medsurg 1-6 all complete questions with correct answers latest update(over 300 q&a)

medsurg 1-6 all complete questions with correct answers latest update(over 300 q&a) Med Surg Exam #6 1. Which stool characteristic should the nurse expect to note from a client with Crohn's disease? a. Chronic constipation b. Diarrhea c. Alteration of diarrhea and constipation ***wrong answer d. Constant oozing from the rectum 2. A client has a nasal gastric tube (NGT) inserted. Before using the tube, which of the following is most important? a. Confirm the type of feeding that will be initiated b. Identify the weight of the patient c. Confirm placement before initiating feedings by installing air in the abdomen and listening for the “swish” sound d. Obtain a radiographic exam to confirm non-respiratory placement of the tube 3. A client is scheduled to have a barium enema. Which statement by the client indicates proper understanding of the pre-procedure instructions? a. “I will need to eat a low fiber diet 2 days before the test.” b. “I do not have to be NPO since this procedure does not involve my upper GI system.” c. “I can eat anything I want the day of the procedure as long as I drink the barium 30 minutes before the procedure” d. “I will need to take a preparation to cleanse my bowels.” 4. Ordered: Ancef 0.375g IM q6hr, Available: Ancef 500 mg/2 ml How many ml with the nurse administer in 24 hours? a. 6 ml 0.375g=375 mg/500 mg x’s 2 ml x’s 4 5. Which of the following statements from the client diagnosed with diverticulitis demonstrates understanding of disease management? a. “I will need to avoid alcoholic beverages” b. “I should lay down after eating meals.” c. “I should eliminate strawberries, seeds, nuts and corn from my diet” d. “I will need to take an antacid daily” 6. During assessment of a client with a 15-year history of diabetes the nurse notes the client has decreased tactile sensation in both feet. Which action does the nurse take first? a. Perform assessment of the patient’s feet b. Call the provider c. Check the patient’s blood sugar d. Provide diabetic teaching 7. A client is worrying about gas build up in his colostomy. Which foods would the nurse advise the client to avoid or prevent gas? a. Beans b. Fish c. Bananas d. Chocolate 8. Metoclopramide (Regian) is prescribed for a client who suffers from GERD. The nurse accurately explains the action of this drug by saying which statement? a. “It helps to promote movement in the esophagus.” b. “It acts as an antacid to reduce gastric acidity” c. “It decreases the time food and fluids are in the stomach” d. “It has a local anesthetic effect on the lower esophagus” 9. A nurse is monitoring a client who was diagnosed with diabetes mellitus and is being treated with both short acting and long acting insulins. Which of the following manifestations would alert the nurse of possible hypoglycemia? Select all that apply a. Tremors b. Anorexia c. Hot, dry skin d. Nervousness 10. A client on an intensified insulin regimen consistently has a fasting blood glucose level between 70 to 80 mg/d and a hemoglobin A1c level of 5.5%. Which is the nurse’s interpretation of these findings? a. Good Glucose Control b. Poor Glucose Control c. Increase risk for the development of ketoacidosis d. Need for increase insulin dosage 11. Which of the following manifestations would the nurse expect to see in a client with hypothyroidism? a. Blurred vision, night sweats, and palpitation b. Muscle cramps, parenthesis, and numbness of the fingers and toes c. Heat intolerance, weight loss, and diarrhea d. Weakness, constipation, and cold extremities 12. While assessing a client post-thyroidectomy, the nurse noted the client is rather irritable and c/o a tingling feeling in the lips. What is the nurse’s best response to these findings? a. Plan to administer calcium gluconate b. Provide the client with mouth and lip care c. Administer Synthroid immediately to address symptoms of myxedema d. Document the normal findings 13. The nurse notes a diabetic client has fruity smelling breath and respiration 30. Which action should the nurse take immediately? a. Provider the client with crackers and 2 % milk b. Administer glucagon IV push c. Assess blood glucose level for hyperglycemia and urine for ketones d. Perform a respiratory assessment 14. The nurse is caring for a 78 y/o who is diagnosed with acute viral gastroenteritis with diarrhea. Which of the following would be the nurse’s priority assessment? a. Temperature b. Skin integrity c. Color of stool d. Lab values***wrong answer 15. A client has been ordered Zantac (ranitidine) 75 mg PO BID for the management of GERD. Available is Zantac 150 mg per tablet. How many tablets will the client receive over 24 hours? a. 1 tablet 75mg/150 mg = .5 tablet x’s 2 = 1 tablet 16. A client with cirrhosis is exhibiting asterixis and noted increase spreading of jaundice. What is the priority of care? a. Abdominal girth measurement b. Maintenance of a low protein diet c. Safety precautions and cognitive assessment d. Fluid restriction 17. A patient has been diagnosed with GERD. Which of the following factors increases manifestations of GERD? a. Sodium b. Milk c. Meat products d. Tight, restrictive clothing 18. A client with Type II diabetes ask the nurse how to prevent complications associated diabetes. Which of the following are appropriate responses from the nurse? Select all that apply a. Manage stress b. Avoid all sugar and carbohydrates c. Be sure to get annual flu vaccine d. Seek care from a podiatrist regularly 19. The client with gastroenteritis is being discharged from the emergency room? which of the following statements by the client indicates an understanding of the discharge teaching? a. “I will call the doctor if I have diarrhea or constipation” b. “I will need to take steroids for the rest of my life” c. “I should wash my hands before I eat or cook any food” d. “I should avoid smoking; it will make my problem worse” 20. Which statement by the client supports the diagnosis of a gastric ulcer? a. “I have bright red rectal bleeding after a bowel movement” b. “I get pain in my stomach about 30 minutes after I eat, so I don’t eat much” c. “After I eat a big meal, I get pain in my right side so bad I double over” d. “If I lay down after eating a meal, I get a burning in my chest” 21. The nurse is providing teaching to a client newly diagnosed with diabetes type I. which of the following should the nurse include in the discharge teaching? Select all that apply a. Be sure to rotate injection sites to avoid lipodystrophy b. Store unused insulin in the refrigerator c. If you become sick monitor your blood sugar and take oral hypoglycemics d. Be sure to inspect your feet daily using a mirror to view the soles of the feet 22. Which diagnostic test would be best to confirm the diagnosis of peptic ulcer disease? a. EGD b. MRI c. Gastric acid stimulation d. Fecal occult blood 23. The nurse determines more teaching is required when a client poet gastric bypass surgery states which of the following? a. “I should have well balanced meals” b. “I should have small frequent meals throughout the day” c. “I will need to have B-12 injections” d. “I should limit myself to (2) two large meals a day? 24. A client has a newly created colostomy and is reluctant to participate in self care of colostomy. Which of the following is the nurse’s best response? a. Insist that the client becomes involved b. Allow care to be deferred to the client’s family member c. Provide a mirror for the client to observe the stoma d. Assess the client for readiness to learn 25. The client with hyperparathyroidism is admitted to the unit. The client asks the nurse why is she receiving so much IV fluid and a “water pill”? Which of the following is the nurse best response? a. Both are needed to improve your cardiac output b. They work together to help eliminate metabolic waste c. We need to restore