Med-surg review 1

Helpfulness: 0
Set Details Share
created 5 weeks ago by nursingschoollife
20 views
updated 4 weeks ago by nursingschoollife
show moreless
Page to share:
Embed this setcancel
COPY
code changes based on your size selection
Size:
X
Show:
1

After a transurethral resection of the prostate (TURP), a client has bloody urine output with large clots. The nurse implements the postoperative prescription to irrigate the indwelling catheter PRN to maintain the catheter's patency. Which action should the nurse implement ?

Clamp the catheter for 30 minutes prior to irrigating with saline.

2

An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action?

Administer IV antibiotics as prescribed ( Acute pyelonephritis, a bacterial infection in the kidney and renal pelvis, requires prompt treatment with antibiotics to prevent worsening of infection and related sequelae. A broad spectrum antibiotic is initiated until urine culture results are obtained.

3

An older male client with long-standing lung disease is admitted to the medical unit for treatment of pulmonary infection. In assessing for signs of increasing hypoxia, which actions should the nurse include? Select all that apply

Check for changes in mental status

Observe color of skin and mucous

Assess breathing patterns

4

A woman who works as a data entry clerk is concerned as to how recent diagnosis of Raynaud's syndrome is going to affect her job performance. Which instructions should the nurse provide this client?

Use a space heater to keep the workplace warm

5

The nurse is providing discharge instructions to a client who is receiving prednisone ( Deltasone) 5mg PO daily for a rash due to contact with poison ivy. Which symptom should the nurse tell the client to report to the healthcare provider?

Rapid weight gain

6

A 70-year-old male client with type 2 diabetes mellitus is hospitalized with an infected ulcer on his great right toe. Which instruction should the nurse emphasize during discharge teaching?

Check the insides and linings of all enclosed shoes before putting the shoes on

Peripheral neuropathy is a common complication of DM, resulting in loss of sensation

7

A male client with a history of asthma reports having episodes of bronchconstriction and increased mucous production while exercising. Which action should the nurse implement?

Determine if the client is using an inhaler before exercising

8

A client with ulcerative colitis is admitted to the medical unit during an acute exacerbation. The nurse should instruct the unlicensed assistive personnel to report which finding related to the client's bowel movements?

Blood in the stool

9

The nurse assists a male client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. He tells the nurse that he is pretending to step over a crack on the floor? How should the nurse respond ?

Confirm that this is an effective technique to help with ambulation

Intentionally stepping over a real or imaginary line is an effective technique for those with PD who experience bradykinesic "freezing" during ambulation.

10

A client with pheochromocytoma reports the onset of a severe headache. The nurse observes that the client very diaphoretic. Which assessment data should the nurse obtain next ?

Blood pressure

(Pheochromocytoma, a tumor of the adrenal gland, causes several episodic hypertension and presents with a classic triad of symptoms including a headache, diaphoresis, and tachycardia. The client is exhibiting two of these three symptoms, so it is most important for the nurse to assess the client’s blood pressure)

11

A client with chronic kidney disease (CDK) arrives at the clinic reporting shortness of breath on exertion and extreme weakness. Vital signs are temperature 100.4 F (38 C), heart rate 110 beats/minute, respirations 28 breaths/minute, and blood pressure 175/98 mmHg. The client usually receives dialysis three times a week but missed the last treatment. STAT blood specimens
are sent to the laboratory for analysis. Which laboratory results should the nurse report to the healthcare provider immediately?

Potassium 6.5 mEq/L (mmol/L)

12

What information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)?

A. Sleep without pillows at night to maintain neck alignment.
B. Adjust food intake to three full meals per day and no snacks.
C. Minimize symptoms by wearing loose, comfortable clothing
D. Avoid participation in any aerobic exercise programs

Minimize symptoms by wearing loose, comfortable clothing

13

An older adult with heart failure is hospitalized during an acute exacerbation. To reduce cardiac workload, which intervention should the nurse include in the client’s plan of care?

Provide a bedside commode for toileting

14

A client with draining skin lesions of the lower extremity is admitted with possible Methicillin-Resistant Staphylococcus Aureus (MRSA). Which nursing interventions should the nurse include in the plan on care? (Select all that apply.)

