RN VATI Medical Surgery
2019
1.D. Maintain abduction of the affected extremity.
The nurse should ensure that the affected extremity is in a position of ab- duction to
prevent hip dislocation. The nurse should place an abductor pillow or several pillows
between the client's legs to keep the affected extremity in abduction while the client is
in bed: A nurse is caring for a client who is 24 hr postoperative following a total hip
arthroplasty. Which of the following actions should the nurse take?
A. Place the affected leg in external rotation.
B. Encourage the client to use the incentive spirometer every shift.
C. Instruct the client to lean forward when rising from a chair.
D.Maintain abduction of the affected extremity.
2.A. The client's daily peak expiratory flow (PEF) measures 85% above per- sonal
best.
A client who has asthma should use a peak flow meter twice daily to monitor asthma
control. A PEF in the green zone, or 80% or above personal best, indicates the
effectiveness of medication therapy: A nurse is assessing a client who takes salmeterol to
treat moderate asthma. Which of the following findings should indicate to the nurse that
the medication has been effective?
A.The client's daily peak expiratory flow (PEF) measures 85% above personal best.
B.The client's ABGs shows a pH level of 7.32.
C. The client's forced expiratory volume is decreased after treatment with medica- tion.
D.The client's wheezing is limited to expiratory.
3.C. Thinning of the hair
Thinning of the skin and delayed healing are adverse effects of topical glu-
cocorticoid preparations. The client should only apply the ointment to dry patches of
the skin because topical steroids can cause atrophy of the dermis and epidermis,
which can result in thinning of the skin: 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?
A. Increased pigmentation
B. Localized hair loss
C. Thinning of the hair
D.Increased sensitivity to the sun
4.D. Frothy sputum
The nurse should identify that frothy sputum, dyspnea, and wheezing are man-
, RN VATI Medical Surgery
2019
ifestations of left-sided heart failure. Treatment includes fluid restriction and
diuretics to decrease preload and reduce pulmonary congestion. 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.-
: 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?
A. Dependent edema
B. Jugular distention
C. Weight Gain D/
Frothy sputum
5.A. Respiratory Alkalosis
This pH is alkaline (increased) and the PCO2 is decreased, representing alveolar
hyperventilation and resultant respiratory alkalosis.: A nurse is caring for a client who
is experiencing anxiety as well as numbness and tingling of the lips and fingers. The
client's ABGs are: pH 7.48, PCO2 30 mm Hg, HCO3 - 24 mEq/L, PaO2 85 mm Hg.
Which of the following acid-base imbalances should the nurse identify that the client is
experiencing?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D.Metabolic acidosis
6.B. Osteoporosis
Osteoporosis is a common finding with Cushing's syndrome. Bones become thinner
as a result of mineral loss and nitrogen depletion, and the risk for fractures
increases: A nurse is assessing a client who has Cushing's syndrome. Which of the
following findings should the nurse expect?
A. Vitiligo
B. Osteoporosis
C. Myxedema
D.Heat intolerance
7.A. A pearly, waxy nodule
A client who has basal cell carcinoma has a nodular lesion with well-defined borders
and a pearly or waxy appearance, resulting from overexposure to the sun, especially
on the face, head, and neck: A nurse is inspecting the skin of a client who has basal cell
carcinoma. The nurse should identify which of the following lesion characteristics on the
client's skin?
A. A pearly, waxy nodule
B. An irregular border on a variegated-colored lesion
, RN VATI Medical Surgery
2019
C. A firm, nodular, crusty, or ulcerated lesion
D. A weeping vesicle
8.A is correct. The nurse should tap the client's cheek just in front of the ear and
below the zygomatic arch. The client who has hypocalcemia w Chvostek'sillsign, display
which is a twitching of the facial muscle: A nurs a
a client who has hypocalcemia. In which of the following areas should tape is
on the client's face to detect the presence of Chvostek's sign? (Yo spots to assessing
select in the artwork below. Select only the hot spot that corr your answer.) the nurse
9.B. Low urine specific gravity
A client who has hyponatremia as a result of diuretic overuse has a low urine specific
gravity. The increased excretion of water alters the ratio of particulate matter, which
affects the specific gravity: A nurse in an emergency department is assessing a client who
is overusing prescribed diuretics and has a sodium level of 127 mEq/L. Which of the
following laboratory findings should the nurse expect?
a. High lipase
B. Low urine specific gravity
C. Low Hemoglobin
D. High creatine kinase-MB (CK-MB)
10.D. Review the daily schedule with the client every morning
The nurse should instruct the family member to use short, simple sentences when
explaining an activity to the client. The explanation should be done immediately
before the activity to aid the client's memory and ability to follow directions.: A home
health nurse is assisting a client with planning care for a family member who has
Alzheimer's disease. Which of the following instructions should the nurse include?
A. Remove clutter from room and hallways
B. Place a monthly calendar in the client's room
C. Use confrontation to manage the client's behavior
D.Review the daily schedule with the client every morning
11.C. Refractory hypoxemia
ARDS is a systemic inflammatory response to trauma, sepsis, burns, pancre- atitis,
and blood transfusions, when excess lung fluid dilutes surfactant ac- tivity in the
lungs. A client who has ARDS has refractory hypoxemia, which is hypoxemia that
does not improve with oxygen therapy. Extensive pulmonary edema evident on a
chest x-ray is a manifestation of ARDS: A nurse is caring for a client who has developed
acute respiratory distress syndrome (ARDS). Which of the following findings should the
nurse identify as a manifestation of this syndrome?
