MED SURG CAPSTONE PREASSESSMENT QUESTIONS & ANSWERS

Angina - ANSWER is characterized as chest discomfort that last no more than 15 minutes; exerted by stress and relieved by rest. MI - ANSWER is characterized by chest discomfort or epigastric distress without any impeding cause and relieved by opioids, such as morphine sulfate. Heart Failure (HF) - ANSWER evidence of pulmonary congestion and orthopnea. Screws are placed into the skull. - ANSWER Halo The pulling force is applied by weights that are attached to straps, boots or cuffs. - ANSWER Skin Pulling force is applied by attaching weights to a rods and/or screws in the bone. - ANSWER Skeletal A pulling force is applied by the hands of the provider for temporary immobilization - ANSWER Manual The nurse is caring for a client in end-stage renal failure client with an arterial blood gas (ABG) reading of metabolic acidosis. Which of the following ABG readings demonstrates this acid-base imbalance? a. pH - 7.55, PaC02 - 37, HC03 - 29 b. pH - 7.25, PaC02 - 56, HC03 - 26 c. pH - 7.28, PaC02 - 36, HC03 - 20 d. pH - 7.35, PaC02 - 36, HC03 - 26 - ANSWER C A client in acute renal failure is discussing with the nurse dietary considerations. Which statement by the client would be a dietary contraindication for this condition and require further teaching? Select one: a. "I will decrease my fruit intake, such as cherries." b. "I will increase my vegetable intake." c. "I will decrease my bread intake." d. "I will increase my intake of nuts." - ANSWER D A nurse is caring for a client with Alzheimer 's disease. Which of the following is most important to include when providing care? Select one: a. Be consistent and repetitive in actions when providing care. b. Use short directions when explaining a procedure. c. Stimulate memory by repeating client's last statement. d. Provide supervision to protect the client from injury. - ANSWER D The nurse is making evening rounds. Which intervention would be priority when checking the 2 hour post-above the knee amputation client's status? Select one: a. Medicating with opiods to control incisional pain. b. Ensuring there is an overbed trapeze to facility client mobility. c. Comparing the pulse most proximal to the incision to the same pulse point on the opposite extremity. d. Providing cefazolin IV. - ANSWER C The nurse is reinforcing the discharge teaching for the client who has undergone total knee arthroplasty. Which statement by the client indicates understanding of the teaching? Select one: a. "My ability to kneel will be limited, indefinitely." b. "I will need to be careful not to externally rotate my toes. " c. "I should not cross my legs to avoid dislocation." d. "My new joint will last for up to 35 years." - ANSWER A A nurse is caring for a client with asthma who uses a bronchodilator. Which of the following client statements indicates the client understands the instructions of the medication? Select one: a. "I will use my bronchodilator before I exercise. " b. "This medication has a slow onset." c. "This medication can cause weight gain." d. "I will take this medication with food." - ANSWER A The nurse is preparing to administer packed red blood cells (RBCs) for an anemic client. Which of the following solutions is used to safely administer blood products? Select one: a. 0.33% sodium chloride b. 0.45% sodium chloride c. 0.9% sodium chloride d. 3% sodium chloride - ANSWER C Which of the following clients has evidence of an acute myocardial infarction? Select one: a. A client with an ECG reading of sinus rhythm. b. A client with a triglyceride level of 108 mg/dL. c. A client with a serum potassium level of 3.5 meq/L. d. A client with a troponin level of 0.50 ng/L. - ANSWER D The nurse is performing a dressing change on a client who is 12 hours post-cholecystectomy. The nurse notes no drainage from the t-tube at the operative site. What would be the best action by the nurse at this time? Select one: a. Place the collection bag at the nipple line to better facilitate drainage. b. Inquire if the client has had any nausea or increased pain. c. Document the finding as normal. d. Apply a pressure dressing. Feedback - ANSWER B The nurse is reviewing the health care provider's new prescription written for a client with cirrhosis. What order would the nurse question and verify? Select one: a. Dicyclomine taken 30 minutes before meals. b. Paracentesis to decrease high levels of protein. c. Administration of a H2 receptor. d. Lactulose - ANSWER B A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which of the following client statements indicates a need for further education? Select one: a. "I should eat soft, high-calorie foods." b. "I should limit my intake of fluids." c. "I will take my vitamins to help prevent infections." d. "My disease increases my caloric needs - ANSWER B The nurse has an order for nail care on a client who has diabetes and extremely thick toenails. Which would be most appropriate action by the nurse? Select one: a. Cleanse the nails with antiseptic wash prior to clipping to decrease chance of infection. b. Clip the toenails straight across and round the edges toward the nail bed. c. Remove the dead skin from the nail using a scrub brush. d. File nails straight across according to hospital protocol. - ANSWER D After a transurethral resection of the prostate (TURP), the nurse is to monitor the continuous bladder irrigation (CBI). The client begins to complain of painful bladder spasms. What is the best action by the nurse? Select one: a. Record the amount of irrigation solution instilled and the amount of return. b. Increase the rate of the CBI to facilitate a better flow of fluid from the bladder. c. Turn off the bladder irrigation and manually irrigate the catheter. d. Provide reassurance to the client, since this sensation of urgency and spasms is a part of the irrigation process. - ANSWER C The nurse is caring for a client diagnosed with heart failure. Which of the clinical manifestations associated with heart failure best characterizes the cardiac disorder? Select one: a. Petechiae, gastric distress and flat jugular neck veins. b. Raynaud's phenomenon and popliteal entrapment. c. Liver enlargement, ascites and dependent edema. d. Nonpalpable jugular and radial pulses. Feedback - ANSWER C The