your fluid volume d. It will help promote calcium excretion 26. Which of the following statements from a client is consistent with the diagnosis of duodenal ulcer? a. “I have stomach pain before I eat and in the middle of the night” b. “I have been vomiting blood” c. “food makes my stomach hurt” d. “When I eat certain types of food my stomach hurts” 27. The nurse observes a client with diabetes mellitus walking in the room barefoot, although slippers are at the bedside. Which of the following is the best nursing diagnosis for this client? a. Risk of injury related to potential for falls while walking barefoot b. Risk for infection related to impaired tissue perfusion and walking barefoot c. Risk for impaired cerebral perfusion related to low blood glucose levels d. Risk for injury related to lack of resources to purchase clothing and shoes 28. A client is diagnosed with a gastric ulcer and has been prescribed sucralfate (Carafate). Which statement by the client indicates a good understanding of the mechanism of the medication? a. “I have to drink 8 ounces of water before taking my medicine” b. “I should take my medicine before meals so I can tolerate my meals” c. “I need to take my medicine before meals so I can tolerate my meals” d. “I only need to take my medicine when I eat spicy food” 29. The nurse is caring for a client newly diagnosed with type 2 diabetes. Which interventions should the nurse implement? a. Assess the client for ketonuria b. Administer oral hypoglycemic medications as ordered c. Monitor the client’s arterial gases d. Administer pancreatic enzymes 30. An 18-year-old client presents with severe abdominal pain in the RLQ and nausea. The nurse also notes that the client’s WBC is 20,000 and abdomen is rigid. Which action is most appropriate for the nurse? a. Have the client’s blood redrawn to check WBC level? b. Prepare the client for surgery c. Administer antibiotic d. Administer an antiemetic 31. The nurse is discussing dietary modifications with a client diagnosed with lower esophageal sphincter dysfunction. Which menu selection indicates the client understands the diet restrictions? a. One piece of fish, buttered carrots, and a cup of pudding for a snack b. Four pieces of fried chicken, mashed potatoes with gravy and water c. A large pepperoni pizza, green salad and coffee d. Tortillas with hot sauce, three bean and cheese enchiladas and tea 32. A client is suffering from gastritis and is complaining of epigastric discomfort. Which nursing intervention will provide the greatest relief? a. Administer an antacid b. Encourage the client to eat large meals c. Administer a narcotic d. Place client in a supine position 33. The nurse is caring for a client who has an active upper GI bleed. What is the appropriate diet for this client? a. NPO b. Clear liquids c. Regular d. Skim milk 34. Non-pharmacologic management of GERD includes which of the following? a. Weight reduction: Wrong answer b. High calorie, high fat diet c. Lying down and resting after meals d. Drinking large amounts of fluid with meals 35. A client who underwent a colonoscopy returns to the nursing unit, BP 140/80 pulse 78, RR 20. When the nurse returns later to reassess the client. The client is lethargic BP 110/60 Pulse weak at 70, RR 12. The nurse makes which interpretation of these assessment findings? a. The client needs to eat b. The client is just tired, and the body is adjusting to the relief of the anxiety related to the procedure c. The client needs rehydration treatment d. The client experiencing adverse effect from the analgesic given for the procedure ***wrong answer 36. A nurse is preparing to flush a gastric tube. Which of the following steps are included in this procedure? Select all that apply a. Position client supine or flat in bed b. Insert tip of syringe into the end of the gastric tube and slowly instill flushing solution (water) c. Perform hand hygiene and apply clean gloves d. Identify client and explain procedure 37. A patient is admitted for vomiting blood for 12 hours. What test should the nurse anticipate being ordered? a. Endoscopic retrograde cholangiopancreatography (ERCP) b. Upper GI radiographic series c. Barium enema d. Xray 38. The nurse is caring for a client with an upper GI bleed. Which are the priority actions the nurse tales when caring for this patient? (select all that apply) a. Review CBC results b. Be sure the patient has a large bore IV line c. Prepare to infuse 0.9% normal saline solution of lactated ringers d. Provide client with a full liquid diet e. Prepare for NG tube insertion 39. An 18-year-old client presents with severe abdominal pain in the RLQ and nausea. The nurse also notes that the client’s WBC count 20,000 and abdomen is rigid. Which action is most appropriate for the nurse? a. Have the client’s blood redrawn to check WBC level b. Prepare the client for surgery c. Administer antibiotic d. Administer an antiemetic 40. The provider orders Lansoprazole (Prevacid) 30 mg PO TID. The pharmacy provides Prevacid 15 mg per tablet. How many tablets will the client expected to receive in 24 hrs? a. 30mg/15 mg = 2 x’s 3 = 6 tablets 41. A nurse is caring for a client who has had diarrhea for the past 10 days. When assessing the client, the nurse would expect to find which of the following clinical manifestations? Select all that apply a. Hypertension b. Poor skin turgor c. Dry mucous membranes d. Tachycardia 42. A client admits to not taking Synthroid and is diagnosed with myzedema coma. Which of the following is the highest priority of the nurse at this time? a. Promote oxygenation and prevent skin breakdown b. Prevent injury related to mental confusion and elevated blood pressure c. Promote nutrition with low fiber foods d. Monitor for signs and symptoms of decreased cardiac output and airway obstruction 43. The student nurse is caring for a patient who is receiving ismolite feedings continuously via a nasal gastric tube. The supervising nurse intervenes when the student does which of the following? a. Flushes the tube with 30 ml of water between medications b. Places the client supine before stopping the tube feedings c. Obtains a sample of gastric secretions d. Performs a GI assessment 44 A client with hyperthyroidism is recovering from thyroidectomy. The nurse notes the client is speaking in a whisper and reports concern of hoarseness. Which of the following is the nurse’s best response to the findings and the client concerns? a. Tell the client these symptoms should be temporary and continue to monitor b. Call the surgeon, this is a medical emergency c. Encourage client to perform ROM exercises of neck to promote healing d. Administer pain medicine so the client can speak normally 45. A client with diabetes mellitus presents with a blood glucose level of 750 and positive ketones. Which of the following is the likely treatment plan for this client? a. Regular insulin 30 units subcutaneously b. Metformin 500 nmg BID c. Regular insulin at 10 units/hour with 40 mEq of potassium d. Lantus insulin at 20 units/hour with 40 mEq of potassium 46 What is the most likely cause of gastritis? a. History of alcohol abuse b. High carbohydrate diet c. Vegetarian diet d. Recent course of oral penicillin 47 A home care nurse finds a client who has diabetes awake and alert, clammy skin, shaky, diaphoretic, and weak. The client’s blood sugar is 50. Which of the following should the nurse *** a. Administer regular insulin as ordered per sliding scale b. Give the client a complex carbohydrate c. Administer NPH insulin as ordered d. Call the provider 48 Which of the following beverages should the nurse caution a client with peptic ulcer to avoid? a. Alcoholic beverage b. Water c. Apple juice d. Lemonade 49 The nurse notes the following when assessing a client’s new colostomy, postoperative day one. Stoma large, beefy red, draining small amount of stool. What is the nurse’s appropriate response to the assessment findings? a. Notify the surgeon b. Reassure the client that the color will improve in 2-3 days c. Document as a normal finding d. Irrigate the colostomy 50 Which of the following signs and symptoms characterize thyroid storm? a. Elevated temperature, tachycardia, and delirium b. Paranoia, delusions, and depression c. Coma, hypothermia, and respiratory acidosis d. Decreased blood pressure, anuria, and edema 51 A client is due to receive 10 units of Novolog due at 12 noon and an additional dose of insulin based on the following sliding scale. 