Test Bank For Lewiss Medical-Surgical Nursing, 12th Edition by
Mariann M. Harding, Jeffrey Kwong, Debra Hagler Chapter 1-
69 | 9780323789615 | All Chapters with Answers and
Rationals
A nurse is reviewing the medical record of a client who is receiving heparin therapy for treatment of
DVT. Which of the following interventions should the nurse anticipate taking if the client's aPTT is 96
seconds?
a. Increase the heparin infusion flow rate by 2 mL/hr
b. continue to monitor the heparin infusion as prescribed
c. request a prothrombin time
d. stop the heparin infusion - ANSWER: d
A nurse is providing teaching for a client who is 2 days post-op following a heart transplant. Which of
the following statements should the nurse include in the teaching?
a. "you may no longer be able to feel chest pain.
"b. "your level of activity tolerance will not change.
"c. "after 6 months, you will no longer need to restrict your sodium intake.
"d. "you will be able to stop taking immunosuppressants after 12 months." - ANSWER: a
A nurse is assess a client in the emergency room who has a bradydysrhythmia. Which of the following
findings should the nurse expect?
A. confusion
B. friction rub
C. hypertension
D. dry skin - ANSWER: a
A nurse in the emergency department is caring for a client who had an anterior MI. The client's
history reveals she is 1 week post-op open cholecystectomy. The nurse should recognize that which of
the following interventions is contraindicated?
A. administering IV morphine sulfate
B. administering oxygen at 2 :/min via nasal cannula
C. helping the client to the bedside commode
D. assisting with thrombolytic therapy - ANSWER: d
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse
recognize as a potential complication?
A. ventricular depolarization
B. Guillain-Barre syndrom
C. myelodysplastic syndrome
D. Valvular disease - ANSWER: D
A nurse is caring for a client who presents to the ER with a BP of 254/138 mmHg. The nurse
recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse
take first?
A. obtain blood samples for laboratory testing
B. Tell the client to report vision changes
C. Place the head of the bed at 45 degrees
D. initiate an IV - ANSWER: C
a nurse is caring for a client who has HF and is experiencing AF. The nurse should plan to monitor for
and report which of the following findings to the provider immediately?
a. slurred speech
b. irregular pulse
c. dependent edema
,d. persistent fatigue - ANSWER: a
A nurse is assessing a client who has left-sided HF. Which of the following manifestations should the
nurse expect to find?
a. inc abdominal girth
b. weak peripheral pulses
c. jugular vein distention
d. dependent edema - ANSWER: b
a nurse is caring for a client who is being treated for HF and has prescriptions for digoxin and
furosemide. The nurse should plan to monitor for which of the following as an adverse effect of these
medications?
a. SOB
b. lightheadedness
c. dry cough
d. metallic taste - ANSWER: b
a nurse is monitoring a client following coronary artery bypass graft surgery. Which of the following
findings can indicate cardiac tamponade?
a. sternal instability
b. inc WBC count
c. BP 140/82 mmHg on inspiration and 154/90 mmHg on expiration
d. sinus rhythm with occasional premature atrial contraction and HR 88/min - ANSWER: c
A nurse is preparing a client for coroncary angiography. The nurse should report which of the
following findings to the provider prior to the procedure?
a. hemoglobin 14.4 g/dL
b. history of peripheral arterial disease
c. urine output 200 mL/4 hr
d. previous allergic reaction to shellfish - ANSWER: d
A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following
client statements indicates a potential complication of the insertion procedure?
a. "I can't get rid of these hiccups.
"b. "I feel dizzy when i stand.
"c. "My incision site stings."
d. "I have a headache." - ANSWER: a
A nurse is providing discharge teaching for a client who has a prescription for the transdermal
nitroglycerin patch. Which of the following instructions should the nurse include in the teaching?
a. apply the new patch to the same site as the previous patch
b. place the patch on an area of skin away from skin folds and joints
c. keep the patch on 24 hr per day
d. replace the patch at the onset of angina - ANSWER: b
A nurse is caring for a client in the first hour following an aortic aneurysm repair. Which of the
following findings can indicate shock and should be reported to the provider?
a. serosanguinous drainage on dressing
b. severe pain with coughing
c. urine output of 20 mL/hr
d. increase in temp from 36.C (98.2F)- 37.5C (99.5F) - ANSWER: c
A nurse caring for a client following an abdominal aortic aneurysm resection. Which of the following is
the priority assessment for this client?
a. neck vein distention
b. bowel sounds
c. peripheral edema
, d. urine output - ANSWER: d
A nurse is watching a client's ECG monitor and notes that the client's rhythm has changed from a
normal sinus rhythm to supraventricular tachycardia. The client is conscious with a HR of 200-210
bpm and has a faint radial pulse. The nurse should anticipate assisting with which of the following
interventions?
