Medical Surgical Assessment A v v v
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1. A nurse is reviewing the laboratory results of a client who is scheduled for a
v v v v v v v v v v v v v v v v
CT scan with an IV contrast agent. Which of the following laboratory findings s
v v v v v v v v v v v v v
hould the nurse report to the provider prior to the procedure?
v v v v v v v v v v
A) Sodium 136 mEq/L v v
B) Potassium 4.8 mEq/L v v
C) Creatinine 1.9 mg/dL v v
D) Calcium 10 mg/dL: C) Creatinine 1.9 mg/dL v v v v v v
Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse
v v v v v v v v v v v v v
should report the finding to the provider before the client has a CT scan with an IV cont
v v v v v v v v v v v v v v v v v
rast agent. This finding places the client at risk for developing contrast-
v v v v v v v v v v v
induced nephropathy. v
2. A nurse is monitoring a client who is taking acarbose. Which of the following
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findings should the nurse identify as an adverse effect of the medication?
v v v v v v v v v v v
A) Polyuria
B) Abdominal cramps v
C) Renal insufficiency v
D) Insomnia: B) Abdominal cramps v v v
Acarbose affects the gastrointestinal system. Therefore, the nurse should monitor the
v v v v v v v v v v
vclient for abdominal cramping, rumbling bowel sounds, and diarrhea as adverse effec
v v v v v v v v v v v
ts of this medication.
v v v
3. A nurse is assisting with the care of a client who had a cardiac catheterizatio
v v v v v v v v v v v v v v v
n via the right femoral artery. Which of the following actions should the nurse ta
v v v v v v v v v v v v v v
ke to prevent postprocedure complications? (Select all)
v v v v v v
A) Monitor the insertion site for bleeding v v v v v
B) Position the affected extremity at a 45 degree angle v v v v v v v v
C) Restrict the client's fluid intake v v v v
D) Maintain the pressure dressing v v v
E) Check the client's peripheral pulses: A) Monitor the insertion site for bleeding
v v v v v v v v v v v
The nurse should monitor the client's insertion site for manifestations of hemorrhagin
v v v v v v v v v v v
g.
1v/v32
, Medical Surgical Assessment A v v v
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D) Maintain the pressure dressing.
v v v v
The nurse should maintain the client's pressure dressing to prevent hemorrhaging a
v v v v v v v v v v v
nd allow for the cannulation site to heal. E) Check the client's peripheral pulses.
v v v v v v v v v v v v v
The nurse should assess the client's peripheral pulses to help identify signs of arterial
v v v v v v v v v v v v v v
occlusion.
4. A nurse is contributing to the plan of care for a client who has chronic obstru
v v v v v v v v v v v v v v v v
ctive pulmonary disease (COPD) and is dyspneic. Which of the following interv
v v v v v v v v v v v
entions should the nurse include in the plan?
v v v v v v v
A) Encourage abdominal breathing v v
B) Direct the client to inhale with pursed lips
v v v v v v v
C) Set the oxygen therapy at 5L/min
v v v v v
D) Instruct the client to lean back while coughing: A) Encourage abdominal breat
v v v v v v v v v v v
hing
The nurse should encourage abdominal breathing, which reduces the workload on th
v v v v v v v v v v v
e accessory muscles of respiration during dyspneic episodes.
v v v v v v v
5. A nurse is preparing to administer phytonadione 7 mg subcutaneously to
v v v v v v v v v v v
a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many m
v v v v v v v v v v v v v v v
L should the nurse administer? (Round the answer to the nearest tenth. Use a l
v v v v v v v v v v v v v v
eading zero is it applies. Do not use a trailing zero.: 7mg/10 mg *1mL= 0.7 mL
v v v v v v v v v v v v v v v
6. A nurse is examining a client's IV site and notes a red line up his arm. The c
v v v v v v v v v v v v v v v v v
lient reports a throbbing, burning pain at the IV site. The nurse should identify t
v v v v v v v v v v v v v v
hat the client's manifestations indicate which of the following complications of
v v v v v v v v v v
vIV therapy?v
A) Thrombophlebitis
B) Infiltration
C) Hematoma
D) Venous spasms: A) Thrombophlebitis v v v
The nurse should identify pain, warmth, and a red streak up the arm as indications of t
v v v v v v v v v v v v v v v v
hrombophlebitis.