Institute contact precautions for staff and visitors
Send wound drainage for culture and sensitivity
Monitor the client’s white blood cell count

15

A client with a liver abscess undergoes surgical evacuation and drainage of the abscess. Which laboratory value is most important for the nurse to monitor following the procedure?

White blood cell count
(Clients with a liver abscess are at high risk for sepsis. It is most
important for the nurse to monitor for signs of infection, including an increase in the client’s white blood cell count)

16

Two days following abdominal surgery a client begins to report cramping abdominal pain, and the nurse’s inspection of the abdomen indicates slight distention. Which action should the nurse
implement first?

Auscultate the client’s abdomen

17

A client’s telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression. After another minute of compressions, the client’s
rhythm converts to supraventricular tachycardia (SVT) on the monitor. At this point, what is the
priority intervention for the nurse?

Give IV dose of adenosine rapidly over 1-2 seconds

18

A client with type 2 diabetes mellitus (DM) is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with an initial dose of Humulin N insulin at 0800. At 1600, the client
complains of diaphoresis, rapid heartbeat, and feeling shaky. What should the nurse do first?

Determine the client’s current glucose level

19

A nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate intervention by the nurse?

Serum sodium of 185 mEq/L

20

A male client with pernicious anemia takes supplemental folate and self-administers monthly Vitamin B12 injections. He reports feeling increasingly fatigued. Which laboratory value should
the nurse review?

Complete blood count

21

A client returns to the unit following a suprapubic prostatectomy. He has a three-way catheter in place with a continuous bladder irrigation infusing. Which assessment finding warrants
immediate intervention by the nurse?

Urine leaking around the meatus

22

A client tells the nurse that her biopsy results indicate that the cancer cells are well-differentiated. How should the nurse respond?

Ask the client if the healthcare provider has given her any information about the classification of her cancer

23

An older client is admitted after falling while walking. The left leg is externally rotated and shorter than the right leg, and the client is having severe pain and tingling in the left foot. The nurse is unable to palpate the left pedal pulses. Which action is most important for the nurse to implement?

Use a doppler to assess bilateral pedal pulses

24

A male client in skeletal traction tells the nurse that he is frustrated because he needs help repositioning himself in bed. Which intervention should the nurse implement

Provide an overhead trapeze to the bed for the client to use

25

The nurse is assessing clients in an outpatient diabetic clinic. Which entry provides the best medication that the client is adhering to the prescribed diabetic regimen?

Hemogloblin A1C of 6.2%

26

During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?
A. An old friend with eczema came for a visit
B. Recently received an influenza immunization
C. A grandson and his new dog recently visited
D. Corticosteroid cream was applied to eczema

A Grandson and his new dog recently visited

27

A male client tells the clinic nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement?
A. Observe the perineal area for a chancroid-like lesion
B. Obtain a specimen of urethral drainage for culture
C. Assess for perineal itching, erythema and excoriation
D. Identify all sexual partners in the last four days

Obtain a specimen of urethral drainage for culture

28

An older male client tells the nurse that he is losing sleep because he has to get up several times at night to use bathroom, that he has trouble starting urinary stream, and that he does not feel like his bladder is ever completely empty. Which interventions should the nurse implement?

A. Collect a urine specimen for culture analysis
B. Review the client's fluid intake prior to bedtime
C. Palpate the bladder above the symphysis pubis
D. Obtain a fingerstick blood glucose level

Palpate bladder above the symphysis pubis

29

During a paracentesis, 2 Liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed , and 50 ml of clear straw-colored fluid drains within the first hour. What action should the nurse implement.

A. Palpate for abdominal distention
B. Send fluid to the lab for analysis
C. Continue to monitor the fluid output
D. Clamp the drainage tube for 5 minutes

Continue to monitor the fluid output

30

A client who was discharged 8 months ago w/cirrhosis and ascities is admitted w/ anorexia and recent hemopytis. The client is drowsy but responds to verbal stimuli. The nurse programs a bp monitor to take readings every 15 mins. Which assessment should the nurse implement first?

