Med Surg Final Quiz Q & A Graded A

A nurse is planning dietary teaching for a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first? Ask the client to identify the types of foods she prefers. the nurse should first ask the client about individual food preferences to provide an opportunity for the nurse to include these foods in her diet. Involving the client in the planning will help promote her adherence to the dietary plan. A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect? Diaphoresis a client who has a blood glucose level below 70 mg/dL to exhibit manifestations of hypoglycemia. Expected findings associated with hypoglycemia include weakness, hunger, diaphoresis, nausea, shakiness, and confusion A nurse is caring for a client who is 72 hr postoperative following an above-the-knee amputation. Which of the following actions should the nurse take? Assist the client to a prone position every 4 hr. because it reduces the risk of flexion contractures. A nurse is providing teaching to a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse make? (Select all that apply.) Take allopurinol as prescribed. Exercise several times a week. Limit intake of foods high in purine. A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? Clear fluid coming from the nares The nurse should identify cerebrospinal fluid, which appears as a clear fluid, coming from the nares or ears as an indication of a basilar skull fracture. A nurse is teaching a client how to perform a breast self exam (BSE). The nurse should identify which of the following findings as an indication of breast cancer? A nontender, hard lump that is palpated in one breast A nurse is providing discharge teaching about improving gas exchange to a client who has emphysema. Which of the following instructions should the nurse include in the teaching? Use pursed-lip breathing during periods of dyspnea. A nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit of 24%. Prior to initiating a transfusion of packed red blood cells (RBCs), which of the following actions should the nurse take? (Select all that apply.) Assess and document the client's vital signs. Verify with another nurse the blood type and Rh of the packed RBCs. Change IV tubing to a set that has a filter. A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) should the nurse don prior to providing client care? (Select all that apply.) Gown Gloves A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first? Lower the client to the floor. if a client begins to have a seizure while sitting or standing, the nurse should first lower the client to the floor to protect him from injury. A nurse is caring for a client following a hip arthroplasty. The nurse places an abduction pillow on the client for which of the following purposes? Preventing dislocation of the hip during position changes or movement Following surgery, the nurse should use an abduction pillow to prevent dislocation of the new hip joint. The nurse should place the wedge-shaped pillow between the client's legs. The purpose of the abduction pillow is to prevent adduction beyond the midline of the body during position changes or client movement, which can lead to subluxation or total dislocation of the hip joint. A nurse in the emergency department is caring for a client who has fruity breath odor, dry mouth, and extreme thirst. Which of the following assessments should the nurse make? Blood glucose level A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? Check the client's pain level. A nurse is providing postoperative care for a client who has two chest tubes in place following a lobectomy. The client asks the nurse the reason for having two chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons? Draining blood and fluid from the pleural space A nurse is providing teaching to a client who has stomatitis due to chemotherapy and radiation therapy. Which of the following statements by the client indicates a need for further teaching? "I will use lemon and glycerine swabs after meals." they cause drying and irritation of the mucous membrane A nurse is providing discharge teaching to a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching? "I should check my heart rate at the same time each day." The nurse should instruct the client to check his heart rate at the same time each day and to document the rate in a log for communication with the provider. A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mm HG, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances? Respiratory alkalosis A nurse is preparing to care for a group of clients after receiving change-of-shift report. Which of the following clients should the nurse assess first? A client who has emphysema and reports dyspnea The nurse should apply the ABC priority-setting framework. A nurse is obtaining a weekly weight for a client who has obesity and osteoarthritis and is on a weight management program. The nurse determines that the client gained 1.36 kg (3 lb) in the past week. Which of the following statements should the nurse make? "Were there any issues last week that kept you from focusing on your diet?" The nurse should use an open-ended question that allows the client to reassess the past week in a non-threatening manner A nurse is caring for a client who is receiving intermittent peritoneal dialysis. The nurse observes that the peritoneal fluid is not adequately draining. Which of the following actions should the nurse take? Turn the client from side to side. Turn the patient side to side to facilitate removal of peritoneal drainage. This action helps ensure there are no kinks in the tubing or an air lock in the peritoneal catheter. A nurse is providing teaching to a client who has tuberculosis (TB) and a prescription for isoniazid. Which of the following instructions should the nurse include? "You should take this medication on an empty stomach." The nurse should instruct the client to take isoniazid on an empty stomach to improve absorption of the medication. To ensure the stomach is empty, the client should take the medication either 1 hr before or 2 hr after a meal. A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider? Viscous urinary output with clots The nurse should report urine output that is bright red with clots or urine that resembles ketchup to the provider because this is an indication of arterial bleeding. A nurse is providing discharge teaching to an adult female client who has infective endocarditis about how to prevent recurrence. Which of the following statements by the client indicates understanding of the teaching? "I will notify my doctor before I have dental procedures." The nurse should inform the client of ways to decrease the risk of recurrence of infective endocarditis. The client should notify the provider prior to invasive or dental procedures due to the need for prophylactic antibiotic therapy to reduce the risk of a streptococcal infection. A nurse is providing teaching about antiretroviral medication therapy to a client who has a new diagnosis of AIDS. Which of the following statements should the nurse include in the teaching? "You should take antiretroviral medications on a routine schedule." A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should the nurse include in the client's plan of care? Encourage increased fluid intake. because dehydration increases the viscosity of the blood, which can increase sickling and client discomfort.