A. An audile pleural friction rub
2019
1.D. Maintain abduction of the affected extremity.
The nurse should ensure that the affected extremity is in a position of ab- duction to
prevent hip dislocation. The nurse should place an abductor pillow or several pillows
between the client's legs to keep the affected extremity in abduction while the client is
in bed: A nurse is caring for a client who is 24 hr postoperative following a total hip
arthroplasty. Which of the following actions should the nurse take?
A. Place the affected leg in external rotation.
B. Encourage the client to use the incentive spirometer every shift.
C. Instruct the client to lean forward when rising from a chair.
D.Maintain abduction of the affected extremity.
2.A. The client's daily peak expiratory flow (PEF) measures 85% above per- sonal
best.
A client who has asthma should use a peak flow meter twice daily to monitor asthma
control. A PEF in the green zone, or 80% or above personal best, indicates the
effectiveness of medication therapy: A nurse is assessing a client who takes salmeterol to
treat moderate asthma. Which of the following findings should indicate to the nurse that
the medication has been effective?
A.The client's daily peak expiratory flow (PEF) measures 85% above personal best.
B.The client's ABGs shows a pH level of 7.32.
C. The client's forced expiratory volume is decreased after treatment with medica- tion.
D.The client's wheezing is limited to expiratory.
3.C. Thinning of the hair
Thinning of the skin and delayed healing are adverse effects of topical glu-
cocorticoid preparations. The client should only apply the ointment to dry patches of
the skin because topical steroids can cause atrophy of the dermis and epidermis,
which can result in thinning of the skin: 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?
A. Increased pigmentation
B. Localized hair loss
C. Thinning of the hair
D.Increased sensitivity to the sun
4.D. Frothy sputum
The nurse should identify that frothy sputum, dyspnea, and wheezing are man-
, RN VATI Medical Surgery
2019
ifestations of left-sided heart failure. Treatment includes fluid restriction and
diuretics to decrease preload and reduce pulmonary congestion. 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.-
: 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?
A. Dependent edema
B. Jugular distention
C. Weight Gain D/
Frothy sputum
5.A. Respiratory Alkalosis
This pH is alkaline (increased) and the PCO2 is decreased, representing alveolar
hyperventilation and resultant respiratory alkalosis.: A nurse is caring for a client who
is experiencing anxiety as well as numbness and tingling of the lips and fingers. The
client's ABGs are: pH 7.48, PCO2 30 mm Hg, HCO3 - 24 mEq/L, PaO2 85 mm Hg.
Which of the following acid-base imbalances should the nurse identify that the client is
experiencing?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D.Metabolic acidosis
6.B. Osteoporosis
Osteoporosis is a common finding with Cushing's syndrome. Bones become thinner
as a result of mineral loss and nitrogen depletion, and the risk for fractures
increases: A nurse is assessing a client who has Cushing's syndrome. Which of the
following findings should the nurse expect?
A. Vitiligo
B. Osteoporosis
C. Myxedema
D.Heat intolerance
7.A. A pearly, waxy nodule
A client who has basal cell carcinoma has a nodular lesion with well-defined borders
and a pearly or waxy appearance, resulting from overexposure to the sun, especially
on the face, head, and neck: A nurse is inspecting the skin of a client who has basal cell
carcinoma. The nurse should identify which of the following lesion characteristics on the
client's skin?
A. A pearly, waxy nodule
B. An irregular border on a variegated-colored lesion
, RN VATI Medical Surgery
2019
C. A firm, nodular, crusty, or ulcerated lesion
D. A weeping vesicle
8.A is correct. The nurse should tap the client's cheek just in front of the ear and
below the zygomatic arch. The client who has hypocalcemia w Chvostek'sillsign, display
which is a twitching of the facial muscle: A nurs a
a client who has hypocalcemia. In which of the following areas should tape is
on the client's face to detect the presence of Chvostek's sign? (Yo spots to assessing
select in the artwork below. Select only the hot spot that corr your answer.) the nurse
9.B. Low urine specific gravity
A client who has hyponatremia as a result of diuretic overuse has a low urine specific
gravity. The increased excretion of water alters the ratio of particulate matter, which
affects the specific gravity: A nurse in an emergency department is assessing a client who
is overusing prescribed diuretics and has a sodium level of 127 mEq/L. Which of the
following laboratory findings should the nurse expect?
a. High lipase
B. Low urine specific gravity
C. Low Hemoglobin
D. High creatine kinase-MB (CK-MB)
10.D. Review the daily schedule with the client every morning
The nurse should instruct the family member to use short, simple sentences when
explaining an activity to the client. The explanation should be done immediately
before the activity to aid the client's memory and ability to follow directions.: A home
health nurse is assisting a client with planning care for a family member who has
Alzheimer's disease. Which of the following instructions should the nurse include?
A. Remove clutter from room and hallways
B. Place a monthly calendar in the client's room
C. Use confrontation to manage the client's behavior
D.Review the daily schedule with the client every morning
11.C. Refractory hypoxemia
ARDS is a systemic inflammatory response to trauma, sepsis, burns, pancre- atitis,
and blood transfusions, when excess lung fluid dilutes surfactant ac- tivity in the
lungs. A client who has ARDS has refractory hypoxemia, which is hypoxemia that
does not improve with oxygen therapy. Extensive pulmonary edema evident on a
chest x-ray is a manifestation of ARDS: A nurse is caring for a client who has developed
acute respiratory distress syndrome (ARDS). Which of the following findings should the
nurse identify as a manifestation of this syndrome?
A. An audile pleural friction rub
