Med Surg vati assessment 2/5/2026
Terms in this set (154)
Alzheimer's interventions - Single date calender
- Redirect the client by starting another activity
- Use short, simple senteces when explaining an activity
- Explanation should be done immediately before an activity
Arterial ulcer - Assess the tip and between the toes
- Cyanosis
- Cool to the touch
- Weak or absent pulses
Complete heart block - Regular rhythm
- Low HR
- Clear P waves that outnumber QRS complexes
-
Contact Precautions The nurse should implement contact precautions for clients who have known or
suspected infections due to micro-organisms that spread by direct contact or contact
with items in the environment, such as C. Diff , vancomycin-resistant enterococci, and
MRSA.
diabetes macrovascular complications - Coronary Artery Disease
- Stroke
- Hypertension
Med Surg vati assessment Page 1 of 40
,Med Surg vati assessment 2/5/2026
Diabetic ulcer - Assess the ball of the foot
- Deep with pale even edges
- granulation in the wound bed
Dialysate interventions - Do NOT use infusion pump
- Report cloudy dialysate drainage
- Warm solution using a heating pad or place in the warming section of cycling
machine
- Dwell time: 4-8 hours
- Drainage: 10-20 minutes
Droplet precautions The nurse should implement droplet precautions for clients who have known or
suspected infections transmitted by droplets that travel up to 0.9 m (3 feet) but do not
remain suspended for prolonged periods, such as diphtheria, rubella, mumps,
pertussis, and meningococcal pneumonia or sepsis.
Dumping syndrome - Anorexia
- Iron deficiency anemia
- Hypocalcemia
- Tachycardia
- Rapid gastric emptying
- Nausea & abdomnial cramping
Med Surg vati assessment Page 2 of 40
,Med Surg vati assessment 2/5/2026
An emergency room nurse is assessing a client who has USE OF ASSCESSORY MUSCLES.
asthma and difficulty breathing. Which of the following
findings should indicate to the nurse that the client is - A client who has status asthmaticus uses accessory muscles to help facilitate
experiencing status asthmaticus? breathing, which is a manifestation of a severe airflow obstruction. The situation is
life-threatening and the nurse should intervene immediately with strong systemic
bronchodilators, epinephrine, corticosteroids, and oxygen.
Fetal occult blood test - Do not take NSAIDs for 7 days
- Do not eat raw vegetables, red meat, or citritus fruits for 3 days before
- Do not take Vitamin C supplements for 3 days before
First-degree heart block - Atrial impulses reach the ventricles through the AV node at a slower-than-normal
rate.
- P waves have a regular shape and appear consistently in front of the QRS complex.
A home health nurse is assisting a client with planning care Remove clutter from rooms and hallways
for a family member who has Alzheimer's disease. Which of
the following instructions should the nurse include? - This allows the client is able to walk without the risk of falling or tripping over
objects. Later in the disease, the client can experience seizures, so cluttered areas
could be a risk to the client
Med Surg vati assessment Page 3 of 40
, Med Surg vati assessment 2/5/2026
A home health nurse is assisting a family member with Remove clutter from rooms and hallways.
planning care for a client who has Alzheimer's disease.
Which of the following instructions should the nurse The nurse should instruct the family member to remove clutter from rooms and
include? hallways so the client is able to walk without the risk of falling or tripping over
objects. Later in the disease, the client can experience seizures, so cluttered areas
Remove clutter from rooms and hallways. could be a risk to the client.
Place a monthly calendar in the client's room.
Use confrontation to manage the client's behavior.
Review the daily schedule with the client every morning.
A home health nurse is inspecting a client's residence for AN IV PUMP IS PLUGGED INTO AN OUTLET NEAR THE SINK.
electrical hazards as part of the agency's quality
improvement plan. Which of the following findings should - The nurse should plug all electrical appliances into outlets away from wet areas.
the nurse identify as a safety hazard? Water conducts electricity and places the client at risk for electrocution.