1 unit 150 – 200 mg/dL 2 units regular insulin 201-300 mg/dL 3 units regular insulin 301-400 mg/dL Call the provider for glucose level 400 mg/dL The client’s blood glucose level is 152. How many total units of insulin should the client receive? a. 10 units b. 11 units c. 13 units d. 0 units Med Surg Exam #5 1. After administering newly prescribed captopril (Capoten) to a client with heart failure. Which of the following interventions should be a *** a. Provide food to decrease nausea and aid in absorption b. Collaborate with unlicensed assistive personal to bathe the client c. Monitor potassium levels and check for symptoms of hypokalemia d. Instruct the client to ask for assistance when rising from bed 2. The nurse is teaching prevention and management of Buerger’s disease to a client. Which of the following would be most important for the nurse to include in the teaching? a. Low protein diet b. Exposure to cold can be helpful c. Smoking cessation d. Physical therapy 3. A client is diagnosed with right sided heart failure. Which assessment findings will the nurse expect the client to have? a. Pink frothy sputum b. Ascites c. Productive cough d. Lung congestion 4. A client is diagnosed with Peripheral Arterial Disease (PAD). Which of the following manifestations would the nurse the nurse expects to find upon assessment? **** 5. *** 6. A client has a platelet count of 18,000. What intervention should the nurse include in the plan of care? a. Institute isolation precautions b. Institute bleeding precautions c. Obtain temperature rectally only d. Medications should be given intravenously (IM) as often as possible 7. The nurse is preparing to administer IV heparin to the client. Which of the following actions of the nurse is appropriate? a. Review the client’s PTT results b. Review the client’s PT, INR results 8. A client with leukemia should be monitored for which of the following symptoms? a. Lethargy and shortness of breath b. Flu-like symptoms, fever and weakness c. Decreased urine output and sore throat d. Fever, red flushed skin and dehydration 9. Which of the following client’s has the highest risk for the development of folic acid deficiency anemia? a. An alcoholic b. An athlete c. A diabetic d. A teenager 10. Severe anemia can cause which of the following cardiovascular changes? a. ST elevation ***got this one wrong*** b. Widen QRS c. ST depression d. Sinus Tachycardia 11. A patient with tricuspid valve disorder will have blood flow disorder between: a. Left ventricle and left atrium b. Right atrium and right ventricle c. Pulmonary artery and right ventricle d. Aortic valve and left ventricle 12. A patient with bicuspid valve disorder will have blood flow disruption between: a. Aortic valve and left ventricle b. Pulmonary artery and right ventricle c. Left ventricle and left atrium d. Right atrium and right ventricle 13. The nurse is reviewing the lab results of a client diagnosed with arthrosclerosis. Which of the following should be of concern? a. HDL 55 b. LDL 200 c. LDL 50 d. Total Cholesterol 150 14. A clinical manifestation of autoimmune thrombocytopenic purpura is: a. Increased platelet levels b. Ecchymoses c. Increased Hct and Hgb d. Decreased WBC’s 15. Once receiving blood from the blood bank, the nurse has how long before beginning the transfusion? a. 30 minutes b. 1 hour c. 2 hours d. 3 hours 16. The nurse is providing care to a client with infective endocarditis. What assessment finding has highest priority? a. Testing of reflexes b. Evaluation of level of orientation c. Pupillary checks d. Auscultation of murmurs 17. A nurse is providing discharge instructions to a client with infective endocarditis. Which of the following statements from the client indicates understanding of instructions? a. “I need to weigh myself everyday to monitor for fluid overload” b. “I will never be able to work again” c. “I need to control my blood pressure” d. “I will be sure to inform my dentist of conditions, especially before having any invasive procedures” 18. A client with a history of heart failure is being discharged, which priority instructions will assist the client in the prevention of complications associated *** a. “Eat six small meals daily instead of three larger meals” b. “Adhere to a reduced sodium diet” c. “Weigh yourself monthly while wearing the same amount of clothing” d. “When you feel short of breath, take an additional diuretic” 19. Order: Heparin 3500 units subcut Q8H Available: Heparin labeled 5000 units mL. How many mL will the nurse administer per day? Label the answer a. 2.1 mL 3500 units/5000 units multiplied by 3 20. A client is receiving a blood transfusion of 300 mL of packed red blood cells (PRBC) at 100 ml/hr. the nurse started the transfusion at 1300. What time will they *** a. 1600 21. A client is admitted to the telemetry unit after a cardiac catheterization. What is the nurse’s priority when caring for this client? a. Position the client in a sitting position to improve breathing b. Apply oxygen at 2 L/min via nasal cannula c. Monitor the client’s arterial insertion site d. Assess the intensity and quality of the client’s pain ***got this one wrong*** 22. A client with heart failure is to receive enalapril (Vasotec). The blood pressure is 88/50 mmHg. What is the appropriate response Select all that apply a. Recheck the blood pressure b. Hold the Vasotec c. Administer the Vasotec d. Initiate 0.9% Normal Saline at 100 ml/hr 23. The client with heart failure is prescribed Nitroglycerin and Furosemide (Lasix) for pulmonary edema. Which is the priority intervention? a. Monitor the client’s serum glucose level b. Monitor the client’s blood pressure c. Insert an indwelling urinary catheter d. Obtaining an ECG 24. A client diagnosed with disseminated intravascular coagulopathy (DIC) is receiving Heparin. The family member questions the medications. The nurse best describes a. “I am just following the doctor’s orders” b. “I will have you speak with the doctor” c. “The medication will help stop the bleeding that is occurring” d. “The medication is given to stop the abnormal clotting in the capillaries and arterioles” 25. Which of the following conditions is responsible for myocardial ischemia? a. Renal failure b. Aneurysm c. Vasoconstriction d. Heart failure 26. An order is written for Digoxin 0.25 mg PO BID. The drug is supplied in 0.125 mg 5ml. how many milliliters will you administer for one dose? a. 10 ml 0.25/0.125 multiplied by 5ml 27. Which of the following should prompt concern caring for a client post bone marrow aspiration? a. Excessive bruising b. Tenderness at the incision site c. The client’s order for non-aspirin pain medicine d. Dressing over incision dry and intact 28. *** 29. The client is to receive a blood transfusion. The client’s temperature is 100.6 F orally. Which of the following is the *** a. Begin the transfusion and recheck the temperature in 15 min b. Delay hanging the blood and notify the healthcare provider c. Administer an antihistamine and begin the transfusion d. Administer two tablets (650 mg) of acetaminophen and begin the transfusion immediately 30. A client has tried to control his blood pressure with lifestyle changes, but has been unsuccessful. What medications does the nurse anticipate? a. Thiazide-type diuretic b. ACE inhibitor c. Calcium Channel Blocker d. Beta Blocker 31. A