2v/v32
, Medical Surgical Assessment A v v v
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7. A nurse is reinforcing teaching about management of constipation with a cl
v v v v v v v v v v v v
ient who has hypothyroidism. Which of the following should the nurse includ
v v v v v v v v v v v
e in the teaching?
v v v
A) Increase intake of fiber-rich foods v v v v
B) Take a laxative every morning
v v v v
C) Maintain a fluid intake of 1200 mL per day v v v v v v v v
D) Limit activity to preserve energy: A) Increase intake of fiber-rich foods
v v v v v v v v v v
The nurse should instruct the client to increase the amount of fiber-
v v v v v v v v v v v
rich foods in his diet. Dried beans and brown rice are examples of fiber-rich foods.
v v v v v v v v v v v v v v
8. A nurse is caring for a client who has a compound fracture of the femur and w
v v v v v v v v v v v v v v v v v
as placed in balanced suspension skeletal traction 4 days ago. Which of the foll
v v v v v v v v v v v v v
owing actions should the nurse take?
v v v v v
A) Perform pin site care daily v v v v
B) Remove the overbed trapeze v v v
C) Remove the boot every 2 hr v v v v v
D) Keep the weights on a stable, flat surface: A) Perform pin site care daily
v v v v v v v v v v v v v
The nurse should perform pin site care daily with chlorhexidine solution or use a soluti
v v v v v v v v v v v v v v
on according to facility protocol. The nurse should also monitor the pin sites for manife
v v v v v v v v v v v v v v
stations of infection. v v
9. A nurse observes a client who is lying in bed experiencing a tonic-
v v v v v v v v v v v v v
clonic seizure. Which of the following actions should the nurse take?
v v v v v v v v v v
A) Lower the side rails of the client's bed
v v v v v v v
B) Apply wrist restraints to the client
v v v v v
C) Position the client in the semi-Fowler's position v v v v v v
D) Loosen clothing around the client's neck: D) Loosen clothing around the client'
v v v v v v v v v v v
s neck v
The nurse should loosen clothing around the client's neck to maintain an open airway
v v v v v v v v v v v v v v
and prevent aspiration.
v v
3v/v32
, Medical Surgical Assessment A v v v
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10. A nurse is contributing to the plan of care for a client who has multiple scler
v v v v v v v v v v v v v v v v
osis and is taking dantrolene to manage muscle spasms. Which of the followin
v v v v v v v v v v v v
g interventions should the nurse include?
v v v v v
A) Apply hot packs to the client's muscles v v v v v v
B) Schedule physical therapy in the afternoon v v v v v
C) Encourage the client to complete ADLs v v v v v
D) Administer valerian to promote sleep: C) Encourage the client to complete ADL v v v v v v v v v v v
s
The nurse should encourage the client to complete ADLs and provide assistance as n
v v v v v v v v v v v v v
eeded. Performing self- v v
care increases the client's independence, strength, and level of functioning.
v v v v v v v v v
11. A nurse is reinforcing discharge teaching to prevent dumping syndrome for
v v v v v v v v v v v
a client following a partial gastrectomy for ulcers. Which of the following infor
v v v v v v v v v v v v v
mation should the nurse include in the teaching?
v v v v v v v
A) Avoid liquids at mealtimes v v v
B) Exclude eating starchy vegetables v v v
C) Avoid eating high-protein meals v v v
D) Plan to increase intake of sweetened fruits: A) Avoid liquids at mealtimes
v v v v v v v v v v v
The nurse should remind the client to avoid drinking liquids at mealtimes to prevent th
v v v v v v v v v v v v v v
e food from emptying into the small bowel too quickly.
v v v v v v v v v
12. A nurse is collecting data from a client who has heart failure and is taking di
v v v v v v v v v v v v v v v v
goxin. Which of the following outcomes from the medication should the nurse
v v v v v v v v v v v v
expect?