a. delivery of precordial thump
b. vagal stimulation
c. administration of atropine IV
d. defibrillation - ANSWER: b
A nurse is providing discharge teaching for a client who has HF. The nurse should instruct the client to
report which of the following findings immediately to the provider?
a. weight gain of 2 lb in 24 hr
b. inc of 10 mmHg in systolic BP
c. dyspnea with exertion
d. dizziness when rising quickly - ANSWER: a
A nurse is admitting a client who has a leg ulcer and a history of DM. The nurse should use which of
the following focused assessments to help differentiate between an arterial ulcer and a venous stasis
ulcer?
a. explore the clients family history of peripheral vascular disease
b. note the presence or absence of pain at the ulcer site
c. inquire about the presence or absence of claudication
d. ask if the client has had a recent infection - ANSWER: c
A nurse is reviewing the laboratory results of several clients who have peripheral arterial disease. The
nurse should plan to provide dietary teaching for the client who has which laboratory values?
a. Cholesterol 180 mg/dL, HDL 70 mg/dL, LDL 90 mg/dL
b. Cholesterol 185 mg/dL, HDL 50 mg/dL, LDL 120 mg/dL
c. Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL
d. Cholesterol 195 mg/dL, HDL 55 mg/dL, LDL 125 mg/dL - ANSWER: c
a nurse is providing health teaching for a group of clients. Which of the following clients is at risk for
developing peripheral arterial disease?
a. a client who has hypothyroidism
b. a client who has DM
c. a client whose daily caloric intake consists of 25% fat
d. a client who consumes two bottles of beer a day - ANSWER: b
a nurse is planning a presentation about hypertension for a community women's group. which of the
following lifestyle modifications should the nurse include (select all that apply)
a. limited alcohol intake
b. regular exercise program
c. dec Mg intake
d. reduced K intake
e. smoking cessation - ANSWER: a, b, e
A nurse is caring for a client in the first 8 hr following coronary artery bypass graft surgery. Which of
the following client findings should the nurse report to the provider?
a. mediastinal drainage 100 mL/hr
b. BP 160/80 mmHg
c. Temp 37.1 (98.8)
d. K 3.8 mEq/L - ANSWER: b
Mariann M. Harding, Jeffrey Kwong, Debra Hagler Chapter 1-
69 | 9780323789615 | All Chapters with Answers and
Rationals
A nurse is reviewing the medical record of a client who is receiving heparin therapy for treatment of
DVT. Which of the following interventions should the nurse anticipate taking if the client's aPTT is 96
seconds?
a. Increase the heparin infusion flow rate by 2 mL/hr
b. continue to monitor the heparin infusion as prescribed
c. request a prothrombin time
d. stop the heparin infusion - ANSWER: d
A nurse is providing teaching for a client who is 2 days post-op following a heart transplant. Which of
the following statements should the nurse include in the teaching?
a. "you may no longer be able to feel chest pain.
"b. "your level of activity tolerance will not change.
"c. "after 6 months, you will no longer need to restrict your sodium intake.
"d. "you will be able to stop taking immunosuppressants after 12 months." - ANSWER: a
A nurse is assess a client in the emergency room who has a bradydysrhythmia. Which of the following
findings should the nurse expect?
A. confusion
B. friction rub
C. hypertension
D. dry skin - ANSWER: a
A nurse in the emergency department is caring for a client who had an anterior MI. The client's
history reveals she is 1 week post-op open cholecystectomy. The nurse should recognize that which of
the following interventions is contraindicated?
A. administering IV morphine sulfate
B. administering oxygen at 2 :/min via nasal cannula
C. helping the client to the bedside commode
D. assisting with thrombolytic therapy - ANSWER: d
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse
recognize as a potential complication?
A. ventricular depolarization
B. Guillain-Barre syndrom
C. myelodysplastic syndrome
D. Valvular disease - ANSWER: D
A nurse is caring for a client who presents to the ER with a BP of 254/138 mmHg. The nurse
recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse
take first?
