PN VATI Adult Medical Surgical 2020 Quiz questions and answers verified

A home health nurse is reinforcing teaching with a client who has human immunodeficiency virus (HIV). Which or the following instructions should the nurse reinforce to maintain infection control in the client's home? Wash dishes in hot soapy water. The client should wash dishes in hot soapy water to minimize infectious agents and prevent the spread of infection. A nurse is reinforcing discharge teaching with a client regarding food safety in the home. Which of the following statements should the nurse include? Do not leave perishable foods at room temperature for longer than 2 hours. The nurse should reinforce with the client that perishable foods should be refrigerated within 2 hr to reduce the risk of micro-organism growth. A nurse is implementing transmission prevention measures for a client who has active tuberculosis. Which of the following measures should the nurse include? Place a surgical mask on the client when transporting them to other departments While transporting the client within the facility, the nurse should have the client wear a surgical mask to protect others from coming in contact with tuberculosis. A client who has tuberculosis requires airborne isolation precautions because tuberculosis can remain in the air for several hours. A nurse is transferring a client who has lower extremity paralysis from a bed to a chair using a transportable hydraulic lift. Which of the following actions should the nurse take to help prevent injury to the client during the transfer? Place the lower edge of the sling under the knees and the upper edge under the shoulders. The nurse should place the lower edge of the sling under the client's knees and the upper edge under the client's shoulders to ensure that the majority of the client's weight is positioned on the sling. This action helps prevent injury to the client during transfer. A nurse is observing an assistive personnel (AP) provide care to a client in the immediate postoperative period following a subtotal thyroidectomy. Which of the following actions by the AP requires intervention by the nurse? The AP positions the client supine. The nurse should ensure that the AP places the client in a high-Fowler's position following a subtotal thyroidectomy to decrease swelling that could compromise the client's airway. A nurse is reinforcing teaching with an older adult client about the influenza vaccine. Which of the following statements should the nurse make? "Make sure you receive the high-dose vaccine." The nurse should inform the client that the CDC recommends that older adults receive the high-dose vaccine. This vaccine contains four times the amount of virus antigens and helps to boost immunity in the older adult. A nurse is assisting with teaching a class of clients about health promotion and prevention. Which of the following statements should the nurse make? "You should receive a tetanus booster every 10 years." The nurse should instruct the clients to receive a tetanus booster every 10 years to reduce the risk of tetanus. A nurse is collecting data from a client who reports hearing loss. Which of the following tests should the nurse perform to identify conductive hearing loss? Weber The nurse should plan to perform the Weber test to identify if the client has conductive hearing loss. A nurse is assisting a client who is having a pelvic examination for the first time. The client states, "I am really nervous." Which of the following statements should the nurse make? "I'll be in the room with you throughout the examination." The nurse should tell the client that they will be with them during the examination and will explain the steps of the procedure as they occur. A nurse is caring for a client who has expressive aphasia. Which of the following actions should the nurse take? Offer the client a communication board with pictures The nurse should provide the client with a communication board that shows pictures because a client who has expressive aphasia is unable to articulate their needs. The nurse should provide the client with a communication board that shows pictures because a client who has expressive aphasia is unable to articulate their needs. "Keep two points of support on the floor at all times." The client must have both feet or one foot and the quad cane on the floor at all times to keep an equal balance and avoid being off balance, which can lead to a fall. A nurse is caring for a client who has Parkinson's disease and reports difficulty eating. Which of the following interventions should the nurse implement to help the client eat? Offer the client an adaptive fork during meals. Clients who have Parkinson's disease have tremors. Adaptive utensils, including weighted or gripped forks, provide the client with a greater ability to eat independently while compensating for their existing dysfunctions. A nurse is reinforcing teaching with a client who is postoperative following a subtotal gastrectomy about dietary changes to help prevent dumping syndrome. Which of the following statements by the client indicates an understanding of the teaching? "I should restrict eating sugary and starchy food." A client who had a subtotal gastrectomy should avoid high-carbohydrate meals due to the risk of hypoglycemia caused by a rapid insulin release. A nurse is reinforcing teaching with a client who is at risk for osteoporosis. Which of the following foods should the nurse identify as providing the highest amount of dietary calcium? 