Hyponatremia - Low specific gravity
- Elevated hemoglobin
Hypovolemia S/S - Flat neck veins
- Rapid pulse rate
- Urine output less than 30 mL/hr
- High specific gravity
- Increased RR
Med Surg vati assessment Page 4 of 40
Terms in this set (154)
Alzheimer's interventions - Single date calender
- Redirect the client by starting another activity
- Use short, simple senteces when explaining an activity
- Explanation should be done immediately before an activity
Arterial ulcer - Assess the tip and between the toes
- Cyanosis
- Cool to the touch
- Weak or absent pulses
Complete heart block - Regular rhythm
- Low HR
- Clear P waves that outnumber QRS complexes
-
Contact Precautions The nurse should implement contact precautions for clients who have known or
suspected infections due to micro-organisms that spread by direct contact or contact
with items in the environment, such as C. Diff , vancomycin-resistant enterococci, and
MRSA.
diabetes macrovascular complications - Coronary Artery Disease
- Stroke
- Hypertension
Med Surg vati assessment Page 1 of 40
,Med Surg vati assessment 2/5/2026
Diabetic ulcer - Assess the ball of the foot
- Deep with pale even edges
- granulation in the wound bed
Dialysate interventions - Do NOT use infusion pump
- Report cloudy dialysate drainage
- Warm solution using a heating pad or place in the warming section of cycling
machine
- Dwell time: 4-8 hours
- Drainage: 10-20 minutes
Droplet precautions The nurse should implement droplet precautions for clients who have known or
suspected infections transmitted by droplets that travel up to 0.9 m (3 feet) but do not
remain suspended for prolonged periods, such as diphtheria, rubella, mumps,
pertussis, and meningococcal pneumonia or sepsis.
Dumping syndrome - Anorexia
- Iron deficiency anemia
- Hypocalcemia
- Tachycardia
- Rapid gastric emptying
- Nausea & abdomnial cramping
Med Surg vati assessment Page 2 of 40
,Med Surg vati assessment 2/5/2026
An emergency room nurse is assessing a client who has USE OF ASSCESSORY MUSCLES.
asthma and difficulty breathing. Which of the following
findings should indicate to the nurse that the client is - A client who has status asthmaticus uses accessory muscles to help facilitate
experiencing status asthmaticus? breathing, which is a manifestation of a severe airflow obstruction. The situation is
life-threatening and the nurse should intervene immediately with strong systemic
bronchodilators, epinephrine, corticosteroids, and oxygen.
Fetal occult blood test - Do not take NSAIDs for 7 days
- Do not eat raw vegetables, red meat, or citritus fruits for 3 days before
- Do not take Vitamin C supplements for 3 days before
First-degree heart block - Atrial impulses reach the ventricles through the AV node at a slower-than-normal
rate.
- P waves have a regular shape and appear consistently in front of the QRS complex.
A home health nurse is assisting a client with planning care Remove clutter from rooms and hallways
for a family member who has Alzheimer's disease. Which of
the following instructions should the nurse include? - This allows the client is able to walk without the risk of falling or tripping over
objects. Later in the disease, the client can experience seizures, so cluttered areas
could be a risk to the client
Med Surg vati assessment Page 3 of 40
, Med Surg vati assessment 2/5/2026
A home health nurse is assisting a family member with Remove clutter from rooms and hallways.
planning care for a client who has Alzheimer's disease.
Which of the following instructions should the nurse The nurse should instruct the family member to remove clutter from rooms and
include? hallways so the client is able to walk without the risk of falling or tripping over
objects. Later in the disease, the client can experience seizures, so cluttered areas
Remove clutter from rooms and hallways. could be a risk to the client.
Place a monthly calendar in the client's room.
Use confrontation to manage the client's behavior.
Review the daily schedule with the client every morning.
A home health nurse is inspecting a client's residence for AN IV PUMP IS PLUGGED INTO AN OUTLET NEAR THE SINK.
electrical hazards as part of the agency's quality
improvement plan. Which of the following findings should - The nurse should plug all electrical appliances into outlets away from wet areas.
the nurse identify as a safety hazard? Water conducts electricity and places the client at risk for electrocution.
Hyponatremia - Low specific gravity
- Elevated hemoglobin
Hypovolemia S/S - Flat neck veins
- Rapid pulse rate
- Urine output less than 30 mL/hr
- High specific gravity
- Increased RR
Med Surg vati assessment Page 4 of 40
