Med Surg vati Assessment Test With Complete Solution

A nurse is preparing to discharge a client who is postoperative following a total hip arthroplasty. Which of the following equipment should the nurse ensure that the client has available at home prior to discharge? Continuous passive motion device Elevated toilet seat Trapeze bar Compression garment - Answer Elevated toilet seat A client who is postoperative following a total hip arthroplasty is at risk for dislocation of the hip prosthesis. Limitations on hip flexion and adduction decrease the risk. The client should avoid flexing the hip greater than 90° and should avoid using toilet seats that are low to the ground. An elevated toilet seat should be in place in the client's home prior to the client's discharge. A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect? (select all that apply) Elevated WBC count Elevated amylase level Rebound tenderness Ascites Anorexia - Answer Elevated WBC count A client who has acute appendicitis will show a moderate elevation of the WBC count from 10,000 to 18,000/mm3. If the WBC count is greater than 20,000/mm3, it can indicate a perforated appendix. Rebound tenderness A client who has appendicitis develops localized pain over the right lower quadrant of the abdomen. When the area is palpated, pain occurs during release of pressure on the client's abdomen. Anorexia A client who has acute appendicitis experiences nausea, vomiting, and reduced appetite. A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? "I am aware that my diabetes is caused by an autoimmune disorder." "I know that my diabetes developed slowly over several years." "If I lose weight, I may be able to stop taking insulin." "I have developed a resistance to insulin." - Answer "I am aware that my diabetes is caused by an autoimmune disorder." Type 1 diabetes mellitus is an autoimmune disorder that destroys pancreatic beta cells. This autoimmune reaction is often triggered by a viral infection. A nurse is caring for a male client who has a new prescription for cyclosporine following a kidney transplant. Which of the following findings should the nurse identify as an adverse effect of this therapy? WBC count 8,000/mm3 RBC count 6 million/mm3 BUN 24 mg/dL Potassium 3.5 mEq/L - Answer BUN 24 mg/dL A BUN of 24 mg/dL is above the expected reference range of 10 to 20 mg/dL, indicating renal impairment. An adverse effect of cyclosporine is nephrotoxicity. The nurse should monitor the client for increases in BUN and creatinine and report any elevation to the provider. A rise in BUN could indicate transplant rejection. A nurse in a long-term care facility is caring for a client who has dementia. Which of the following actions should the nurse take? Give detailed directions when addressing the client. Provide finger food at mealtime. Use written signs to redirect the client. Seat the client at a large table for meals. - Answer Provide finger food at mealtime. The nurse should provide the client who has dementia with fingers foods. Clients who have dementia can have difficulty sitting still and tend to wander, which makes weight loss and malnutrition a concern. Therefore, foods that the client can hold while ambulating are ideal. A nurse is caring for a client immediately following intubation with an endotracheal (ET) tube. Which of the following methods should the nurse identify as the most reliable for verifying placement of the ET tube? Feel for exhaled air emerging from the endotracheal tube. Assess for bilateral breath sounds. Observe for symmetric chest movement. Check for end-tidal carbon dioxide levels. - Answer Check for end-tidal carbon dioxide levels. According to evidence-based practice, the most reliable method for verifying ET tube placement is checking for end-tidal carbon dioxide levels by using capnometry. A chest x-ray is another reliable method for verifying placement. A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching? (select all that apply) "I will avoid crowds." "I will wash my toothbrush weekly." "I will change my cat's litter box twice weekly." "I will take my temperature daily." "I will eat plenty of fresh fruits and vegetables." - Answer "I will avoid crowds." The client who is immunocompromised should avoid crowds while undergoing chemotherapy to reduce the risk of infection. "I will take my temperature daily." The client who is immunocompromised should take daily temperature readings and report an elevated temperature to the provider. A nurse is planning care for a. client who has a lump in their right breast. Which of the following findings increases the client's risk of developing breast cancer? Menarche started at age 15 First born child was at 20 years of age History of a fibrocystic breasts Menopausal obesity - Answer Menopausal obesity During menopause, increased fat tissue can lead to higher stores of estrogen. Higher levels of estrogen in the body increase the risk for postmenopausal breast cancer. A nurse is teaching a client who is scheduled to receive radioactive iodine therapy for treatment of hyperthyroidism. Which of the following instructions should the nurse include in the teaching? Remain 0.3 m (1 ft) away from children. Limit the time spent around women who are pregnant to 10 min daily. Use disposable utensils for meals. Use an absorbent pad if incontinent. - Answer Use disposable utensils for meals. The client who receives radioactive iodine has radioactivity in the body fluids, including saliva, for several weeks