A) Increased weight v
B) Increased heart rate v v
C) Decreased urinary output v v
D) Decreased shortness of breath: D) Decreased shortness of breath v v v v v v v v
The nurse should expect the client to have decreased shortness of breath. Digoxin inc
v v v v v v v v v v v v v
reases the contractility of the heart, which decreases pulmonary congestion.
v v v v v v v v v
4v/v32
Studyvonlinevatvhttps://quizlet.com/_8awv9t
1. A nurse is reviewing the laboratory results of a client who is scheduled for a
v v v v v v v v v v v v v v v v
CT scan with an IV contrast agent. Which of the following laboratory findings s
v v v v v v v v v v v v v
hould the nurse report to the provider prior to the procedure?
v v v v v v v v v v
A) Sodium 136 mEq/L v v
B) Potassium 4.8 mEq/L v v
C) Creatinine 1.9 mg/dL v v
D) Calcium 10 mg/dL: C) Creatinine 1.9 mg/dL v v v v v v
Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse
v v v v v v v v v v v v v
should report the finding to the provider before the client has a CT scan with an IV cont
v v v v v v v v v v v v v v v v v
rast agent. This finding places the client at risk for developing contrast-
v v v v v v v v v v v
induced nephropathy. v
2. A nurse is monitoring a client who is taking acarbose. Which of the following
v v v v v v v v v v v v v v v
findings should the nurse identify as an adverse effect of the medication?
v v v v v v v v v v v
A) Polyuria
B) Abdominal cramps v
C) Renal insufficiency v
D) Insomnia: B) Abdominal cramps v v v
Acarbose affects the gastrointestinal system. Therefore, the nurse should monitor the
v v v v v v v v v v
vclient for abdominal cramping, rumbling bowel sounds, and diarrhea as adverse effec
v v v v v v v v v v v
ts of this medication.
v v v
3. A nurse is assisting with the care of a client who had a cardiac catheterizatio
v v v v v v v v v v v v v v v
n via the right femoral artery. Which of the following actions should the nurse ta
v v v v v v v v v v v v v v
ke to prevent postprocedure complications? (Select all)
v v v v v v
A) Monitor the insertion site for bleeding v v v v v
B) Position the affected extremity at a 45 degree angle v v v v v v v v
C) Restrict the client's fluid intake v v v v
D) Maintain the pressure dressing v v v
E) Check the client's peripheral pulses: A) Monitor the insertion site for bleeding
v v v v v v v v v v v
The nurse should monitor the client's insertion site for manifestations of hemorrhagin
v v v v v v v v v v v
g.
1v/v32
, Medical Surgical Assessment A v v v
Studyvonlinevatvhttps://quizlet.com/_8awv9t
D) Maintain the pressure dressing.
v v v v
The nurse should maintain the client's pressure dressing to prevent hemorrhaging a
v v v v v v v v v v v
nd allow for the cannulation site to heal. E) Check the client's peripheral pulses.
v v v v v v v v v v v v v
The nurse should assess the client's peripheral pulses to help identify signs of arterial
v v v v v v v v v v v v v v
occlusion.
4. A nurse is contributing to the plan of care for a client who has chronic obstru
v v v v v v v v v v v v v v v v
ctive pulmonary disease (COPD) and is dyspneic. Which of the following interv
v v v v v v v v v v v
entions should the nurse include in the plan?
v v v v v v v
A) Encourage abdominal breathing v v
B) Direct the client to inhale with pursed lips
v v v v v v v
C) Set the oxygen therapy at 5L/min
v v v v v
D) Instruct the client to lean back while coughing: A) Encourage abdominal breat
v v v v v v v v v v v
hing
The nurse should encourage abdominal breathing, which reduces the workload on th
v v v v v v v v v v v
e accessory muscles of respiration during dyspneic episodes.
v v v v v v v
5. A nurse is preparing to administer phytonadione 7 mg subcutaneously to
v v v v v v v v v v v
a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many m
v v v v v v v v v v v v v v v
L should the nurse administer? (Round the answer to the nearest tenth. Use a l
v v v v v v v v v v v v v v
eading zero is it applies. Do not use a trailing zero.: 7mg/10 mg *1mL= 0.7 mL
v v v v v v v v v v v v v v v
6. A nurse is examining a client's IV site and notes a red line up his arm. The c
v v v v v v v v v v v v v v v v v
lient reports a throbbing, burning pain at the IV site. The nurse should identify t
v v v v v v v v v v v v v v
hat the client's manifestations indicate which of the following complications of
v v v v v v v v v v
vIV therapy?v
A) Thrombophlebitis
B) Infiltration
C) Hematoma
D) Venous spasms: A) Thrombophlebitis v v v
The nurse should identify pain, warmth, and a red streak up the arm as indications of t
v v v v v v v v v v v v v v v v
hrombophlebitis.