A. Evaluate distal capillary refill for delayed perfusion
B. Check the extremities for bruising and petechiae
C. Examine the pretibial regions for pitting edema
D. Palpate the abdomen for tenderness and rigidity

Palpate abdomen for tenderness and rigidity

31

A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the clients post-op discharge instructions?

A. Report when hematuria becomes pink tinged
B. Use incentive spirometer
C. Restrict physical activities
D. Monitor urinary stream for decrease in output

Monitor for decreased urinary output

32

A client with a carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 meq/L. Which nursing problem should the nurse include in this clients plan of care?

A. Altered urinary elimination
B. Impaired gas exchange
C. Fluid volume excess
D. Decreased cardiac output

Fluid volume excess

33

A client with cushings syndrome is recovering from an elective laproscopic procedure. Which assessment finding warrants immediate intervention by the nurse?

A. Irregular apical pulse
B. Purple marks on the skin of the abdomen
C. Quarter size blood spot on dressing
D. Pitting ankle edema

Irregular apical pulse

34

A male client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning him, the wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. What intervention should the nurse implement next?
A. Bring additional sterile dressing supplies to the room
B. Prepare the client to return to the operating room
C. Obtain a sample of the drainage to send to the lab
D. Auscultate the abdomen for bowel sound activity

prepare client to return to operating room

35

An overweight, young adult male who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.)
A. Check his fingerstick glucose level
B. Assess his skin temperature and moisture
C. Measure his pulse and blood pressure
D. Document anxiety on the surgical checklist
E. Administer a PRN dose of regular insulin

A. Check his fingerstick glucose level
B. Assess his skin temperature and moisture
C. Measure his pulse and blood pressure

36

A male with muscular dystrophy fell in his home and is admitted with a right hip fracture. Right foot cool with palpable pedal pulses. Lungs are coarse with diminished breath sounds, VS are 101F, 128, 28, 122/82. Which intervention should be implemented 1st?

A. Obtain oxygen saturation level
B. Encourage incentive spirometry
C. Assess lower extremity circulation
D. Administer PRN oral antipyretic

D. Administer PRN oral antipyretic

37

Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client?

Avoid coiling the tubing and keep if free of kinks
B. Cleanse the perineal area with soap and water twice daily
C. Keep the drainage bag lower than the level of the bladder
D. Drink 1,000 ml of fluids daily to irrigate catheter

Keep drainage bag lower than the level of the of the bladder

38

A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply.)
A. Offer ice chips and oral clear liquids
B. Verify pedal pulses using a doppler pulse device
C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure
D. Evaluate the application of the splint to the left leg
E. Administer oral antispasmodics and narcotic analgesics

Verify pedal pulses using doppler

monitor left leg for pain, pallor, paresthesia, paralysis, pressure

Evaluate the application of the splint to the left leg

39

When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing diagnosis of, "visual sensory/perceptual alterations." This diagnosis is based on which etiology?
A. Limited eye movement
B. Decreased peripheral vision
C. Blurred distance vision
D. Photosensitivity

decreased peripheral vision

40

A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action?

A. Administer the first dose of antibiotic therapy
B. Observe the color, consistency, and amount of sputum
C. Encourage the client to consume plenty of warm liquids
D. Send the specimen to the lab for analysis

Observe the color, consistency and amount of sputum

41

A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress. The client is intubated and is receiving 100% oxygen per self-inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the nurse to obtain?
A. Breath sounds over bilateral lung fields.
B. Carotid pulsation during compressions
C. Deep tendon reflexes
D. Core body temperature

Breath sounds over bilateral lung fields.

42

After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops pontine myselinolysis. Which intervention should the nurse implement first?
A. Reorient client to his room
B. Place a patch on one eye
C. Evaluate client's ability to swallow
D. Perform range of motion exercises

Reorient client to his room

43

A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain?
A. What time did he take his last medications?
B. Has his weight changed in the last several days?
C. Is he still able to tighten his belt buckle?
D. How many hours did he sleep last night?

Has his weight changed in the last several days?

