Med Surg Mid Term Exam Questions and Answers

What is the best way to assess pain? - Answer-Client self-report How to assess pain in a confused patient? - Answer-FACES pain scale-revised Which patient to see first after hand-off - Priority with pain? - Answer-A client with new-onset abdominal pain rated as an 8 on a 0 to 10 scale. The process how is pain perceived by a patient. - Answer-Modulation, sensory perception, transduction and transmission Which patients are at risk for dehydration? - Answer-Diabetic patients with hyperglycemia and diabetic ketoacidosis (DKA) A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first? - Answer-Apply oxygen by mask or nasal cannula After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding, Which statement indicates the client correctly understood the teaching? - Answer-I will weigh myself each morning before I eat or drink. A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotesin-converting enzyme (ACE inhibitor), For which expected therapeutic effect should the nurse assess? - Answer-Blood pressure decrease from 180/72 mm Hg to 144/ 50 mm Hg A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss.? - Answer-Anxious client who has tachypnea A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan? - Answer-Decreased orthostatic lightheadedness and dizziness.After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicated the client correctly understood the teaching? - Answer-Grilled chicken breast with glazed carrots. A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia? - Answer-A 34-year old on NPO (Nothing by mouth status) who is receiving intravenous D5W. A nurse teaches a client who is at risk for mild hypernatremia Which statement should the nurse include in this client's teaching? - Answer-Read food labels to determine sodium content. A nurse is caring for a client who has the following laboratory results: potassium 3.4mEq/L, magnesium 1.8mEq/L, calcium 8.5mEq/L. Which assessment should the nurse complete first? - Answer-Depth of respiration Nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.36, PaO2 98 mmHg, PaCO2 33 mmHg, and HCO3-18 mEq/L. Which manifestation should the nurse identify as an example of the client's compensation mechanism? - Answer-Increased rate and depth of respiration A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.34, PaO2 88 mmHg, PaCO2 38mmHg, and HCO3-19 mEq/L. Which assessment should the nurse perform first? - Answer-Cardiac rate and rhythm A nurse assess a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complication of this therapy? - Answer-Metabolic alkalosis A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess? - Answer-Kussmaul respirations A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60-pack-year smoking history. Which action is most important for the nurse to takewhen interviewing this client? - Answer-Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? - Answer-Client has reduced breath sounds. Nurse call physician immediately.