client with pericarditis is admitted. What assessment findings is characteristics of this condition? a. Coarse crackles bilaterally in lung bases b. Presence of a regular rhythm c. Heart rate that speeds up and slow down d. Friction rub at the left sternal boarder 32. While caring for the client with Sickle Cell Anemia, which of the following is the priority for the nurse? a. Administer pain medicine as ordered b. Draw CBC c. Provide time for client to rest d. Encourage green leafy vegetables 33. A client with a possible myocardial infarction, complains of sever chest pain, is sweaty, with a pulse of *** a. Administer morphine as ordered and notify the provider b. Administer oxygen c. Obtain the blood pressure and an electrocardiogram d. Administer nitroglycerin for a one-time dose 34. The nurse has just received a unit packed red blood cells from the blood bank for transfusion. The nurse knows to select tubing *** a. An air vent b. An In-line filter c. A microdrip chamber d. Tinted tubing to protect the blood from light 35. *** 36. Which of the following laboratory test results would be most helpful to the nurse in the assessment of a client with a bleeding a. Electrolytes b. Platelets c. Hemoglobin d. White blood cells 37. A client is to receive a transition of red blood cells. The nurse should obtain which of the following intravenous (IV) solutions to infuse ** a. 0.9% normal saline b. 5% dextrose in 0.45% sodium chloride c. 5% dextrose in 0.9% normal saline d. 5% dextrose in Lactated Ringers 38. A client has an order for 1000ml of LR over 8 hours. The drop factor is 20 gtt/ml. How many gtt/min should the client receive? a. 42 gtt/min 1000ml multiplied by 20 gtt/ml/ 8 hours 480 mins 39. Which of the following are non-modifiable risk factors for hypertension? a. Diet b. Genes c. Obesity d. Smoking 40. A client is being treated with blood transfusion therapy. During the first 15 minutes of the transfusion the client becomes severely short of breath and c/o itching. The transfusion next intervention by the nurse should be: a. Draw labs b. Flush the IV line with NS c. Administer Lasix d. Return the blood and the blood tubing to the blood bank 41. The client is admitted for possible infective endocarditis. Which test will confirm a positive diagnosis? Select all that apply a. Blood cultures b. CT scan c. MRI d. Echocardiogram 42. After cardiac catheterization, the client complains of tingling sensations in the affected leg. The nurse should: select all that apply: a. Inform the healthcare provider b. Compare distal pulses in the operative leg c. Inform the client that this is a normal feeling after the procedure d. Assess for bleeding at the catheter insertion site 43. A client reports discomfort of the right lower extremity. The nurse notices the extremity is warm to touch and suspects the client has developed a Deep *** following nursing interventions should be avoided? a. Application of a warm compress to the RLE b. Elevated of the RLE c. Check the RLE for a Homan’s sign d. Limit unnecessary movement of RLE 44. Which of the following laboratory results would indicates iron deficiency anemia? a. Elevated hemoglobin level b. Decreased reticulocyte count c. Elevated red blood cell count d. Red blood cell that are microcytic and hypochronic ***got this wrong*** 45. An older client has a history of stable angina. Which non-modifiable risk factor will the nurse access to guide the clients teaching plan? a. Activity level b. Tobacco use c. Older age d. Serum lipid levels 46. Which blood pressure findings would require further evaluation for stage 2 hypertension? a. Blood pressure of 110/70 b. Blood pressure of 162/100 c. Blood pressure of 142/88 d. Blood pressure of 120/82 47. Before beginning a blood transfusion after checking the blood with another nurse, the nurse should be sure *** a. Vital signs b. Skin color c. Urinary output d. Electrolyte 48. A client with heart failure is due to receive lisinopril. The blood pressure is 118/70 mmHg. What is the best action? a. Recheck the blood pressure b. Notify the healthcare provider c. Hold the medication d. Administer the medication 49. Which of the following laboratory results would indicate iron deficiency anemia? a. 50. A client has been admitted for an exacerbation of heart failure. Which is the nurse’s priority intervention? a. Assess respiratory status b. Weight the client c. Administer intravenous fluid d. Monitor electrolyte levels Med Surg Exam #4 1. The nurse is observing a client with Acute Respiratory Distress Syndrome (ARDS). Which complication should the nurse be most observant for? (got this one wrong) a. Pulmonary edema b. Pneumonia c. Cor pulmonale d. Atelectasis 2. A Mantoux Test was given 48 hours ago to a 65-year-old. The nurse interprets the reaction as positive. The client states, “I did not know I had the disease.” Which of the following responses would be correct? a. “This means that you have active TB at this time.” b. “A positive Mantoux test means that you have been exposed to TB.” c. “A positive test rules out TB infection or disease.” d. “A negative means that you need treatment at this time.” 3. A client with a stroke is being evaluated for fibrinolytic therapy. What information is most important for the nurse to obtain? (got this wrong) a. Onset symptoms b. Medications client is currently taking c. Medical history d. Vital signs 4. The nurse is caring for several clients. Which client does the nurse assess first? (got this one wrong) a. Young adult with an arterial oxygen level of 94% b. Older adult with a Sp02 of 96% on room air c. Young adult with an arterial oxygen level of 85% d. Adult client with a Sp02 of 90% on 2 liters of oxygen/min 5. A 57-year-old being treated for pneumonia, has Pa02 of 75% on room air. What is the nurse’s most appropriate immediate response to this assessment finding? a. Call the provider and prepare for intubation b. Administer oxygen to treat for hypoxemia c. The patient is doing well with the current treatment program, and no modifications are needed. d. Obtain an arterial blood gas to confirm diagnosis 6. A client diagnosed with Parkinson Disease is receiving carbidopa/levodopa (Sinemet) for treatment. Which of the following should be included in the nurse’s care of this client? (got this one wrong) a. Be sure to keep the scheduled medication administration times b. Administer medication with meals c. Observe for signs and symptoms of bleeding d. Increase fluid intake 7. A client is experiencing a tonic-clonic seizure. Which of the following actions would be most important? a. Padding the bed rails b. Placing a tongue blade between the client’s clenched teeth c. Elevating the clients head to 30 degrees d. Firmly restraining the client’s arms and legs alongside of the body 8. The nurse is evaluating a client with a diagnosis of Meningitis. Which of the following would confirm the diagnosis? a. A Glascow Coma Scale of 15 b. Absence of nuchal rigidity c. A positive Brudzinski sign d. A negative Kerning sign 9. A client diagnosed with Alzheimer’s disease stage 2 is being admitted to the unit. Which room assignment would be the most appropriate? a. A room in the back of the hallway b. A room closes to the kitchen c. A semi-private room d. A private room near the nurse station 10. A patient with a history of migraine headache reports that light makes her head hurt worse. How does the nurse document this subjective finding? a. Patient reports phonophobia b. Patient reports diplopia c. Patient reports vertigo d. Patient reports photophobia 11. The nurse identifies the following nursing diagnosis for the client with Multiple Sclerosis, impaired physical mobility related to muscle weakness as evidenced by client being too weak to assist with ADL’s. Which of the following should the nurse include in the client’s plan of care? a. Schedule the client to attend Physical Therapy b. Perform range of motion