Medical-Surgical Nursing Exam 1

The nurse is caring for a client who has as a son with a streptococcus throat infection. Which nurse recommendation would be best to advise the client to do in order to prevent acquiring the infection? - Correct Answer Frequently wash her hands and surfaces of the home. The nurse is caring for a client infected with Rocky Mountain spotted fever. The nurse should ask if the client has experienced which of the following? - Correct Answer Was bitten by a tick The nurse is caring for a client with a protozoa infection. Which is the most likely mode of transmission? - Correct Answer Ingestion of contaminated food or water The nurse is caring for a client who is recovering from an allergic reaction. Which leukocyte level would the nurse expect to be the most elevated? - Correct Answer Eosinophils The nurse is caring for a client who has an infected wound on the great toe that is red with a purulent exudate. The nurse expects that this client has which type of infection? - Correct Answer Localized The client experienced a fall. Nursing assessment reveals that the client is experiencing tachycardia, hypotension, confusion, tachypnea, and flat jugular veins. What should be the nurse's first response? - Correct Answer Administer oxygen. The family wants to know why the nurse is putting a urinary catheter in a client experiencing shock. What is the nurse's best response? - Correct Answer "It will help monitor how much urine the kidneys are able to produce." A client experiencing shock has had a urinary output of 250 mL in the last 10 hours. What is the nurse's most appropriate response? - Correct Answer Notify the physician. Which client is most likely to be experiencing hypovolemic shock? - Correct Answer A client who had surgery 24 hours ago and who also has a nasogastric tube The physician has ordered arterial blood gases for a client experiencing shock. The nurse knows that which value indicates shock? - Correct Answer pH 7.32 A 63-year-old Arab American male states his left leg is "hot." What is the nurse's best first response? - Correct Answer Assess for pain The client is complaining of excruciating pain in a foot that has been amputated. The family tells the nurse that the client is just addicted to pain medications. What is the nurse's best response? - Correct Answer "He is experiencing phantom limb pain." A client has had abdominal surgery and has orders to be ambulated three times a day. Oral pain medication has been ordered for the client. What should the nurse do to facilitate ambulation? - Correct Answer Mediate 1 hour prior to ambulating the client. The client reports frequent use of acetaminophen. How should the nurse best respond? - Correct Answer "Do you drink alcohol?" A client with chronic pain has been admitted with a fever. The nursing assessment reveals that the client has a decreased level of consciousness. What should the nurse ask the family about? - Correct Answer What medications the client has taken The practical nurse is reviewing the social history from a client diagnosed with small cell carcinoma of the lung. Which information is significant for this disease? - Correct Answer The client has smoked two (2) packs of cigarettes a day for 20 years The practical nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical unit. Which information provided by the UAP warrants immediate intervention by the practical nurse? - Correct Answer The client receiving Procrit (epoetin alfa) has a T 99.2˚F, P 68, R 24, and BP of 198/102 The client diagnosed with lung cancer has been told the cancer has metastasized to the brain. Which intervention should the practical nurse expect to implement? - Correct Answer Discuss implementing an advance directive The client diagnosed with lung cancer is being discharged. Which statement made by the client indicates a reiteration of information is required? - Correct Answer "It doesn't matter if I smoke now. I already have cancer." The practical nurse is interviewing clients at the clinic. Which information provided by a client warrants further investigation? - Correct Answer The client has been coughing up blood in the mornings