MED SURG A - (2022)

MED SURG A A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experiencing increased intracranial pressure (ICP)? (Select all that apply.) A. Flat jugular veins B. A Glasgow Coma Scale score of 15 C. Sleepiness exhibited by the client D. Widening pulse pressure E. Decerebrate posturing ANS - C, D, E A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion? A. Enoxaparin B. Metformin C. Diazepam D. Digoxin ANS - D. Digoxin A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority? A. Anorexia B. Abdominal pain radiating to the right shoulder C. Tachycardia D. Rebound abdominal tenderness ANS - C. Tachycardia A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the client's bedside? A. Suction machine B. Wire cutters C. Padded clamp D. Communication board ANS - A. Suction machine A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse's priority? A. Loosen the clothing around the client's neck B. Check the client's pupillary response C. Turn the client to the side D. Move furniture away from the client ANS - C. Turn the client to the side A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication? A. Ginkgo biloba B. Glucosamine C. Calcium D. Vitamin C ANS - C. Calcium A nurse is planning to irrigate and dress a clean, granulating would for a client who has a pressure injury. Which of the following actions should the nurse take? A. Apply a wet-to-dry gauze dressing B. Irrigate with hydrogen peroxide solution C. Use a 30-mL syringe D. Attach a 24-gauge angiocatheter to the syringe ANS - C. Use a 30-mL syringe A nurse is providing teaching to a female client who has a history of urinary tract infections (UTIs). Which of the following information should the nurse include in the teaching? A. Avoid foods that are high in ascorbic acid B. Add oatmeal to the water when taking a tub bath C. Urinate every 6 hr D. Take daily cranberry supplements ANS - D. Take daily cranberry supplements A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A. "I will was the ink markings off the radiation area after each treatment." B. "I will use my hands rather than a washcloth to clean the radiation area." C. "I will be able to be out of the sun 1 month after my radiation treatments are over." D. "I will use a heating pad on my neck if it becomes sore during the radiation therapy." ANS - B. "I will use my hands rather than a washcloth to clean the radiation area." A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority? A. Initiate oxygen at 2 L/min via nasal cannula B. Apply firm pressure to the insertion site C. Take the client's vital signs D. Obtain a stat order for an aPTT ANS - B. Apply firm pressure to the insertion site A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding Which of the following actions should the nurse take first? A. Obtain ABGs B. Administer propofol to the client C. Instruct the client to allow the machine to breathe for them D. Disconnect the machine and manually ventilate the client ANS - C. Instruct the client to allow the machine to breathe for them A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory values should the nurse expect? A. Decreased prothrombin time B. Elevated bilirubin level C. Decreased ammonia level D. Elevated albumin level ANS - B. Elevated bilirubin level A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A. "I should avoid walking as much as possible." B. "I should sit down and read for several hours a day." C. "I will wear clean graduated compression stockings every day." D. "I will keep my legs level with my body when I sleep at night." ANS - C. "I will wear clean graduated compression stockings every day." A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following laboratory values should the nurse report to the provider? A. Potassium 4 mEq/L B. WBC count 10,000/mm^3 C. Hct 45% D. Hgb 8 g/dL ANS - D. Hgb 8 g/dL The nurse should report an Hgb level of 8 g/dL, which is below the expected reference range and is an indicator of postoperative hemorrhage or anemia A nurse is caring for a client who has a stage III pressure injury. Which of the following findings contributes to delayed wound healing? A. WBC count 6,000/mm^3 B. BMI 24 C. Urine output 25 mL/hr D. Albumin 4 g/dL ANS - C. Urine output 25 mL/hr Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing. A nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in their hands. Which of the following medications should the nurse plan to administer? A. Epoetin alfa B. Furosemide C. Captopril D. Calcium carbonate ANS - D. Calcium carbonate Hypocalcemia is a manifestation of ESKD and an adverse effect of dialysis. Often occurring late in the dialysis session, hypocalcemia can cause the client to experience muscle cramping and tingling to extremities. The nurse should plan to administer a calcium supplement, such as calcium carbonate, as a calcium replacement. A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which of the following actions should the nurse include in the client's plan of care? A. Collect and place the client's urine and feces in a biohazard bag B. Limit the client's ambulation to their own room C. Wear a lead apron while providing care to the client D. Limit each visitor to 1 hr per day ANS - C. Wear a lead apron while providing care to the client A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take? A. Remain with the client for the first 15 min of the infusion B. Prime the blood administration IV tubing with lactated Ringer's solution C. Verify the client's identity by using the client's room number prior to starting the transfusion D. Infuse the unit of packed RBCs within 8 hr ANS - A. Remain with the client for the first 15 min of the infusion A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after hospitalization for heart failure. Based on the information in the client's chart, which of the following findings should the nurse report to the provider? A. Potassium 4.1 mEq/L B. Heart rate 55/min C. SaO2 92% D. Weight 67.1 kg (148 lb) ANS - B. Heart rate 55/min A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect? A. Positive Trousseau's sign B. 4+ deep tendon reflexes C. Deep respirations D. Hypoactive bowel sounds ANS - D. Hypoactive bowel sounds A nurse is providing dietary teaching to a client who is postoperative following a thyroidectomy with removal of the parathyroid glands. The nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in her diet? A. 12 almonds B. One small banana C. 1 tbsp peanut butter D. 1/2 cup tomato juice ANS - A. 12 almonds A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To help reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client to avoid? A. Shellfish B. Aged cheese C. Peppermint candy D. Enriched pasta ANS - B. Aged cheese A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? A. Heart rate 110/min B. Blood pressure 138/90 mm Hg C. Urine specific gravity 1.020 D. BUN 15 mg/dL ANS - A. Heart rate 110/min A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching? A. "I will monitor my blood sugar carefully because the medication increases the secretion of insulin." B. "I should take this medication with a meal." C. "I can expect to gain weight while taking this medication." D. "While taking this medication, I will experience flushing of my skin." ANS - B. "I should take this medication with a meal." A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first? A. Obtain a sputum sample B. Administer antipyretics C. Provide hand hygiene education D. Initiate airborne precautions ANS - D. Initiate airborne precautions A nurse is performing a cardiac assessment for a client who had a myocardial infarction 2 days ago. Which of the following actions should the nurse take first after hearing the following sound? A. Obtain a 12-lead ECG for the client B. Request to obtain the client's cardiac enzymes C. Check the clients blood pressure manually D. Listen with the client on their left side ANS - D. Listen with the client on their left side A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse's priority? A. Temperature 38.4 C (101.1 F) B. Increased respiratory secretions C. Fluid intake of 200 mL in the prior 8 hr D. Limited range of motion