exercises at least twice a day c. Administer baclofen (Lioreasal) Q4 hours prn d. Assist with activities of daily living 12. Which of the following are risk factors for CVS (stroke)? Select all that apply a. High blood pressure b. Young age c. Smoking d. Previous transient ischemic attacks (TIA) 13. A nurse answers a call light and finds a post-operative client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52mmHg on the cardiac monitor. What action by the nurse takes priority? a. Assess the client’s lung sounds b. Take a full set of vital signs c. Provide reassurance to the client d. Notify the Rapid Response Team 14. A client is scheduled for pulmonary function test (PFT’s). The nurse calls the client for pre-procedure teaching. Which client statement indicates a need for further teaching? a. “I should not smoke for at least 6 hours before the test’ b. “PFT’s can determine whether my lung problem has gotten worse” c. “I should use my inhaler 20 minutes before the test” d. “If I get really short of breath, I’ll tell the technician” 15. A nurse plans care for a client who has chronic, obstructive, pulmonary disease and thick tenacious secretions. Which interventions should the nurse include in this client’s plan of care? Select all that apply (got this wrong) a. Suction the client every 2 to 3 hours b. Recommend respiratory therapy c. Add humidity to the prescribed oxygen d. Ask the client to increase daily fluid intake 16. The nurse assesses a client who has myasthenia gravis. Which clinical manifestation does the nurse expect to observe in this client? a. Absent deep tendon reflexes b. Lateralization to the affected side during the weber test c. Inability to perform the six cardinal positions of gas due to extraocular weakness d. Impaired stereognosis 17. The nurse is assessing the client with chronic bronchitis. Which finding should the nurse expect? a. Minimal sputum with cough b. Copious frothy sputum c. Barrel chest appearance d. Stridor on expiration 18. The nurse assesses a client with Pneumonia and notes decreased lung sounds on the left side and decreased lung expansion. What is the nurse best actions? a. Have the client cough and deep breath b. Increase oxygen flow of 10 liters/min c. Check the oxygen saturation and notify the healthcare provider d. Perform an arterial blood gas analysis 19. A nurse is caring for a client with Parkinson’s disease. The nurse notes that the client’s spouse is exhausted and confides in the nurse as being the only care provider for her spouse. Which nursing intervention would be most helpful? a. Encourage the spouse to talk about the difficulties involved in providing care b. Recommends that the client be placed in a long-term care facility c. Inform the spouse that this is just what has to be done d. Suggesting that the spouse seeks psychological counseling 20. Which teaching point is most important for the client with bacterial pharyngitis? a. Take all antibiotics as directed b. Wash hands frequently c. Gargle with warm salt water d. Use a humidifier in the bedroom 21. A client is admitted with cough, fever, dyspnea, and a diagnosis of pneumonia. Which of the following interventions should the nurse include in the client’s plan of care? a. Suction oral secretions every 2 hours b. Provide continuous use of oxygen at 2 LNC c. Encourage the client to use the incentive spirometer hourly d. Teach the client to cough every 12 hours 22. A nurse is caring for a disoriented client who is attempting to pull out an IV line. Which of the following actions by the nurse would be appropriate? a. Discontinue the IV line b. Attempt to orient patient c. Review primary care orders d. Apply soft restraints 23. Which of the following clinical manifestations would alert the nurse to the possibility of meningitis? a. Nuchai rigidy b. Unilateral mouth drooping c. Impaired speech and swallowing d. Muscle weakness and tingling 24. The client informs the nurse that he is experiencing leg stiffness when walking and slowness with performing activities of daily living and slight tremors in his hands at rest. Which of the following condition would the nurse suspect? a. Myasthenia gravis b. Huntington’s disease c. Parkinson’s disease d. Guillian-Barre’ syndrome 25. A nurse assesses several client’s who have a history of asthma. Which client should the nurse assess first? a. A 66-year-old client with a barrel chest and clubbed fingernails b. A 27-year-old client with a heart rate of 120 beats/min c. 35-year-old client who has a longer expiratory phase than inspiratory phase d. A 48-year-old client with an oxygen saturation level of 92% at rest 26. You are receiving a client after cervical fusion surgery. Which of the following is the priority assessment? a. Assessment of gag reflex b. Pain assessment c. Gi distress (nausea) d. Assessing pulses 27. A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which of the following is the best response of the nurse? a. Tell the client not to drink beverages with caffeine before bed b. Educate the client to sleep upright in a reclining chair c. Ask the client if he or she has ever been evaluated for sleep apnea d. Contact the provider for a prescription for sleep medication 28. The nurse assesses a client with asthma and find wheezing throughout the lungs, decreased oxygen saturation, and suprasternal retractions on inhalation. What is the nurses best action? a. Administer oxygen and rescue inhaler b. Call a code c. Perform peak expiratory flow readings d. Assess for midline trachea 29. A client with a history of Chronis Obstructive Pulmonary Disease (COPD) presents with increased cough, increased WBC, and a low-grade temperature. Which question elicits the most useful information? a. “Has your sputum changed color? b. “Is anyone else in your house sick?” c. “Do you take any medications?” d. “How long have you been sick?” 30. A hospitalized client with late-stage Alzheimer’s disease says that breakfast has not been served. The nurse witnessed the client eating breakfast earlier. Which of the following is the best response from the nurse? a. “I see you are still hungry, I will get you some toast.” b. “You are confused about mealtimes this morning.” c. “You look tired. Maybe a nap will help.” d. “You ate your breakfast 30 minutes ago.” 31. When assessing a client’s level of consciousness, the nurse notes that the client opens eyes when spoken to, answers simple questions correctly, and is found sleeping often. The nurse identifies the client’s level of consciousness as: a. Comatose b. Disoriented c. Lethargic d. Confused 32. The nurse assesses a client who has Guillian-Barre’ syndrome. Which clinical manifestation does the nurse expect to find in this client? (got this wrong) a. Ophthalmoplegia and diplopia b. Weakness of the face, jaw, and **can’t read the rest c. Progressive, attending weakness and paresthesia d. Progressive weakness without sensory involvement 33. A client is admitted with a diagnosis of cerebellar stroke is experiencing dysphagia. What intervention is most appropriate to include in the client’s plan of care? a. Ambulate client with gait belt b. Auscultate the client’s lungs after meals c. Encourage double swallowing d. Encourage client to wait for communication 34. A client with asthma reports, not being able to take deep breaths. The nurse hears decreased breath sounds in the lungs and no wheezing. What is the nurse’s best actions? a. Document the findings and continue to monitor b. Have the client cough frequently c. Encourage the client to stay calm and take deep breaths d. Assess the client’s oxygen saturation 35. A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client’s oxygen saturation has not significantly improved. What response by the nurse is best? a. “The blood clot interferes with perfusion in the lungs” b. “the client needs immediate intubation and mechanical ventilation” c. “Maybe the client has respiratory