following treatment. The nurse should instruct the client to use disposable utensils, plates, and cups during this time period to decrease the risk for radiation exposure to other members of the household. A nurse is providing discharge teaching to a client following a loop electrosurgical excision procedure (LEEP) for the treatment of cervical cancer. Which of the following statements by the client indicates an understanding of the teaching? "I can resume sexual intercourse in 48 hours." "I can expect some heavy vaginal bleeding for 24 hours." "I can use tampons when my period comes in a week." "I may have mild cramping for several hours." - Answer "I may have mild cramping for several hours." The client should expect very little discomfort from the LEEP procedure, which is performed in ambulatory care using a painless electrical current. A nurse is providing teaching to a client who has a new prescription for cephalexin oral suspension. Which of the following statements by the client indicates an understanding of the teaching? "I will increase my consumption of foods high in potassium." "I will apply lotion to my skin if I feel any itching." "I will avoid sun exposure while taking this medication." "I will keep the medication refrigerated." - Answer "I will keep the medication refrigerated." A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should identify which of the following findings as an indication of a microvascular complication? Coronary artery disease Retinopathy Cerebrovascular accident Hypertension - Answer Retinopathy Diabetic retinopathy is a microvascular complication of diabetes mellitus resulting from pathologic changes in small blood vessels, which eventually cause tissue damage, cell death in the retina, and blindness. A nurse in an emergency department is caring for a client who is confused, has a temperature of 104 F, a BP of 74/52 mm Hg, and a diagnosis of exertional heat stroke. Which of the following actions should the nurse take first? Measure the client's urine specific gravity. Administer oxygen using a high-concentration mask. Initiate gastric lavage with ice water. Immerse the client in cold water. - Answer Administer oxygen using a high-concentration mask. The first action the nurse should take when using the airway, breathing, and circulation approach to client care is to ensure that the client has a patent airway and administer oxygen using a high-concentration mask to promote oxygen perfusion to vital organs. A nurse notes that a client's eyes are protruding slightly from their orbits. Which of the following laboratory findings should the nurse expect? Decreased calcium levels Decreased somatotropin levels Increased glucose levels Increased T4 levels - Answer Increased T4 levels Exophthalmos, an abnormal protrusion of the eyeballs, is a classic sign of hyperthyroidism. Elevated thyroid hormone levels (T3 and T4) and a decreased thyroid stimulating hormone level reflect primary hyperthyroidism. A nurse is providing teaching to a group of clients about the prevention of coronary artery disease. Which of the following information should the nurse include in the teaching? Walk 30 min daily at a comfortable pace. Limit saturated fat intake to 10% of total daily calories. Maintain a BMI of 30. Consume at least 2,000 mg of sodium per day. - Answer Walk 30 min daily at a comfortable pace. A nurse is assessing a client for fluid volume deficit following lumbar spinal surgery. The nurse should identify which of the following findings as an indication the client is at risk for fluid volume deficit? BUN 16 mg/dL Urine output 40 mL every hour for 3 hr Hct 42% Surgical drain output 300 mL during an 8-hr shift - Answer Surgical drain output 300 mL during an 8-hr shift A client who had lumbar spinal surgery should not have more than 250 mL from a drain in the first 24 hr. Therefore, 300 mL in 8 hr can indicate that the client is at risk for fluid volume deficit. A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance? Breakdown of fatty acids Retention of carbon dioxide Hyperventilation in response to hypoxia Ingestion of large amounts of bicarbonate - Answer Retention of carbon dioxide Respiratory acidosis results from the retention of carbon dioxide. Retention of carbon dioxide can result from respiratory depression, inadequate chest expansion, airway obstruction, or decreased alveolar capillary diffusion. A nurse is caring for a client who is 3 hr postoperative and exhibiting signs of hypovolemia. Which. Of the following findings should the nurse identify as a manifestation of hypovolemia? Distended neck veins Rapid pulse rate Urine output 45 mL/hr Decreased respiratory rate - Answer Rapid pulse rate A client who has hypovolemia has a rapid, weak pulse rate to compensate for the decrease in blood volume in an attempt to increase blood pressure. A nurse is providing teaching for a client who has constipation-predominant irritable bowel syndrome (IBS-C). Which of the following statements should the nurse include in the teaching? "Take a dose of loperamide each morning." "Increase your fluid intake to 1,000 milliliters per day." "Take psyllium in the evening." "Consume a diet that is low in protein." - Answer "Take psyllium in the evening." A client who has IBS-C should take a bulk-forming laxative, such as psyllium, to increase the bulk of the stool, reduce constipation, and promote regular bowel movements. A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurse's priority? WBC count