2v/v32
, Medical Surgical Assessment A v v v
Studyvonlinevatvhttps://quizlet.com/_8awv9t
7. A nurse is reinforcing teaching about management of constipation with a cl
v v v v v v v v v v v v
ient who has hypothyroidism. Which of the following should the nurse includ
v v v v v v v v v v v
e in the teaching?
v v v
A) Increase intake of fiber-rich foods v v v v
B) Take a laxative every morning
v v v v
C) Maintain a fluid intake of 1200 mL per day v v v v v v v v
D) Limit activity to preserve energy: A) Increase intake of fiber-rich foods
v v v v v v v v v v
The nurse should instruct the client to increase the amount of fiber-
v v v v v v v v v v v
rich foods in his diet. Dried beans and brown rice are examples of fiber-rich foods.
v v v v v v v v v v v v v v
8. A nurse is caring for a client who has a compound fracture of the femur and w
v v v v v v v v v v v v v v v v v
as placed in balanced suspension skeletal traction 4 days ago. Which of the foll
v v v v v v v v v v v v v
owing actions should the nurse take?
v v v v v
A) Perform pin site care daily v v v v
B) Remove the overbed trapeze v v v
C) Remove the boot every 2 hr v v v v v
D) Keep the weights on a stable, flat surface: A) Perform pin site care daily
v v v v v v v v v v v v v
The nurse should perform pin site care daily with chlorhexidine solution or use a soluti
v v v v v v v v v v v v v v
on according to facility protocol. The nurse should also monitor the pin sites for manife
v v v v v v v v v v v v v v
stations of infection. v v
9. A nurse observes a client who is lying in bed experiencing a tonic-
v v v v v v v v v v v v v
clonic seizure. Which of the following actions should the nurse take?
v v v v v v v v v v
A) Lower the side rails of the client's bed
v v v v v v v
B) Apply wrist restraints to the client
v v v v v
C) Position the client in the semi-Fowler's position v v v v v v
D) Loosen clothing around the client's neck: D) Loosen clothing around the client'
v v v v v v v v v v v
s neck v
The nurse should loosen clothing around the client's neck to maintain an open airway
v v v v v v v v v v v v v v
and prevent aspiration.
v v
3v/v32
, Medical Surgical Assessment A v v v
Studyvonlinevatvhttps://quizlet.com/_8awv9t
10. A nurse is contributing to the plan of care for a client who has multiple scler
v v v v v v v v v v v v v v v v
osis and is taking dantrolene to manage muscle spasms. Which of the followin
v v v v v v v v v v v v
g interventions should the nurse include?
v v v v v
A) Apply hot packs to the client's muscles v v v v v v
B) Schedule physical therapy in the afternoon v v v v v
C) Encourage the client to complete ADLs v v v v v
D) Administer valerian to promote sleep: C) Encourage the client to complete ADL v v v v v v v v v v v
s
The nurse should encourage the client to complete ADLs and provide assistance as n
v v v v v v v v v v v v v
eeded. Performing self- v v
care increases the client's independence, strength, and level of functioning.
v v v v v v v v v
11. A nurse is reinforcing discharge teaching to prevent dumping syndrome for
v v v v v v v v v v v
a client following a partial gastrectomy for ulcers. Which of the following infor
v v v v v v v v v v v v v
mation should the nurse include in the teaching?
v v v v v v v
A) Avoid liquids at mealtimes v v v
B) Exclude eating starchy vegetables v v v
C) Avoid eating high-protein meals v v v
D) Plan to increase intake of sweetened fruits: A) Avoid liquids at mealtimes
v v v v v v v v v v v
The nurse should remind the client to avoid drinking liquids at mealtimes to prevent th
v v v v v v v v v v v v v v
e food from emptying into the small bowel too quickly.
v v v v v v v v v
12. A nurse is collecting data from a client who has heart failure and is taking di
v v v v v v v v v v v v v v v v
goxin. Which of the following outcomes from the medication should the nurse
v v v v v v v v v v v v
expect?
A) Increased weight v
B) Increased heart rate v v
C) Decreased urinary output v v
D) Decreased shortness of breath: D) Decreased shortness of breath v v v v v v v v
The nurse should expect the client to have decreased shortness of breath. Digoxin inc
v v v v v v v v v v v v v
reases the contractility of the heart, which decreases pulmonary congestion.
v v v v v v v v v
4v/v32