distress syndrome” d. “Breathing so rapidity interferes with oxygenation 36. A patient is ordered phenytoin 100mg IV in 500 ml of 0.9% NS over 30 minutes. What is the infusion rate? a. ** 37. The nurse is providing discharge teaching to a client after a lumber laryngectomy. Which of the following complications does the nurse instructs the client to return to the hospital? a. Decreased appetite b. Pain at the incision site c. Sight redness and itching at the incision site d. Clear drainage from the incision site 38. A client is admitted with left lung pneumonia. Which assessment finding does the nurse correlates with the condition? a. Expiratory wheeze on the right side b. Crepitus of the skin around the lung c. Frothy pink sputum d. Crackles heard on expiration 39. A client complains of worsening paralysis of the lower extremities following a lumbar laminectomy. Which of the following nursing actions would be appropriate? a. Elevate the head of the bed b. Encourage the progressive ambulation c. Recognize that this is expected post operatly d. Notify the physician 40. Which of the following clinical manifestations would the nurse expect to find in a client with Gullain-Barre syndrome? 41. A client recovering from a stroke is ordered Aspirin 487.5 mg. On hand is Aspirin 325 mg. How much will the client receive? 42. The cerebral spinal fluid of a client who is diagnosed with meningitis obtained and has a cloudy appearance. Which of the following is the priority for the nurse? 43. Normal saline infused 40 mL/hr. The nurse has a gtt factor of 60 gtt/mL. How many drops per minute should the nurse set the pump to deliver? 44. After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client’s understanding. Which statement indicates the client comprehends the teaching? (got this one wrong) 45. A patient just returned to the unit after cervical fusion surgery. Which of the following is the priority assessments? (got this one wrong) 46. The client post seizure, which interventions should be included in this client’s immediate plan of care? Select all that apply 47. Which of the following statement is true regarding lumbar puncture? 48. The nurse is preparing to admit a client who has been diagnosed with TB. Which interventions should the nurse plan to implement? Select all that apply (got this wrong) 49. A client admitted the previous day for a suspected neurologic disorder becomes increasingly lethargic. Which is best action? (got this wrong) A nurse assesses clients on the medical surgical unit. Which client is at greatest risk for development of obstructive sleep apnea? Med Surg Exam 3 1. What question would the nurse ask a client to help determine the cause of this ABG result (pH 7.50 PaCO2 40 HCO3 29) ? a. “Do you smoke” b. “Have you experienced diarrhea” c. “Do you have a history of COPD” **do not pick this one** d. “How long have you had the nausea and vomiting” 2. Calculate: Order Gentamycin 75 mg IM q8H Available Gentamycin 40 mg per mL How many ml/dose Ø 5.6 mL/dose 3. Intravenous fluid therapy is an important treatment intervention for electrolyte imbalances. Of the following, which category moves water out of the cell? a. Isotonic **do not pick this one** b. Hypotonic c. Isometric d. Hypertonic 4. The healthcare provider ordered KCL 40 MEQ IV for a client with a potassium level of 2.5. Which of the following is the appropriate nursing action in response to the order? a. Draw up the KCL in a syringe and administer through the peripheral IV line (IV push) b. Administer KCL by an infusion pump c. Call the healthcare provider and clarify the order **do not pick this one** d. Call the Pharmacy and request for the KCL to be provided in oral form (tablet) 5. Which of the following should the nurse be sure to include in the plan of care for a client with hypomagnesemia? Select all that apply a. Continuous ECG monitoring b. Seizure precautions c. Safety precautions as needed **I picked the blue*** d. Eliminate dark green vegetables and whole grains from diet 6. An 89 year old client is presented with complaints of dizziness and fatigue, who has been experiencing vomiting and diarrhea for several days. Which of the following would the nurse perform to gain objective data related to the symptoms presented? a. Ask the client how long the vomiting and diarrhea has been occurring b. Ask the client if there has been any weight loss c. Pinch the skin on the back of the client’s hand and assess for tenting d. Pinch the skin over the sternum and assess for tenting 7. A client is admitted with a diagnosis of dehydration secondary to chronic diarrhea. Which of the following acid-base imbalances would the nurse expect to find? a. Metabolic Alkalosis b. Metabolic Acidosis c. Respiratory Alkalosis d. Respiratory Acidosis 8. A client with which of the following disorders is most likely to develop respiratory acidosis? a. Hypokalemia b. Chronic obstructive pulmonary disease c. Salicylate d. Pulmonary fibrosis 9. A client is to receive 3,000 mL of Ringers Lactate (RL) in 24 hours for dehydration by infusion pump. Provide the infusion rate. Ø 125 mL 10. The nurse caring for a client diagnosed with hyponatremia. Which of the following should the nurse remove from the client’s meal tray? a. Gatorade sports drink b. Water c. Eggs and cheese d. Salt and pepper packets 11. To ensure the client’s weight is documented correctly the nurse is asked to provide the client’s weight in kg, the client weighs 140 lbs. Provide the client’s weight in kg. Ø 63.6 kg 12. The nurse is obtaining orthostatic vital signs on a client diagnosed with fluid volume deficit. Which of the following would the nurse perform after obtaining only blood pressure with client in a sitting position? a. Assist the client to a supine position and take the client’s blood pressure b. Assist the client to a standing position and take the client’s pulse **do not pick this one** c. Take the client’s pulse in current position and note the finding d. Take the client’s blood pressure in the other arm 13. Which of the following should the nurse include in the of plan of care of a client with fluid volume access? Select all that apply a. Daily weight b. Skin care c. Force fluid intake d. Encourage high sodium diet ** I picked the blue** 14. Which of the following most likely leads to the development of the metabolic acidosis? a. Diabetic ketoacidosis (DKA) b. Obesity c. Overdose of barbiturates d. Hyperventilation 15. A client is diagnosed with respiratory acidosis secondary to pneumonia. Which of the following interventions are appropriate to manage the client’s care? Select all that apply a. Administer antibiotics as ordered b. Assess respiratory rate and depth c. Administer high flow oxygen to assist with the retainment of CO2 d. Maintain supine position ** I picked the blue** 16. A client is receiving IV fluids with a high osmolality. Which of the following sites should the nurse select to infuse these fluids? a. Peripheral site, using a vein in the forearm b. Central line site, using the subclavian vein c. Peripheral site, using a vein in the antecubital space d. Peripheral site, using the radial 17. Which of the following statements reflects a priority nursing action for the client receiving an IV infusion via a central venous catheter? a. Remove all dressings and clean the site daily with alcohol b. Take measures to prevent infection at the insertion site c. Rotate the insertion site every 3 days d. Remove all dressings and clean the site daily with alcohol 18. A client has been admitted to hospital with fluid volume deficit after vomiting for several days. Which of the following ABG results would the nurse expect to find? a. pH 7.30 PaCO2 50 HCO3 27 b. pH 734 PaCO2 50 HCO3 28 c. pH 7.47 PaCO2 43 HCO3 28 d. pH 7.47 PaCO2 30 HCO3 23 **do not pick this one** 19. The nurse is providing instructions to a client with fluid volume access. Which of the following responses for the client indicates a good understanding? a. “I should weigh yourself three times a day to ensure accuracy” b. “I should use the same scale if possible, each time I weigh yourself” c. “I should call the doctor if I do not gain at least 2 lbs within a week of being home” d. I should weigh myself at different times of the day to get a good range” 20. The healthcare provider ordered 0.9% NS 100 mL to infuse at 125 ml/hr. Upon arriving in the client’s room, the nurse notices 0.45% NS infusing at 175 ml/hr. What is the nurses appropriate action? a. Switch to 0.9% Normal saline 21. The nurse notices the insertion site of a peripheral IV is swollen and leaking fluid. Which action should the nurse perform first? a. Stop the infusion, call to have the IV site changed b. Apply a warm compress to the site c. Slow the infusion rate d. Apply a cold compress 22. The client with hypocalcemia is instructed to take a vitamin D supplement along with the prescribed calcium. The nurse explains: a. “Vitamin D opposes calcium” b. “Vitamin D prevents renal calculi” c. “Vitamin D is needed for proper absorption of calcium” d. “Vitamin D is just good for you” 23. The client is diagnosed with fluid volume excessed is ordered Furosemide (Lasix) 85 mg PO BID. Available is 20 mg/tablet. How many tablets will the client receive in one dose? Ø 4.25 tablets 24. Which of the following client’s are at greatest risk for developing hypokalemia? a. A client with kidney failure b. A client with CHF and taking Furosemide (Lasix) c. A client with a malignant melanoma d. A client with COPD (Chronic Obstructive Pulmonary Disease) 25. A client with nasogastric tube attached to continuous suction for several days is at risk for developing which of the following? a. Respiratory acidosis b. Metabolic alkalosis c. Metabolic acidosis d. Respiratory alkalosis 26. A client is receiving long term chemotherapy for cancer treatment. Which of the following infusion devices/location is best suited for this client? a. Peripheral site, using the forearm b. Central vein catheter site, using the subclavian vein c. Peripheral inserted central catheter (PICC), using the antecubital site d. Peripheral site, using the femoral vein 27. The CNA provides the following orthostatic vital signs to the nurse. BP lying down 130/60 pulse 60, BP sitting 122/58 Pulse 62, standing BP 110/54 Pulse 68. Which of the following actions by the nurse is appropriate in response to this information? a. I got this one wrong 28. Which of the following ABG results would the nurse expect of a client diagnosed with renal failure? a. pH 7.49 PaCO2 36 HCO3 30 b. pH 7.30 PaCO2 35 HCO3 18 c. pH 7.31 PaCO2 50 HCO3 23 **do not pick this one** d. pH 7.43 PaCO2 48 HCO3 30 29. The client ordered Vancomycin 500 mg in 100 mL of 0.9% NS to infuse over 30 minutes by infusion pump. Provide the infusion rate. Ø 16.6 30. Which of the following would the nurse expect to assess in a client with a magnesium level of 2.8? Select all that apply a. Decreased (Deep Tendon Reflexes) DTRs b. Tremors c. Hyperactive reflexes d. Hypotension **I picked the blue** 31. Which of the following is a priority when planning care of a client with the following lab values K-3.8 Na 138. a. Continuous ECG monitoring b. Provision of calcium rich foods c. Administration of a diuretic d. Maintain a safe environment **do not pick this one** 32. The client is receiving an intravenous infusion and the nurse notices leaking around the IV site, edema, and the skin around the site is cool to touch. Which of the following actions of the nurse is most appropriate? a. Slow down the infusion rate b. Discontinue the IV and apply a warm compress c. Reposition the IV access device to ensure placement d. Flush the IV with normal saline to check patency 33. A client is taking a diuretic and complaints of onset of leg cramps. Which lab results does the nurse correlate with this condition? a. Ca 10.0 mg/dl b. KCL 2.2 mEq/l c. Na 135 mEq/l d. Mg 2.0 mg/dl 34. A client is receiving 2000 ml of NS for an acid base imbalance. The rate is 100 ml/hr using A 15 drop/ml drip factor. What is the drops per minute? Ø 42 gtt/min 35. A client is admitted with metabolic alkalosis. Which of the following would you expect to see in this chart? a. pH 7.54 b. pH 7.25 c. PcCO2 30 mmHg d. Serum calcium 9.0 MEq/L 36. Which of the following indicates the treatment for fluid volume access has been effective? a. Crackles in the left lower lobe b. Flat neck veins with head of bed elevated c. Full, bounding pulses **do not pick this one** d. 2 lb weight gain 37. A client has the following arterial blood gases: pH 7.30, HCO3 22 mEq/L, PaCO2 25 mm Hg. Which interventions by the nurse is most appropriate? a. Assist client with breathing techniques (breathing in a paper bag) to slow breathing b. Administer antianxiety medications c. Prepare to give intravenous sodium bicarbonate d. Administer oxygen 2 L per nasal cannula 38. The nurse is caring for a client with fluid volume access. The nurse notes indentation on the ankles when pressed. The nurse would document this finding as? a. Pitting edema b. Scant edema c. Moderate edema d. Poor skin turgor 39. Which of the following assessment findings support the diagnosis of hypocalcemia? a. The client twitches when the cheek is tapped b. The client does not flex hand when a blood pressure cuff is inflated on arm c. The client complains of neck pain when legs are flexed d. The client has hypoactive bowel sounds 40. A client experiencing metabolic acidosis would have which of the following signs and symptoms? a. Melena (dark stool) b. Shallow and decreased respirations c. Rapid and deep respirations d. Weight gain 41. Which client is at greatest risk for developing hypernatremia? a. A client taking sulfonamide antibiotic b. A client taking ibuprofen (Motrin) c. A client who has a high fever and is vomiting d. A client taking digoxin (Lanoxin) 42. Which of the following treatment options is appropriate for the client with a potassium level of 3.5? a. Continue to monitor and provide foods high in potassium b. Administer oral potassium c. Administer Kayexalate d. Use of salt substitutes in the diet 43. Which of the following is the first sign of dehydration in the elderly? a. Urine specific gravity of 1.035 or higher b. Irritability or restlessness c. Weight loss d. Urine output of 30 ml/hr or less 44. What is the appropriate response of the nurse for the client with the following intake and output measurements over the last 8 hours? Breakfast: one cup of orange juice, toast, one bowl of oatmeal, one cup of coffee Lunch: one 12 oz can of soda ham sandwich, one cup of chicken broth Dinner: chicken casserole, two 12 oz cans of soda one cup of pudding IVFL 0.9% NS infusing at 100 ml/hr started at 0800; 800 ml has infused Foley catheter drained 200 ml dark amber urine a. Initiate an additional bag of IV fluids and infuse at the same rate b. Assess the client’s oral mucosa c. Assess the client’s lower extremities for edema d. Auscultate the client’s lungs 45. While assessing a client’s IV site, the nurse notices redness (erythema), swelling, and soreness with palpation. The nurse would document the assessment finding as which of the following? a. Infiltration b. Phlebitis c. Infection d. Air Embolism 46. The nurse is providing discharge instructions to a client diagnosed with hyperkalemia. Which of the following foods should the nurse instruct the client to avoid? Select all that apply a. Chicken b. Grapefruit c. Bananas d. Shell fish 47. Upon admission a client’s arterial blood gas is as follows: pH 7.28, pCO2 35 mEq/L. Which of the following interpretations of the blood gas is correct? a. Metabolic acidosis b. Respiratory acidosis c. Metabolic alkalosis d. Respiratory alkalosis 48. Which of the following is the best choice of treatment for a client with severe dehydration? a. Intravenous fluid hydration b. Oral hydration c. Fluid