3 oz canned salmon Osteoporosis is a disease that results in a decrease in bone mass and increases the risk for fractures. Methods of limiting the effects of osteoporosis include weight-bearing activities and increasing dietary calcium intake. Foods high in calcium include fish with edible bones such as canned salmon or sardines. The nurse should recognize that 3 oz of salmon contains 183 mg of calcium. A nurse is reinforcing teaching about the use of hearing aids with a client who has hearing loss. Which of the following actions should the nurse take? Instruct the client to disconnect the battery when the device is not in use. When the hearing aids are not in use, it is important that the client turn them off and remove the batteries to prolong the life of the batteries. A nurse is reinforcing teaching about the purpose of insulin with a client who has type 1 diabetes mellitus. Which of the following information should the nurse include in the teaching? It facilitates body cell use of glucose for energy." The nurse should recognize that insulin targets tissue throughout the body to promote uptake and use of glucose for energy by the body's cells. A nurse is caring for a client who is taking digoxin daily and develops digoxin toxicity. The nurse should monitor the client for which of the following adverse effects? Dysrhythmia Hypokalemia is a common cause of digoxin toxicity, and both hypokalemia and digoxin therapy can cause irregular heart rhythm; therefore, the nurse should monitor the client for dysrhythmia. A nurse is reinforcing teaching with a client who has osteoporosis about taking alendronate. Which of the following information should the nurse include? Sit upright for 30 to 60 min after taking the medication. Bisphosphonates, such as alendronate, can cause esophagitis. Sitting upright after taking them can help prevent this adverse effect. A nurse is caring for a client who has a prescription for enalapril 10 mg PO daily and reports dizziness and weakness. Which of the following actions should the nurse take first? Check the client's blood pressure. The first action the nurse should take when using the nursing process is to collect data from the client. By checking the client's blood pressure, the nurse can monitor for hypotension and intervene if needed. A nurse is monitoring a client who is receiving a unit of packed RBCs. Which of the following statements by the client should alert the nurse that the client might be experiencing a transfusion reaction related to an incompatibility with the blood product? "I have pain in my lower back." A client who is having a transfusion reaction related to blood incompatibility can have low back or flank pain. The nurse should discontinue the blood transfusion and notify the charge nurse immediately. A nurse is collecting data from a client 2 months following the initiation of levothyroxine therapy. Which of the following findings should the nurse identify as an indication that the client might require a reduction in their dosage? Difficulty sleeping Levothyroxine is a thyroid hormone supplement used to treat hypothyroidism. A levothyroxine dosage that is too high can cause manifestations of hyperthyroidism including tachycardia, tremors, angina, and insomnia. The nurse should discuss this finding with the provider as a possible indication of a need to reduce the dose of the client's medication. A nurse is reinforcing teaching with a client who has pernicious anemia and is receiving cyanocobalamin. Which of the following statements by the client indicates an understanding of the teaching? "I will be able to switch to a nasal form of cyanocobalamin when my levels stabilize." Following initial therapy with parenteral cyanocobalamin, the client can receive cyanocobalamin intranasally once the client achieves hematologic remission. The client reaches hematologic remission when the folic acid, vitamin B12, iron, hemoglobin, hematocrit, and reticulocyte counts return to expected levels. Pernicious anemia is a disorder in which the client lacks an intrinsic factor in the gastric juices that prevents the absorption of vitamin B12. Manifestations of pernicious anemia include pallor, fatigue, problems with balance, and paresthesia. A nurse is collecting data from a client who is postoperative following permanent pacemaker placement. Which of the following data should the nurse plan to collect? Status of the insertion site A client who is postoperative following permanent pacemaker placement is at risk of hematoma at the insertion site. The client must have both feet or one foot and the quad cane on the floor at all times to keep an equal balance and avoid being off balance, which can lead to a fall. Turn the client on their side. The nurse should turn the client on their side because this helps to prevent the client from aspirating emesis or secretions. A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect? Periorbital edema Glomerulonephritis causes fluid retention that can lead to periorbital edema. A home care nurse finds a client who has just sustained partial-thickness burns to their face and arms. After removing the client from danger and securing their airway, which of the following interventions is the nurse's priority? Remove smoldering clothes. Using the greatest risk priority-setting framework, this intervention has the highest priority. In order to protect the client from further injury, smoldering clothes should be removed first. A nurse is caring for a client who reports excessive perspiration and frequent urination. Which of the following manifestations is an indication of a low sodium level? Dry tongue A dry tongue indicates hypernatremia, not hyponatremia.