MEDICAL SURGICAL NURSING EXAM 2 LATEST 2023, Exams of Nursing

Download MEDICAL SURGICAL NURSING EXAM 2 LATEST 2023 and more Exams Nursing in PDF only on Docsity! MEDICAL SURGICAL NURSING EXAM 2 LATEST 2023 D. Teach strengthing exercises B. Restrict protein intake by including meats and other high protein foods A. Place the client on contact precaution C. Discuss the withdrawal procedure with the family and offer support 1. A client is admitted to the hospital with symptoms consistent with right hemisphere stroke. With Neurovascular assessment requires immediate intervention by the nurse? A. Pupillary changes to ipsilateral dilation B. Orientation to person and place only. C. Left Sided Facial dropping and dysphagia D. Unequal bilateral hand grip strengths 2. Achieve maximum mobility and independence for a client multiple sclerosis (MS). Which intervention is most important for the nurse to implement? A. Provide a walker for ambulation B. Frequently assist client to the bathroom C. Apply alternating patches over the eyes 3. The Nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse recommend the client to follow? A. Limit oral Fluid intake to 500 mL per day C. Increase intake of potassium-rich foods such as bananas or cantaloupe D. Increase intake of high fiber foods, such as bran cereal. 4. The nurse Is caring for a client with herpes zoster who reports painful blisters that align from the back along the chest curvature to the anterior chest. Which intervention is the highest priority for the nurse? B. Administer antiviral medication C. Place wet compresses to ruptured vesicles D. Administer narcotic analgesics 5. A young adult who suffered a severe brain injury in an automobile collision has been mechanically ventilated for the past three days and has no spontaneous respiratory effort. After serial electroencephalograms (EEG) reveal no brain activity, the healthcare provider discusses end-of-life options with family who agree to discontinue life support. Which intervention should the nurse implement? A. Ask the family if they wish would remain at bedside during withdrawal B. Request a living will be placed in the client's medical record D. Turn off the mechanical ventilator and note the time of death 1 B. Drinl 3 liters of water each day D. Asses the client for pain C. Apply Ice intermittently for the first 24 hours C. Dressing must be a frustrating experience for you” B. Last administration of analgesia 6. Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan? A. Eliminate all the spicy food from your diet C. Clamp the catheter when taking a shower D. Avoid driving a car for 2 weeks 7. On the first postoperative day, the nurse finds an older male client disoriented and trying to climb over the bed railing. Previously he was oriented to person, place, and time on admission. Which intervention should the nurse implement first? A. Apply wrist restraints B. Determine the clients blood pressure C. Administer a mild sedative 8. Acute soft-tissue injuries (I.e. sprains, strains) provide the nurse with a variety of teaching opportunities. Which instruction should the nurse provide to a client with a soft-tissue injury? A. Watch for shortness of breath which may indicate a fat embolus B. Begin range of motion exercises within the first 24 hours D. After edema subsides, apply heat continuously 9. A male client is admitted to the rehabilitation unit following a cerebrovascular (CVA), which resulted in paralysis of his right arm. When the nurse enters the room, he is struggling to put on a shirt, and he curses at the nurse. What is the best response from the nurse? A. “We will give you a class on dressing tomorrow” B. This unit has a policy against staff harassment D. “It is important to dress the right arm first” 10. A client returns to unit following a craniotomy for removal of brain tumor and is obtunded but arouses to painful stimuli. Which assessment is most important for the nurse to obtain? A. Drainage on dressing C. Body temperature D. Serial blood pressure and pulse 11. An older client who is agitated, dyspneic, orthopneic, and using accessory muscle to breathe is admitted for further treatment. Initial assessment indicates beats/minute and irregular, respirations 36 2 B. Document the neurovascular assessment as normal A. Acute pain related to renal calculus D. Observe the clients' fingers B. Maintain intravenous therapy 21. The nurse is preparing to administer enoxaparin 90 mg subcutaneously daily to a client with pulmonary embolism. The pharmacy provides a prefilled syringe labeled, “Enoxaparin 100 mg/1ML “How many milliliters should the nurse administer? 22. While performing a neurovascular assessment distal to a client's fracture site, the nurse determines that the client's pulse is present, regular, and full. Which nursing action should be taken next? A. Notify the healthcare provider of assessment finding C. Discontinue elevating the client's affected extremity. D. Asses for color, feeling, discomfort, and movement 23. Magnesium hydroxide, 1.5 ounces P.O is prescribed for a client complaining of heartburn. After taking the prescribed dose 3 times today, how many mL of magnesium hydroxide has the client ingested? 24. A client with renal calculus is complaining of severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority? B. Impaired renal function to pain C. Nutritional deficit related to nausea D. Risk for aspiration related to vomiting 25. Which Technique should the nurse use when assessing for early signs of rheumatoid arthritis? A. Palpate large joints for nodules B. Palpate the lymph nodes C. Observe the skin for lesions 26. A client with cancer develops tumor lysis syndrome (TLS) following chemotherapy. Wich nursing action has the highest priority in responding to the symptoms of this syndrome? A. Identify potential sources of infection C. Instruct the client to take analgesics on a regular schedule. D. Encourage the client to verbalize anxiety and grief 5 A. Provide liberal fluids for hydration and excretion of metabolic waste products C. Circulatory impairment distal to the cast A. Increase the intravenous fluids as prescribed. C. IO Vascular access in lace greater than 24 hours 27. A client with Hepatitis A is complaining of weakness and chronic fatigue. Which intervention is most important for the nurse to implement? B. Place belongings with client reach so bed rest can be maintained C. Encourage dietary selections that are high in essential vitamins