hydration d. Diuretics 49. A client has a peripheral line that is in place and capped (not in use). Before initiating the new order for IV infusion the nurse should be sure to do which of the following? a. Clean the port with betadine then flush the IV line with 3-5 ml of normal saline **do not pick this one** b. Clean the port with alcohol then flush the line with 3-5 ml of heparin c. Clean the port with alcohol then flush the line with 3-5 ml of normal saline d. Flush the port, cleaning the port is not necessary 50. A client has 0.9% normal Saline infusing continuously though a peripheral infusion. The healthcare provider orders an antibiotic as a piggyback. In order to administer the antibiotic, the nurse should do which of the following? a. Start a new peripheral IV for the infusion of the antibiotic b. Increase the flow rate of the 0.9% Normal Saline to facilitate the administration of the antibiotic **do not pick this one** c. Check the compatibility of the antibiotic with the 0.9% Normal Saline d. Call the healthcare provider to question the order Med Surg Exam #2 1. The client who is receiving Vancomycin has an order for a peak and trough. The nurse will be sure of which of the following? a. The peak is drawn at 30-60 mins before starting Vancomycin. b. The peak is drawn at least 30-60 mins after the Vancomycin is finished infusing. c. The peak must be drawn while the Vancomycin is infusing for most accurate results d. The peak is drawn within at least 24 hrs of the Vancomycin being given 2. A client is recovering from a recent total hip replacement of the right hip (posterior approach). The nurse would be certain to maintain which of the following positions? a. Abduction of the right hip b. Adduction of the right hip c. Flexion of the right hip d. External rotation of the right lower extremity 3. Which of the following is an example of primary prevention of cancer? a. Vaccination b. Surgery c. Radiation d. Genetic screening 4. Which of the following are clinical manifestations of rheumatoid arthritis (RA) a. Swelling b. Pallor c. Anemia d. Crepitus 5. The nurse caring for a client diagnosed with Rheumatoid Arthritis (RA). Which outcome would be priority for the client? a. Eat three well balanced meals a day b. Report pain as a 2 or less on a 1-10 pain scale c. Maintain full function of the extremities d. Participation in low impact aerobic exercises 6. The nurse explains the difference between normal cells and benign tumor cells to the client by providing what information about these cells? a. Growing in the wrong place or time is typical of benign tumors b. Benign tumors grow through invasion of other tissue c. Benign tumors have lost their cellular regulation from contact inhibition d. The loss of characteristics of the parent cells is called anaplasia 7. Which of the following would be an appropriate nursing diagnosis for a client diagnosed with HIV and oral candidiasis? Select all that apply a. At risk for nutrition deficit b. Alteration in comfort related to oral infection c. Fear and anxiety related to por prognosis as evidence by client stating “I worry about getting better” d. Knowledge deficit of disease process 8. Which of the following should the nurse include in his/her education to a client regarding cancer prevention? a. Follow cancer screening recommendations b. Limit contact with individuals who are diagnosed with cancer c. The environment poses no risk for carcagentic agents d. It is necessary to obtain family history 9. A nurse has provided a client with education on the use of epinephrine auto-injector (EpiPen) What statement by the client indicates additional instructions needed? a. “I don’t need to go to the hospital after using my Epi-Pen” b. “I must carry my EpiPen with me at all times” c. “I will write the expiration date on my calendar” d. “I should wear a medical bracelet” 10. Which of the following can contribute to the development of pressure ulcers? Select all that apply? a. Having a hypersensitivity to multiple medications b. Patient having difficulty swallowing c. Being of advance age d. Loss of sensation 11. Which of the following are clinical manifestations of a systemic infection? Select all that apply a. Fever b. Edema c. Pain or tenderness d. Tachycardia 12. Which lab finding is an expected finding of a client diagnosed with Rheumatoid Arthritis? a. Negative Rheumatoid Factor b. Increased Erythrocyte Sedimentation Rate c. Decreased C-Reactive Protein d. Decreased level of globulin 13. A client post knee infection is scheduled for physical therapy at 12:00. What is the best time to medicate the client with pain medicine? a. 0800 b. Immediately after returning from therapy c. 1200 d. 1130 14. A client is hospitalized with Pneumocystis pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? a. Perform most activities for the client b. Administer sleeping medication c. Pace activities, allowing for adequate rest d. Increase the client’s oxygen during activity 15. Which of the following is a sign of exacerbation of lupus? a. Fever b. Butterfly rash c. Joint pain d. Tachycardia 16. Which of the following are not a modifiable risk factor for the development of osteoarthritis? a. Joint pain b. Age c. Repetitive recreational use of joint d. Obesity 17. When caring for a wound the nurse should be sure to perform which of the following? Select all that apply a. Assess the wound for redness b. Assess the wound for tunneling c. Cover the wound with prescribed cream being sure to cover the intact surrounding skin d. Measure the depth of the wound 18. An 89-year-old client is being discharged to home following a diagnosis of pneumonia, the nurse should include which of the following education points in the discharge instructions? a. Be sure to keep your immunizations up to date b. You are not at risk for developing other respiratory since you had pneumonia c. Immunizations are not necessary at your age d. You will recover from this very quickly 19. Prevention is the best strategy for Lyme disease. Which of the following should the nurse be sure to include in the teaching? Select all that apply a. Wear dark clothing when hiking in the woods b. Use insect repellent on skin and clothes c. Report flu like symptoms d. Wear clothes shoes or boots and hat or cap 20. Which of the following is the most important factor in preventing the spread of microorganisms? a. Correct hand washing techniques b. Maintenance of aseptic technique when inserting an indwelling catheter c. Use of mask, gowns, and gloves when caring for a client with an infection d. Cleaning up blood spills with sodium chloride 21. Which of the following should the nurse perform first after noticing a reddened area a client’s left hip? a. Massage the area to promote circulation b. Turn the client to the right side for at least 2 hours c. Notify the healthcare provider d. Arrange for a pressure relief device 22. A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection cultured from the urine. What action by the nurse is most important? a. Hand hygiene before and after providing care b. Limit visitors to immediate family only c. Wear a respirator when handling urine output d. Wearing gloves only when handling urine 23. Which transmission precaution should the nurse utilize when caring for a client with AIDS and a diagnosis with TB? a. Airborne and Standard Precautions b. Droplet and Contact Precautions c. Standard Precautions and Droplet d. Airborne and Contact Precautions 24. Which action by the nurse is most helpful to prevent clients from acquiring infections while hospitalized? a. Consistently using appropriate hand hygiene b. Assessing skin and mucus membranes c. Eliminating visitors d. Monitoring daily white blood cell counts 25. The physicians orders a CT scan on a client who is on contact isolation. How should the nurse respond to this order? a. Cancel the CT Scan b. Inform the staff in radiography depar