MED SURG EXAM 2 PRACTICE QUESTIONS AND ANSWERS WITH RATIONALE

MED SURG EXAM 2 PRACTICE QUESTIONS AND ANSWERS WITH RATIONALE 1. After a cerebrovascular accident, a 75 yr old client is admitted to the health care facility. The client has left-sided weakness and an absent gag reflex. He’s incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g/dl. Which of the following is a priority for this client? a. checking stools for occult blood b. performing range-of-motion exercises to the left side c. keeping skin clean and dry d. elevating the head of the bed to 30 degrees 2. The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action: a. destroys the odor-proof seal b. wont affect the colostomy system c. is appropriate for relieving the gas in a colostomy system d. destroys the moisture barrier seal 3. When assessing the client with celiac disease, the nurse can expect to find which of the following? a. steatorrhea b. jaundiced sclerae c. clay-colored stools d. widened pulse pressure 4. A client is hospitalized with a diagnosis of chronic glomerulonephritis. The client mentions that she likes salty foods. The nurse should warn her to avoid foods containing sodium because: a. reducing sodium promotes urea nitrogen excretion b. reducing sodium improves her glomerular filtration rate c. reducing sodium increases potassium absorption d. reducing sodium decreases edema 5. The nurse is caring for a client with a cerebral injury that impaired his speech and hearing. Most likely, the client has experienced damage to the: a. frontal lobe b. parietal lobe c. occipital lobe d. temporal lobe 6. The nurse is assessing a postcraniotomy client and finds the urine output from a catheter is 1500 ml for the 1st hour and the same for the 2nd hour. The nurse should suspect: a. Cushing’s syndrome b. Diabetes mellitus c. Adrenal crisis d. Diabetes insipidus 7. The nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to: a. limit oral fluid intake for 1 to 2 weeks b. report the presence of fine, sandlike particles through the nephrostomy tube. c. Notify the physician about cloudy or foul smelling urine d. Report bright pink urine within 24 hours after the procedure 8. A client with a serum glucose level of 618 mg/dl is admitted to the facility. He’s awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6º F (38.1º C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes the highest priority? a. deficient fluid volume related to osmotic diuresis b. decreased cardiac output related to elevated heart rate c. imbalanced nutrition: Less than body requirements related to insulin deficiency d. ineffective thermoregulation related to dehydration 9. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. The nurse should expect the dose’s: