitor intake and output - Yes, this is critical for assessing fluid balance in a potentially
dehydrated client.
C. Intravenous fluid replacement - Yes, this is essential to correct hypovolemia,
electrolyte imbalances, and prevent further complications.
D. Bedrest - Yes, indicated due to hypotension and risk of falls or further complications.
The floor nurse assesses a client's dialysis fistula and determines that it is non-functional. The
nurse intervenes by notifying the health care provi (HCP) immediately.
What prompted the nurse to contact the HCP?
B. The client cannot survive without the dialysis procedure.
, The nurse educates a new unlicensed assistive personnel (UAP) to provide mouth care to an
unconscious client.
How should the nurse instruct the UAP to prevent the risk of aspiration?
C. Raise the head of the bed to 30 degrees and turn the client's head to the side.
The home health nurse cares for a client with peripheral vascular disease and assesses the
client's feet in the image.
What is important for the nurse to include in the client's plan of care?
C. Elevate the lower extremities whenever possible
A new nurse working on the skilled nursing unit of a nursing home just received a prescription
from the health care provider (HCP) to administe dose heparin via the subcutaneous route to
a client with hip replacement
C. The nurse is administering the injection via an incorrect route.
A client presents to the emergency department with a 4-day history of coughing large
amounts of yellow sputum, sneezing, and a sore throat. Th states, "Everyone in my house had
the flu."
Nursing assessment of the client reveals crackles in the lungs, blood pressure 116/70, heart
rate 84, respiratory rate 22, temperature 101.9 °F (3% and oxygen saturation 90%.
The health care provider has prescribed oxygen at 2 liters, an initial dose of IV antibiotics,
sputum culture, IV fluids, and an antipyretic.
After placing the client on oxygen, which prescription should the nurse implement next?
C. Sputum culture
The nurse cares for a client post left hip open reduction internal fixation (ORIF) and prepares
to administer the evening medication. The nurs these medication orders from the provider:
• Morphine sulfate 4 mg oral suspension every 4 hours as needed for pain
• Famotidine 20 mg oral suspension every 12 hours.
In the medication dispensing machine is morphine oral suspension 20 mg/mL and famotidine
40 mg/5 mL.
How many milliliters (mL) of acid-reducing medication should the nurse administer? Round to
the nearest tenth.
2.5ML
A client was abducted a year ago by an estranged spouse and kept tied in the basement
against her will. The client was finally able to break free the spouse was out of the house and
called a family member for help. The client was started on total parenteral nutrition (PN) in
the emergency department and transferred to the medical floor.
Which finding most likely led to the implementation of TPN?
When the home health nurse visits a 90-year-old client after repair of a hip fracture, the client
states, "The back of my left leg sure does hurt. Can you rub it a bit for me?" Upon assessment
of the client's lower extremities, the nurse places a call to the health care provider.
What assessment findings prompted the call? Select all that apply.
A. There is warmth and redness to the client's left leg.
D. Left leg appears larger than the right.
The catheter-associated urinary tract infection (CAUTI) rate is up in the hospital and the
quality committee is meeting to devise a plan aimed at decreasing the rate. Nurses are
assessing all clients in the hospital with urinary drainage catheters to determine which
catheters can be discontinued.
Which client should have the catheter removed?
C. The client with generalized weakness who is incontinent of bowel and bladder.
A client is in the observation unit of the emergency department with lightheadedness upon
standing, dry mouth, and a headache. The client reports running a marathon two days ago
and has been feeling unwell since then.
Blood pressure is 92/60, temperature 101.1 °F (38.3 °C), respiratory rate 22, heart rate 112,
and oxygen saturation 94%. Serum laboratory tests reveal hyponatremia and hyperkalemia.
The client is asked to give a urine sample for urinalysis and is only able to urinate 30 mL of
very dark urine.
What does the nurse anticipate will be in the client's immediate plan of care? Select all that
apply.
A. Monitor intake and output - Yes, this is critical for assessing fluid balance in a potentially
dehydrated client.
C. Intravenous fluid replacement - Yes, this is essential to correct hypovolemia,
electrolyte imbalances, and prevent further complications.
D. Bedrest - Yes, indicated due to hypotension and risk of falls or further complications.
The floor nurse assesses a client's dialysis fistula and determines that it is non-functional. The
nurse intervenes by notifying the health care provi (HCP) immediately.
What prompted the nurse to contact the HCP?
B. The client cannot survive without the dialysis procedure.
, The nurse educates a new unlicensed assistive personnel (UAP) to provide mouth care to an
unconscious client.
How should the nurse instruct the UAP to prevent the risk of aspiration?
C. Raise the head of the bed to 30 degrees and turn the client's head to the side.
The home health nurse cares for a client with peripheral vascular disease and assesses the
client's feet in the image.
What is important for the nurse to include in the client's plan of care?
C. Elevate the lower extremities whenever possible
A new nurse working on the skilled nursing unit of a nursing home just received a prescription
from the health care provider (HCP) to administe dose heparin via the subcutaneous route to
a client with hip replacement
C. The nurse is administering the injection via an incorrect route.
A client presents to the emergency department with a 4-day history of coughing large
amounts of yellow sputum, sneezing, and a sore throat. Th states, "Everyone in my house had
the flu."
Nursing assessment of the client reveals crackles in the lungs, blood pressure 116/70, heart
rate 84, respiratory rate 22, temperature 101.9 °F (3% and oxygen saturation 90%.
The health care provider has prescribed oxygen at 2 liters, an initial dose of IV antibiotics,
sputum culture, IV fluids, and an antipyretic.
After placing the client on oxygen, which prescription should the nurse implement next?
C. Sputum culture
The nurse cares for a client post left hip open reduction internal fixation (ORIF) and prepares
to administer the evening medication. The nurs these medication orders from the provider:
• Morphine sulfate 4 mg oral suspension every 4 hours as needed for pain
• Famotidine 20 mg oral suspension every 12 hours.
In the medication dispensing machine is morphine oral suspension 20 mg/mL and famotidine
40 mg/5 mL.
How many milliliters (mL) of acid-reducing medication should the nurse administer? Round to
the nearest tenth.
2.5ML
A client was abducted a year ago by an estranged spouse and kept tied in the basement
against her will. The client was finally able to break free the spouse was out of the house and
called a family member for help. The client was started on total parenteral nutrition (PN) in
the emergency department and transferred to the medical floor.
Which finding most likely led to the implementation of TPN?
