MedSurg

MedSurg 2 1. The nurse is preparing the discontinue long term TPN therapy for a client. The nurse should plan to discontinue the TPN gradually to reduce the risk of which of the following adverse effects? a. Hyperglycemia b. Diarrhea c. Constipation d. Hypoglycemia- You taper it off to avoid this!!! Rationale PDF p.298: Never abruptly stop TPN. Speeding up/slowing down the rate is contraindicated. An abrupt rate change can alter blood glucose levels significantly. Rationale PDF nutrition p.58: don’t discontinue abruptly, must taper to prevent rebound hypoglycemia 2. A nurse is preparing a client for an ECG. The client is anxious and says that he is afraid the equipment will give him an electric shock. Which of the following is an appropriate response by the nurse? a. The machine only senses and records electrical currents coming from your heart – pg.170 Electrocardiography uses an electrocardiograph to record the electrical activity of the heart over time. b. The lead wires and cables are insulated for your safety c. The electrode pads will prevent the conduction of electricity to your skin d. The machine voltage delivery is low enough that you won’t feel any discomfort 3. A nurse is caring for client who has hypertension and has a new prescription for lisinopril. The nurse should consult with the provider about which of the following medications in the client’s medication administration record? a. Potassium chloride b. Levothyroxine c. Acetaminophen d. Metformin 4. A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective? a. Elevation in blood pressure b. Adventitious breath sounds c. Weight loss of 1.8 kg (4 lb) in the past 24 hr d. Respiratory rate of 24/min 5. Couldn't paste the picture on here. But it asked where u can hear pericardial friction rub the best at… Erb’s Point (3rd Intercostal, Central) 6. A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS. Which of the following statements by the nurse indicates an understanding of the teaching? a. I will increase the amount of fresh veggies b. I will wipe up areas soiled with body fluids with alcohol and immediately dispose of the trash c. I will need to take my clothes to the dry cleaners to sterilize them d. I will be sure to wear gloves and wash my hands when I change my cat’s litter box 7. A nurse is performing a venipuncture on an older adult client whose veins are difficult. Which of the following actions should the nurse take? a. Apply cool compresses b. Elevate the client’s extremity using a pillow c. Tap the skin around the insertion site d. Raise the angle of the catheter to 30 degrees above the insertion site 8. A nurse is caring for a client in the ER following a myocardial infarction. which of the following actions should the nurse anticipate if the client develops asystole? a. Administer atropine b. Defibrillate with 200 joules c. Starts a continuous lidocaine infusion d. Begin CPR – first line of medical management is CPR and ACLS. 9. A nurse is caring for a client with severe burn injury. The nurse should recognize which of the following client findings as an indication of hypovolemic shock? a. Potassium 5.2 mEq/L b. Capillary refill 1.5 seconds c. Urine output 45 mL/hr d. PaCO3 37 mmHg 10. A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli the client does not open her eyes, displays decerebrate posturing, and makes incomprehensible sounds. Which of the following Glasgow coma scale scores should the nurse assign the client? a. 2 b. 5 c. 10 d. 13 11. A nurse is teaching a client who has heart failure about self-management techniques. Which of the following statements by the client indicates an understanding of the teaching? a. I will keep an exercise diary b. I will take ibuprofen for mild pain c. I will expect swelling in my feet and ankle d. I will weigh myself every other day 12. A nurse is providing discharge teaching for a client who has new tracheostomy. Which of the following statements by the client indicates an understanding of the teaching a. I’ll insert the obturator after cleaning my stoma b. I’ll cut a slit in a clean gauze pad to use as a stoma dressing c. I’ll cleanse the cannula with half strength hydrogen peroxide d. I’ll remove the soiled tracheostomy ties prior to cleaning my stoma 13. A nurse is caring for a client who has a sealed radiation implant which of the following actions should the nurse take? a. Limit family member visits to 30 min per day – pg. 583 Limit visitors to 30-min visits, and have visitors maintain 6 feet distance from the source b. Give the dosimeter badge to the oncoming nurse at the end of the shift c. Apply second pair of gloves before touching the clients implant if it dislodges d. Remove soiled linens from the room after each change 14. A nurse is reviewing the medical record of a client who has pneumonia. Which of the following serum laboratory values should the nurse expect? a. WBC count 15,000/mm b. Hematocrit 35% c. Sodium 130 mg/dl d. BUN 8 mg/dl 15. A nurse is planning care for a client who has a newly implanted arteriovenous graft in the right arm. Which of the following actions should the nurse include in the plan of care? a. Instruct the client to avoid lifting the right arm for 72 hr b. Check blood pressure in the right arm c. Palpate the site for thrill d. Insert a saline lock into a site 10 cm (4in) distal to the graft 16. A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. which of the following should the nurse take first? a. Check the color of the client’s skin – Assessment first b. Prepare the client’s clothing c. Remove all the clients clothing d. Administer an opioid analgesic