214 Med Surg Final Exam: Essential
Concepts and Preparation 2024
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?
Obtain sample menus from the dietitian to give to the client.
Ask the client to identify the types of foods she prefers.
Identify the recommended range for the client's blood glucose level.
Discuss long-term complications that can result from nonadherence to the dietary plan.
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?
Kussmaul respirations
Diaphoresis
Decreased skin turgor
Ketonuria
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?
Elevate the residual limb on a soft pillow.
Assist the client to a prone position every 4 hr.
Reapply a bandage to the residual limb every 12 hr.
Apply dressings to the site in a proximal-to-distal direction.
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.)
A. Take allopurinol as prescribed.
B. Exercise several times a week.
C. Limit intake of foods high in purine.
D. Decrease daily fluid intake.
E. Avoid citrus juices.
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?
A depressed fracture of the forehead
Clear fluid coming from the nares
Motor loss on one side of the body
Bleeding from the top of the scalp
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?
Lumps that are mobile and tender upon palpation prior to a menstrual period
Multiple round masses that are tender and found in both breasts
Bilaterally darkened areolas
A nontender, hard lump that is palpated in one breast
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.
Limit fluid intake to 1,500 mL per day.
Practice chest breathing each day.
Wear home oxygen to maintain an SaO2 of at least 94%.
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.
Restart the IV with a 22-guage needle.
Verify with another nurse the blood type and Rh of the packed RBCs.
Hang a bag of lactated Ringer's IV solution.
Change IV tubing to a set that has a filter.
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
Mask
Hair cover
Goggles
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?
Concepts and Preparation 2024
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?
Obtain sample menus from the dietitian to give to the client.
Ask the client to identify the types of foods she prefers.
Identify the recommended range for the client's blood glucose level.
Discuss long-term complications that can result from nonadherence to the dietary plan.
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?
Kussmaul respirations
Diaphoresis
Decreased skin turgor
Ketonuria
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?
Elevate the residual limb on a soft pillow.
Assist the client to a prone position every 4 hr.
Reapply a bandage to the residual limb every 12 hr.
Apply dressings to the site in a proximal-to-distal direction.
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.)
A. Take allopurinol as prescribed.
B. Exercise several times a week.
C. Limit intake of foods high in purine.
D. Decrease daily fluid intake.
E. Avoid citrus juices.
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?
A depressed fracture of the forehead
Clear fluid coming from the nares
Motor loss on one side of the body
Bleeding from the top of the scalp
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?
Lumps that are mobile and tender upon palpation prior to a menstrual period
Multiple round masses that are tender and found in both breasts
Bilaterally darkened areolas
A nontender, hard lump that is palpated in one breast
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.
Limit fluid intake to 1,500 mL per day.
Practice chest breathing each day.
Wear home oxygen to maintain an SaO2 of at least 94%.
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.
Restart the IV with a 22-guage needle.
Verify with another nurse the blood type and Rh of the packed RBCs.
Hang a bag of lactated Ringer's IV solution.
Change IV tubing to a set that has a filter.
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
Mask
Hair cover
Goggles
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?