44

An older adult woman with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement?
A. Administer a prescribed sedative
B. Encourage client to drink water
C. Apply a high-flow venturi mask
D. Assist her to an upright position

Assist her in a upright position

45

A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?
A. Increase the daily intake of oral fluids to liquefy secretions
B. Avoid crowded enclosed areas to reduce pathogen exposure
C. Call the clinic if undesirable side effects of medications occur
D. Teach anxiety reduction methods for feelings of suffocation

Increase the daily intake of oral fluids to liquefy secretions

46

A cardiac catherterization of a client with heart disease indicates the following blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and 95 % proximal right coronary artery (RCA). The client later asks the nurse "what does all this mean for me?" What information should the nurse provide?

A.Blood supply to the heart is diminished by artherosclerotic lesions, which necessitate lifestyle changes.
B. Blood vessels supplying the pumping chamber have blockages indicating a past heart attack.
C. Three main arteries have major blockages, with only 1 to 5% of blood flow getting through to the heart muscle.
D. The heart is not receiving enough blood, so there is a risk of heart failure and fluid retention.

C. Three main arteries have major blockages, with only 1 to 5% of blood flow getting through to the heart muscle.

47

The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the nurse instruct the client to maintain?
A. he nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the nurse instruct the client to maintain?
A. left lateral
B. Supine, knees flexed
C. Dorsal recumbent
D. Knee-chest

A. left lateral

48

A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider.
A. Belching
B. Amber urine
C. Yellow sclera
D. Flatulence

Yellow sclera

49

While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?
A. Inappropriate laughter
B. Increasing anxiety
C. Weakened cough effort
D. Asymmetrical weakness

Weakened cough effort

50

The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client?
A. Grafting increases the risk for bacterial infections
B. The xenograft is taken from nonhuman sources
C. Grafts are later removed by a debriding procedure
D. As the burn heals, the graft permanently attachesB. The xenograft is taken from nonhuman sources14. A male client who h

The xenograft is taken from nonhuman sources

51

A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the healthcare provider suspects hyperthyroidism and admits her for further testing. Which action should the nurse implement?
A. Begin preparing client for thyroidectomy procedure
B. Space the client's care to provide periods of rest
C. Assess the client for hyperactive bowel sounds
D. Provide warm blankets to prevent heat loss

Space the client's care to provide periods of rest

pg.132

Provide a calm, restful atmosphere

52

The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse encourage the client to follow?

A. Increase intake of high-fiber foods, such as bran cereal
B. Restrict protein intake by limiting meats and other high-protein foods
C. Limit oral fluid intake to 500 ml per day
D. Increase intake of potassium-rich foods such as bananas or cantaloupe

Restrict protein intake by limiting meats and other high-protein foods

53

25. Which client has the highest risk for developing skin cancer?
A. A 16-year old dark-skinned female who tans in tanning beds once a week
B. A 65 year-old fair-skinned male who is a construction worker
C. A 25 year-old dark-skinned male whose mother had skin cancer
D. A 70 year-old fair-skinned female who works as a secretary

A 65 year-old fair-skinned male who is a construction worker

54

An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take?
A. Apply a cool compress to the affected fingers for 20 minutes
B. Secure a pulse oximeter to monitor the client's oxygen saturation
C. Report the finding to the healthcare provider as soon as possible
D. Continue to monitor the fingers until color returns to normal

D. Continue to monitor the fingers until color returns to normal

55

The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the healthcare provider prior to proceeding with the scheduled procedure?
A. Light yellow coloring of the client's skin and eyes
B. The client's blood pressure reading is 184/88 mm Hg.
C. The client vomits 20 ml of clear yellowish fluid
D. The IV insertion site is red, swollen, and leaking IV fluid

The client's blood pressure reading is 184/88 mm Hg.