A. obtain blood samples for laboratory testing
B. Tell the client to report vision changes
C. Place the head of the bed at 45 degrees
D. initiate an IV - ANSWER: C
a nurse is caring for a client who has HF and is experiencing AF. The nurse should plan to monitor for
and report which of the following findings to the provider immediately?
a. slurred speech
b. irregular pulse
c. dependent edema
,d. persistent fatigue - ANSWER: a
A nurse is assessing a client who has left-sided HF. Which of the following manifestations should the
nurse expect to find?
a. inc abdominal girth
b. weak peripheral pulses
c. jugular vein distention
d. dependent edema - ANSWER: b
a nurse is caring for a client who is being treated for HF and has prescriptions for digoxin and
furosemide. The nurse should plan to monitor for which of the following as an adverse effect of these
medications?
a. SOB
b. lightheadedness
c. dry cough
d. metallic taste - ANSWER: b
a nurse is monitoring a client following coronary artery bypass graft surgery. Which of the following
findings can indicate cardiac tamponade?
a. sternal instability
b. inc WBC count
c. BP 140/82 mmHg on inspiration and 154/90 mmHg on expiration
d. sinus rhythm with occasional premature atrial contraction and HR 88/min - ANSWER: c
A nurse is preparing a client for coroncary angiography. The nurse should report which of the
following findings to the provider prior to the procedure?
a. hemoglobin 14.4 g/dL
b. history of peripheral arterial disease
c. urine output 200 mL/4 hr
d. previous allergic reaction to shellfish - ANSWER: d
A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following
client statements indicates a potential complication of the insertion procedure?
a. "I can't get rid of these hiccups.
"b. "I feel dizzy when i stand.
"c. "My incision site stings."
d. "I have a headache." - ANSWER: a
A nurse is providing discharge teaching for a client who has a prescription for the transdermal
nitroglycerin patch. Which of the following instructions should the nurse include in the teaching?
a. apply the new patch to the same site as the previous patch
b. place the patch on an area of skin away from skin folds and joints
c. keep the patch on 24 hr per day
d. replace the patch at the onset of angina - ANSWER: b
A nurse is caring for a client in the first hour following an aortic aneurysm repair. Which of the
following findings can indicate shock and should be reported to the provider?
a. serosanguinous drainage on dressing
b. severe pain with coughing
c. urine output of 20 mL/hr
d. increase in temp from 36.C (98.2F)- 37.5C (99.5F) - ANSWER: c
A nurse caring for a client following an abdominal aortic aneurysm resection. Which of the following is
the priority assessment for this client?
a. neck vein distention
b. bowel sounds
c. peripheral edema
, d. urine output - ANSWER: d
A nurse is watching a client's ECG monitor and notes that the client's rhythm has changed from a
normal sinus rhythm to supraventricular tachycardia. The client is conscious with a HR of 200-210
bpm and has a faint radial pulse. The nurse should anticipate assisting with which of the following
interventions?
a. delivery of precordial thump
b. vagal stimulation
c. administration of atropine IV
d. defibrillation - ANSWER: b
A nurse is providing discharge teaching for a client who has HF. The nurse should instruct the client to
report which of the following findings immediately to the provider?
a. weight gain of 2 lb in 24 hr
b. inc of 10 mmHg in systolic BP
c. dyspnea with exertion
d. dizziness when rising quickly - ANSWER: a
A nurse is admitting a client who has a leg ulcer and a history of DM. The nurse should use which of
the following focused assessments to help differentiate between an arterial ulcer and a venous stasis
ulcer?
a. explore the clients family history of peripheral vascular disease
b. note the presence or absence of pain at the ulcer site
c. inquire about the presence or absence of claudication
d. ask if the client has had a recent infection - ANSWER: c
A nurse is reviewing the laboratory results of several clients who have peripheral arterial disease. The
nurse should plan to provide dietary teaching for the client who has which laboratory values?
a. Cholesterol 180 mg/dL, HDL 70 mg/dL, LDL 90 mg/dL
b. Cholesterol 185 mg/dL, HDL 50 mg/dL, LDL 120 mg/dL
c. Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL
d. Cholesterol 195 mg/dL, HDL 55 mg/dL, LDL 125 mg/dL - ANSWER: c
a nurse is providing health teaching for a group of clients. Which of the following clients is at risk for
developing peripheral arterial disease?
a. a client who has hypothyroidism
b. a client who has DM
c. a client whose daily caloric intake consists of 25% fat
d. a client who consumes two bottles of beer a day - ANSWER: b
a nurse is planning a presentation about hypertension for a community women's group. which of the
following lifestyle modifications should the nurse include (select all that apply)
a. limited alcohol intake
b. regular exercise program
c. dec Mg intake
d. reduced K intake
e. smoking cessation - ANSWER: a, b, e
A nurse is caring for a client in the first 8 hr following coronary artery bypass graft surgery. Which of
the following client findings should the nurse report to the provider?
a. mediastinal drainage 100 mL/hr
b. BP 160/80 mmHg
c. Temp 37.1 (98.8)
d. K 3.8 mEq/L - ANSWER: b