Intake and output ABGs Blood glucose level - Answer ABGs When using the airway, breathing, and circulation (ABC) approach to client care, the nurse's priority assessment is to monitor the client's ABGs, including respiratory status. A nurse is caring for a client who has an NG tube to suction and is receiving IV fluids to maintain fluid volume balance. Which of the following findings should indicate to the nurse that this therapy is effective? Decreased NG tube drainage Potassium 3.3 mEq/L Increased heart rate Hematocrit 46% - Answer Hematocrit 46% An increase in hematocrit can indicate hemoconcentration and hypovolemia. This hematocrit is within the expected reference range of 42 to 52% for a male and 37 to 47% for a female and is an indication that fluid replacement therapy is effective. A nurse is assessing a client who has a new diagnosis of diabetes mellitus. The nurse should identify that which of the following findings is a manifestation of hyperglycemia? Increased thirst Decreased urine output Dry skin Tremors - Answer Increased thirst The nurse should teach the client that increased thirst, or polydipsia, is a manifestation of hyperglycemia, which can lead to dehydration. Other manifestations of hyperglycemia include an increase in appetite, or polyphagia, an increase in urine production, or polyuria, and fatigue. A nurse is providing teaching for a client who is scheduled for a bronchoscopy. Which of the following statements should the nurse include in the teaching? "You will not be able to eat or drink after the procedure until you are able to cough." "You will drink a contrast solution 30 minutes prior to the procedure." "The purpose of this procedure is to remove excess fluid from your lungs." "You will need to lie on your back for 4 to 6 hours following the procedure." - Answer "You will not be able to eat or drink after the procedure until you are able to cough." A client who had a bronchoscopy received a local anesthetic that can suppress the cough reflex. The cough reflex protects the client from aspirating fluids or food. Therefore, the client should not eat or drink until the cough reflex returns. A nurse is providing preoperative teaching to a client who is. Scheduled for a radical prostatectomy. Which of the following information should the nurse include in the teaching? The client will be on bed rest while continuous bladder irrigation is in place. Cold compresses will be used to manage bladder spasms. The client will have an NG tube in place for 48 hr postoperatively. A PCA pump will be used for postoperative pain control. - Answer A PCA pump will be used for postoperative pain control. A PCA pump is a common method of pain management in the first 24 hr following an open radical prostatectomy. The nurse should teach the client how to manage pain during the preoperative period rather than waiting until after surgery when the client is feeling the sedative effects of the anesthesia and pain medication. A home health nurse is assisting a family member with planning care for a client who has Alzheimer's disease. Which of the following instructions should the nurse include? Remove clutter from rooms and hallways. 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. - Answer Remove clutter from rooms and hallways. The nurse should instruct the family member to remove clutter from rooms and 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 could be a risk to the client. A nurse is caring for a client who has dumping. Syndrome following a gastric resection. The nurse should monitor the client for which of the following complications of dumping syndrome? Weight gain Iron-deficiency anemia Hypercalcemia Reduced heart rate - Answer Iron-deficiency anemia The nurse should monitor the client for manifestations of anemia, such as pallor, tachycardia, and fatigue. Rapid emptying of the stomach contents into the intestine can lead to reduced absorption of iron in the duodenum, causing iron-deficiency anemia. A nurse is providing discharge teaching about infection control at home for a client who has tuberculosis. Which of the following statements by the client indicates an understanding of the teaching? "I will have to move out of my family's home until I am no longer contagious." "I will place my used tissues in a plastic bag." "I will cover my mouth with my hands when I have to cough." "I will not go in public areas until I am cured." - Answer "I will place my used tissues in a plastic bag." The sputum of a client who has tuberculosis is considered infectious until there are three consecutive sputum samples that test negative for Mycobacterium tuberculosis. Tissues that are soiled with the client's sputum should be placed in a plastic bag and sealed to avoid spreading the infection. A nurse is caring for a client who has atopic dermatitis and a prescription for triamcinolone ointment. The nurse should assess the client to monitor for which of the following adverse effects? - Answer Thinning of the skin. Only apply the ointment to dry patches of the skin to avoid atrophy. Topical Glucocorticoids Side effects - Answer Tiamcinolone - Hypopigmentation - Excessive hair growth (hypertrichosis) - Thinning of the skin A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse identify as a manifestation of left-sided heart failure? - Answer Frothy sputum Pink-tinged frothy sputum can be an early indication of pulmonary edema and can be life-threatening. Therefore, the nurse should notify the provider immediately.