56

A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse?
A. Facial puffiness and periorbital edema
B. Hematocrit of 30%
C. Cold and dry skin
D. Further decline in level of consciousness

Further decline in level of consciousness

57

When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?
A. Daily weight
B. Vital signs
C. Level of consciousness
D. Bowel sounds

Daily weight

The classic manifestations of nephrotic syndrome are massive proteinuria, hypoalbuminemia, edema

58

A male client with Herpes zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the probable etiology of this problem?
A. Pain
B. Nocturia
C. Dyspnea
D. Frequent cough

Pain

59

A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is best for the nurse to provide the client to assist them with dyspnea self-management?
A. Allow additional time to complete physical activities to reduce oxygen demand
B. Practice inhaling through the nose and exhaling slowly through pursed lips
C. Use a humidifier to increase home air quality humidity between 30-50%
D. Strengthen abdominal muscles by alternating leg raises during exhalation

Practice inhaling through the nose and exhaling slowly through pursed lips

60

A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. What is the greatest clinical risk related to this situation?
A. Impaired skin integrity
B. Fluid volume excess
C. Acute pain and anxiety
D. Peripheral neurovascular dysfunction

Impaired skin integrity

61

A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanasthesia unit. Before selecting which medication to administer, which action should the nurse implement?
A. Document the client's report of pain in the electronic medical record
B. Determine which prescription will have the quickest onset of action
C. Compare the client's pain scale rating with the prescribed dosing
D. Ask the client to choose which mediation is needed for pain

Compare the client's pain scale rating with the prescribed dosing

62

While assisting a female client to the toilet, the client begins to have a seizure and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?
A. Document details of the seizure activity
B. Observe for lacerations to the tongue
C. Observe for prolonged periods of apnea
D. Evaluate for evidence of incontinence

Observe for prolonged periods of apnea

63

A male client with diabetes mellitus (DM) is transferred from the hospital to a rehabilitation facility following treatment for a stroke with resulting right hemiplegia. He tells the nurse that his feet are always uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement.
A. Provide a warming pad (Aqua-pad or K-pad) to feet
B. Medicate the client with a prescribed sedative
C. Use a bed cradle to hold the covers off the feet
D. Place warm blankets next to the client's feet

Place warm blankets next to the client's feet

64

While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. what is the etiology of this problem?
A. Irritation of nerve endings
B. Diminished blood flow
C. Ischemic tissue changes
D. Compression of a nerve

Compression of a nerve

65

The nurse assesses a client being treated for Herpes Zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness of treatment? (Select all that apply)
A. Skin integrity
B. Functional ability
C. Heart sounds
D. Pain scale
E. Bowel sounds

A. Skin integrity
B. Functional ability
D. Pain scale

66

A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value?
A. Osmolarity
B. Glucose
C. Albumin
D. Platelets

Glucose

67

A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse?
A. Elevated temperature
B. Generalized weakness
C. Diminished lung sounds
D. Pain when swallowing

Diminished lung sounds

68

Fluids are restricted to 1,500 ml daily for a male client with acute kidney injury (AKI). He is frustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids. Which intervention should the nurse implement?
A. Remove all sources of liquids from the client's room
B. Allow family to give client a measured amount of ice chips
C. Restrict family visiting until the client's condition is stable
D. Provide the client with oral swabs to moisten his mouth

Provide the client with oral swabs to moisten his mouth

69

While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take?
A. Review the client's dietary intake of high-protein foods
B. Notify the healthcare provider of the finding immediately
C. Discuss approaches to the chronic pain control with the client
D. Assess the client's radial pulses and capillary refill time

Discuss approaches to the chronic pain control with the client

Heberden's nodes is a symptom of osteoarthritis

70

A client who took a camping vacation two weeks ago in a county with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse report to the healthcare provider?
A. Weakness and fatigue
B. Intestinal cramping
C. Weight loss
D. Jaundiced sclera

Jaundiced sclera

71

Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI), a client is receiving a lidocaine infusion for isolated runs of ventricular tachycardia (VT). Which finding should the nurse document in the electronic medical record as a therapeutic response to the lidocaine infusion?
A. Stabilization of blood pressure ranges
B. Cessation of chest pain
C. Reduce heart rate
D. Decreased frequency of episodes of VT

Decreased frequency of episodes of VT

72

After a computer tomography (CT) scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement?
A. Call respiratory therapy to give a breathing treatment
B. Send another nurse for an emergency tracheotomy set
C. Prepare a dose of epinephrine (Adrenalin)
D. Review the client's complete list of allergies