and Iron D. Ensure the client has scheduled rest periods every 4 to 6 hours during the day 28. A client who had a cast yesterday to the lower left arm comes to the clinic complaining of pain in the cast arm. Which assessment finding is most important for the nurse to identify? A. Presence of a pressure ulcer under the cast B. Location of burning pain below the cast D. 29. The nurse review lab values of a female client with metastatic breast cancer and notes that the client's serum calcium level is 14 mg/dL. The client is weak, fatigued, and depressed. New prescriptions include increasing the rate of intravenous fluids. Which action should the nurse take first? B. Offer to provide privacy so the client can rest C. Encourage verbalization of the clients' feelings D. Provide a nutritional supplement for a snack 30. A client with hypovolemic shock is admitted to the intensive care unit with an intraosseous (IO) vascular access device placed in the right proximal tibia. The client has received two liters of normal saline and one unit of packed red blood cells through the IO access device since admission. Which assessment finding warrants immediate intervention by the nurse? A. Client reports tenderness at intraosseous insertion site B. Client verbalizes feeling tightness in right calf muscle. D. Sluggish intraosseous blood return when aspirated 31. A client has a neutrophil count of (ANC) of 500/mm3 (0.5 x 109/L) after completing chemotherapy. Which intervention is most important for the nurse to implement? A. Implement bleeding precaution B. Review needs for pneumococcal vaccine C. Asses Vital signs every 4 hours D. 6 B. Increased pulse rate B. Obtain and record the clients' vital signs A. Loss of height over time 32. Clients' laboratory findings indicate elevations in thyroxine and triiodothyronine hormones. The nurse suspects that the client may have hyperthyroidism. Which symptom is most often associated with hyperthyroidism? A. Atrophied thyroid gland C. Periorbital edema D. Diarrhea Stools 33. Prior to initiating peritoneal dialysis, which nursing action is most important for the nurse to implement? A. Determine the client's oxygen saturation C. Ascultate the clients' vital signs D. Observe the amount and color of the client's urine 34. The nurse is preparing to insert an indwelling catheter for a male client who has diabetes and a semirigid penile implant. After placing the sterile drapes and prepping the meatus, the nurse notes that the client's penis is erect. Which action should the nurse implement? A. Ask the client to deflate the implant B. Talk to the client about his implant C. Continue to insert the catheter D. Wait until the erection subsides 35. Which finding should the nurse document as primary manifestation of osteoporosis in an older woman? B. Decreased serum calcium level C. Pain in the spine and neck D. Abnormal cardiac status in the ECG 36. The nurse is conducting discharge teaching for a male client with a prescription for magnesium hydroxide 15 mL one time per day. His home medication cup is ounces. How many ounces should he take each dose? A. 0.5 ounces B. 0.05 ounces C. 0.25 ounces D. 1 ounce 37. Which change in lab values would indicate to the nurse that treatment for gout is successful? 7 C. The client is most likely responding to treatment C. Gently pat the solution on the sore areas, using cotton tipped applicators D. Cardiac dysrhythmia B. Tell the spouse to wait outside the room so the nurse can interview the client alone D. Obtain an annual prostate digital exam 48. The ESR (sedimentation rate) of a client being treated with corticosteroids for rheumatoid arthritis has decreased. Which explanation should the nurse provide the client to explain this change in lab values? A. The treatment so far has not been effective B. A value of 0 will indicate that that the client is cured D. The client disease is currently in a remission 49. A client has a prescription for a viscous compound containing lidocaine HCL and diphenhydramine to relieve the discomfort of mucositis caused by radiation therapy. Which instructions should the nurse provide the client about administration of this prescription? A. Saturate a sterile dressing with the solution and pack the wound lightly B. Dab the solution over the reddened areas and cover the site with occlusive dressing D. Swish the solution around in the mouth, and swallow the remaining solution 50. A client admitted dehydration resulting from vomiting and diarrhea. The nurse knows that the client is at greatest risk of developing which condition? A. Bowel perforation B. Papilledema C. Tinnitus 51. When the nurse begins discharge instructions for a client and her spouse, the client who had an above the knee amputation for complications associated with diabetes, tells the nurse that she is not ready to go home and wants to stay home in the hospital another day, which intervention is important for the nurse to implement? A. Explain the take home medications that can help the client manage her anxiety C. Ask the client what frightens her about leaving the hospital and returning home D. Review the details of the home health care plan devised by the multidisciplinary team 52. The nurse admits a client who has a medical diagnosis of bacterial meningitis to the unit. Which intervention has the highest priority when providing care for the client? 10 C. Surgical intervention often indicated Family members can be involved in the plan of care B. Continue the range of motion exercises B. Administer initial dose of broad-spectrum antibiotic C. Instruct the client to force fluids hourly D. Asses the client for symptoms of hyponatremia 53. While performing assisted range of motion exercises for a client with osteoarthritis, the nurse notes joint crepitus. Which action should the nurse take? A. Notify the healthcare provider of findings C. Immobilize the extremity joint D. Apply moist heat to the site 54. A female client with metastatic breast cancer is admitted with shortness of breath and pleural effusion. The client has a living will and the family is requesting hospice information. Which information should the nurse provide regarding hospice? (Select all that Apply) A B. C. Hospice services can be initiated prior to discharge D. A living will become invalid when receiving hospice care E. 11 A. Obtain results of culture and sensitivity of CSF Provides comfort, dignity, and emotional support . Can be provided within comfort of home