Timby's Med-Surg Finals Study
A complete Blood count indicates that a client is anemic. What disorder in the client's health
history is most likely contributing to the reduction in red blood cells? - ANSRenal failure
When the nurse reviews the client's complete blood cell count, what finding is most suggestive
that a client is at risk for acquiring an infection? - ANSLoan number of agranulocytes
A physician tells a client that her body is not making enough blood cells. After the physician
leaves, the client appears very upset and states, "I do not even know how my body is supposed
to make blood cells." What is the simplest, yet correct, instruction for the nurse to give the client
at this time? - ANSThe bone marrow produces blood cells.
What blood type could be transfused into anyone if there is no time to perform a type and
crossmatch of the recipient's blood? - ANSO, Rh negative
After completion of a bone marrow aspiration, what is most important for the nurse to monitor? -
ANSBleeding from the puncture site.
A client arrives at the emergency department after a motorcycle accident. Vital signs are T,
97.7F; P, 122; R, 28; and BP, 96/54. The client has suffered profuse blood loss. From the clinical
picture, what position is best for the nurse to place the client? - ANSReverse Trendelenburg
The nurse is assessing a client with anemia possibly resulting from malaria. What information
would be most important to ascertain to assist a physician in making a correct diagnosis? -
ANSForeign travel
A client has been diagnosed with pernicious anemia. She says, "I'm worried because my
grandmother died of the disease years ago." What nursing explanation is most accurate? -
ANS"We now give vitamin B12 to control the disease."
A college student diagnosed with infectious mononucleosis asks the school health nurse how
old the condition was acquired. The best answer by the nurse is that the virus is transmitted by
what methods? - ANSContact with the saliva of an infected person
A hospitalized client with Hodgkin's disease is at risk for ineffective airway clearance and
impaired gas exchange related to compression of the trachea by enlarged lymph nodes. What
, measures should the nurse take first to help ensure that breathing and blood oxygen saturation
remain adequate? - ANSPlace the client in semi- to high-Fowler's position.
When performing a physical assessment of the client in the early stages of Hodgkin's disease,
what is the most likely finding when the nurse palpates the client's lymph nodes? - ANSThe
lymph nodes are enlarged and painless
A nurse is asked to assist the physician with a diagnostic Romberg test, what nursing
intervention is most appropriate to ensure client safety? - ANSStand close to the client in
case the client should begin to sway
What level of consciousness (LOC) is correct for a nurse to document when calling a client's
name causes the client to awaken temporarily, followed by drifting back to sleep? -
ANSSomnolent
When a nurse uses the Glasgow coma scale to assess a client, what method should the nurse
use to determine the "best verbal response" from the client? - ANSNote the client's
responses to general orientation questions
Immediately following a lumbar puncture, a client asks to ambulate to the restroom. What
nursing action is most correct? - ANSExplained that the client must temporarily lie flat and
use a urinal
Because older adults often do not exhibit the typical signs and symptoms of meningitis, what
assessment findings should the nurse be especially vigilant for an older clients with suspected
meningitis? - ANS-Low-grade fever
-Nuchal rigidity
-Altered mental status
When the nurse select the equipment to place in the room of a client who has been diagnosed
with Guillain-Barre syndrome, what item is essential to managing the client's care? -
ANSSupplemental oxygen
To promote adequate nutrition and reduce the risk for aspiration when caring for a client with
Parkinson's or Huntington's disease, what nurse measures are appropriate? - ANS-Modify
the texture and consistency of food
-Have the client flex the chin when swallowing
-Position the client in a sitting position
A client arrives at the headache center for an initial evaluation. The client describes flashing
lights in the field of vision before the headache begins. What nursing interpretation of the
assessment data is most correct? - ANSThe client is experiencing an aura prior to a
migraine headache
A complete Blood count indicates that a client is anemic. What disorder in the client's health
history is most likely contributing to the reduction in red blood cells? - ANSRenal failure
When the nurse reviews the client's complete blood cell count, what finding is most suggestive
that a client is at risk for acquiring an infection? - ANSLoan number of agranulocytes
A physician tells a client that her body is not making enough blood cells. After the physician
leaves, the client appears very upset and states, "I do not even know how my body is supposed
to make blood cells." What is the simplest, yet correct, instruction for the nurse to give the client
at this time? - ANSThe bone marrow produces blood cells.
What blood type could be transfused into anyone if there is no time to perform a type and
crossmatch of the recipient's blood? - ANSO, Rh negative
After completion of a bone marrow aspiration, what is most important for the nurse to monitor? -
ANSBleeding from the puncture site.
A client arrives at the emergency department after a motorcycle accident. Vital signs are T,
97.7F; P, 122; R, 28; and BP, 96/54. The client has suffered profuse blood loss. From the clinical
picture, what position is best for the nurse to place the client? - ANSReverse Trendelenburg
The nurse is assessing a client with anemia possibly resulting from malaria. What information
would be most important to ascertain to assist a physician in making a correct diagnosis? -
ANSForeign travel
A client has been diagnosed with pernicious anemia. She says, "I'm worried because my
grandmother died of the disease years ago." What nursing explanation is most accurate? -
ANS"We now give vitamin B12 to control the disease."
A college student diagnosed with infectious mononucleosis asks the school health nurse how
old the condition was acquired. The best answer by the nurse is that the virus is transmitted by
what methods? - ANSContact with the saliva of an infected person
A hospitalized client with Hodgkin's disease is at risk for ineffective airway clearance and
impaired gas exchange related to compression of the trachea by enlarged lymph nodes. What
, measures should the nurse take first to help ensure that breathing and blood oxygen saturation
remain adequate? - ANSPlace the client in semi- to high-Fowler's position.
When performing a physical assessment of the client in the early stages of Hodgkin's disease,
what is the most likely finding when the nurse palpates the client's lymph nodes? - ANSThe
lymph nodes are enlarged and painless
A nurse is asked to assist the physician with a diagnostic Romberg test, what nursing
intervention is most appropriate to ensure client safety? - ANSStand close to the client in
case the client should begin to sway
What level of consciousness (LOC) is correct for a nurse to document when calling a client's
name causes the client to awaken temporarily, followed by drifting back to sleep? -
ANSSomnolent
When a nurse uses the Glasgow coma scale to assess a client, what method should the nurse
use to determine the "best verbal response" from the client? - ANSNote the client's
responses to general orientation questions
Immediately following a lumbar puncture, a client asks to ambulate to the restroom. What
nursing action is most correct? - ANSExplained that the client must temporarily lie flat and
use a urinal
Because older adults often do not exhibit the typical signs and symptoms of meningitis, what
assessment findings should the nurse be especially vigilant for an older clients with suspected
meningitis? - ANS-Low-grade fever
-Nuchal rigidity
-Altered mental status
When the nurse select the equipment to place in the room of a client who has been diagnosed
with Guillain-Barre syndrome, what item is essential to managing the client's care? -
ANSSupplemental oxygen
To promote adequate nutrition and reduce the risk for aspiration when caring for a client with
Parkinson's or Huntington's disease, what nurse measures are appropriate? - ANS-Modify
the texture and consistency of food
-Have the client flex the chin when swallowing
-Position the client in a sitting position
A client arrives at the headache center for an initial evaluation. The client describes flashing
lights in the field of vision before the headache begins. What nursing interpretation of the
assessment data is most correct? - ANSThe client is experiencing an aura prior to a
migraine headache