Prepare a dose of epinephrine (Adrenalin)

73

The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?
A. Nuchal rigidity
B. Carotid bruit
C. Jugular vein distention
D. Palpable cervical lymph node

Carotid bruit

74

The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?
A. Collect the blood sample
B. Assess radial pulse volume
C. Apply pressure to the site
D. Select another finger

Collect the blood sample

75

A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The healthcare provider prescribes a nasogastric tube (NGT) to be inserted and placed to intermittent low wall suction. Which intervention should the nurse implement to facilitate proper tube placement?
A. Soak nasogastric tube in warm water
B. Insert tube with client's head tilted back
C. Apply suction while inserting tube
D. Elevate head of bed 60 to 90 degrees

Elevate head of bed 60 to 90 degrees

76

A young female client with seven children is having frequent morning headaches, dizziness, and blurred vision. Her blood pressure (BP) is 168/104 mmHg. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV medication, which intervention is most important for the nurse to implement?
A. Measure urine output hourly to assess for rental perfusion
B. Request a prescription for pain medication
C. Use an automated BP machine to monitor for hypotension
D. Provide a quiet environment with low lighting

Use an automated BP machine to monitor for hypotension

77

The wife of a client with Parkinson's disease expresses concern because her husband has lost so much weight. Which teaching is best for the nurse to provide?
A. Invite friends over regularly to share in meal times
B. Encourage the client to drink clear liquids between meals
C. Coach the client to make an intentional effort to swallow
D. Talk to the healthcare provider about prescribing an appetite stimulant

Invite friends over regularly to share in meal times

78

Which nursing problem has the highest priority when planning care for a client with osteomalacia ?

risk for injury

79

A client with Guillain-Barre syndrome has paralysis of all extremities and requires mechanical ventilation. The nurse observes that the client is not blinking. Which action should the nurse
implement?

Protect cornea with lubricant and eye shields

80

An older client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse
implement?

Provide an eye shield to be worn while sleeping

81

A client who suffered an electrical with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client’s plan of care?

Continuous cardiac monitoring

82

A client is receiving combination chemotherapy for treatment of metastatic carcinoma. For which systemic side effect should the nurse monitor the client?

1.Ascites
2.Nystagmus
3.Leukopenia
4.Polycythemia

Leukopenia

83

client cardiovascular disease is reporting blurred vision is likely experiencing complications of hypertension. Patient outcome ?

less than 140/80 this month

84

normal finding of AV fistula

enlarged vein

85

the client has diabetes mellitus is admitted to hospital with upper respiratory infection several hours after admission client reports having severe headache and feeling dizzy.Intervention?

1. Reassess vs

2. obtain sputum for culture

3. administer antipyretic

re assess vs

86

throcentises

position the client sitting up

87

cancer -pain

administering analgesic on fixed and continuous schedule

88

hypothyroidism may experience protruding eye balls

get prescription for artificial tears

89

at risk for hepatitis c ask..

when 1st blood transfusion was received

90

metabolic syndrome

abdominal obesity

high triglycerides

hyperglycemia

hypertension

91

pathological evaluation of tissue sample is definitive to diagnosis cancer

nurse prepare client for tissue biopsy

92

urolithiasis related to

recent marriage frequency of sexual intercourse-explore client hygiene practices

93

Kaposi sarcoma

most common cancers in individual with HIV

determine clients sexual patterns and history before

94

video of nurse

contaminated sterile field- needs new pair of sterile gloves

95

nurse places mirror in room

use large mirror while dressing

96

PACU assessment - sudden drop in blood pressure can be sign of active bleeding

assess operative site for bleeding

97

An older adult recently diagnosed with type 2 diabetes mellitus (DM) suddenly becomes confused and weak, with cool, clammy skin. The client is unable to remember what to do for such symptoms and is taken to a near by urgent care facility by a neighbor. Which nursing intervention should the nurse implement?

Observe respiratory rate and pattern

palpate for bladder pain or distention

prepare to administer insulin

Check a blood sample for glucose level

Report any changes in blood pressure

Check blood glucose level