Medical-Surgical Nursing Questions and Answers, Exams of Nursing

Download Medical-Surgical Nursing Questions and Answers and more Exams Nursing in PDF only on Docsity! MEDSURG QUESTIONS AND ANSWERS. Download to score 1. A nurse is caring for a group of clients. The nurse should obtain a blood pressure using only the left extremity from which of the following clients? a. A client who has left-sided Bell’s Palsy b. A client who has a peripherally inserted central catheter (PICC) in the left arm c. A client who has right-sided weakness due to Parkinson’s disease d. A client who has right upper extremity arteriovenous fistula ANS: D 2. A nurse in a long-term facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility? a. Blurred vision b. Confusion c. Polyuria d. Diarrhea ANS: B 3. A client is assessing a client who has pericarditis. In which of the following areas should the nurse place the stethoscope to best hear pericardial friction rub. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer) MEDSURG QUESTIONS AND ANSWERS. Download to score 1. A nurse is preparing to administer thrombolytic therapy to a client who had an ischemic stroke. Which of the following is an appropriate nursing action? a. Start the therapy within 8 hr b. Insert an indwelling urinary catheter after therapy begins c. Monitor blood pressure every 30 min during infusion d. Elevate the head of bed between 25` and 30` ANS: D 2. A nurse is teaching the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching? a. Place hands on the upper abdomen during inhalation b. Exhale slowly through pursed lips c. Hold breaths about 3-5 seconds before exhaling d. Position the mouthpiece 2.5 cm (1 in) from the mouth ANS: C 3. A nurse is assessing a client who is 12 hr postoperative following a colon resection. Which of the following findings should the nurse report to the surgeon? a. Heart rate 90/min b. Hbg 8.2 g/dL c. Gastric pH of 3.0 d. Absent bowel sounds ANS: B 4. A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the nurse plan to administer? a. Regular insulin b. Furosemide c. Desmopressin d. Lithium carbonate ANS: C 5. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several MEDSURG QUESTIONS AND ANSWERS. Download to score c. Use a soft washcloth to clean the area around the radiation site d. Pat the skin on the radiation site to dry it ANS: D; p. 584 10.A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate administering which of the following prescribed medications? MEDSURG QUESTIONS AND ANSWERS. Download to score a. Acetaminophen b. Furosemide c. Diphenhydramine d. Pantoprazole ANS: B 11.A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of hypomagnesemia, which of the following findings indicates effectiveness of the medication? a. Lungs clear b. Hyperactive bowel sounds c. Blood pressure 90/50 mm Hg d. Apical pulse 82/min ANS: D 12.A nurse is preparing a client for a lumbar puncture which of the following images indicates the position the nurse should assist the client for this procedure? MEDSURG QUESTIONS AND ANSWERS. Download to score 13.A nurse is reviewing a client’s ABG results: pH 7.42, PaCO2 30 mmHg, and HCO3 21 mEq/L. The nurse should recognize these findings as an indication of which of the following conditions? a. Compensated respiratory alkalosis b. Uncompensated respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis MEDSURG QUESTIONS AND ANSWERS. Download to score 18.A nurse is preparing to administer a medication for a client through a nontunneled percutaneous central catheter. Which of the following actions should the nurse take? a. Close the inline clamp b. Apply local anesthetic to the skin c. Don sterile gloves d. Flush the catheter with 10 mL of 0.9% sodium chloride ANS: D pg. 166 19. A nurse is caring for a client who was admitted with nausea, vomiting and a possible bowel obstruction. An NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider? a. The client reports being extremely thirsty with a sore throat b. The drainage is bright green in color with brown fecal material c. The amount of drainage is gradually decreasing d. The client’s abdomen becomes distended and firm ANS: D 20. A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect? a. Elevated blood pressure b. Hypothermia c. Urine specific gravity 1.001 d. BUN 15 mg/dL ANS: C 21.A nurse is caring for a client who has hyperthyroidism and develops thyroid storm. Which of the following instructions should the nurse give to the client regarding management of thyroid storm? a. “You will need to begin taking an ACE inhibitor medication.” b. “You will need a pacemaker to increase your heart rate.” c. “You will need a cooling blanket to lower your body temperature.” d. “You will need additional thyroid MEDSURG QUESTIONS AND ANSWERS. Download to score supplementation.” ANS: C; p.509 22.A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results? a. Uric acid b. Intrinsic factor c. Creatinine kinase MEDSURG QUESTIONS AND ANSWERS. Download to score d. Chloride level ANS: A 23.A nurse is preparing to administer peritoneal dialysis to a client. Which of the following actions should the nurse take? a. Use clean technique to access the catheter. b. Chill the dialysate before administration. c. Hang the drainage bag below the client’s abdomen. d. Place the client in high-Fowler’s position. ANS: C; p.370 24.A nurse in the emergency department is caring for a client who has deep partial-thickness burns over 30% of his body, including his upper chest and abdomen. Which of the following actions is the nurse’s priority? a. Insert an 18 gauge IV catheter. b. Administer tetanus toxoid. c. Check the client’s mouth for black particles. d. Remove the client’s burned clothing. ANS: C or D - priority? 25.A nurse is presenting an in-service program about Parkinson’s disease (PD). Which of the following statements should the nurse include in the teaching? a. “PD results from a decreased amount of dopamine in the client’s brain.” b. “PD causes clients to have an increased sympathetic nervous system response.” c. “PD results in the development of neurofibrillary tangles within the client’s brain.” d. “PD manifestations worsen due to the client’s deceased production of acetylcholine.” MEDSURG QUESTIONS AND ANSWERS. Download to score a. Take a laxative to prevent constipation. b. Drink 2 to 3 L of fluids daily. c. Take an antacid 30 minutes before taking the medication. d. Monitor heart rate once daily. ANS: B 31.A nurse is providing teaching to a client who has a deep-vein thrombosis (DVT). Which of the following findings should the nurse identify as a risk factor for the development of DVTs? MEDSURG QUESTIONS AND ANSWERS. Download to score a. NSAID use b. Cirrhosis c. Hypertension d. Oral contraceptive use ANS: D 32.A nurse is caring for a client who has Cushing’s disease. Which of the following actions should the nurse take first? (Click on the “exhibit” button for additional info. a. Auscultate the client’s lung sounds. b. Check the client’s medication administration record for antihypertensive medications. c. Determine the need for further glucose monitoring. d. Verify the client’s understanding of sodium restriction. ANS: A? 33.A nurse is assessing a client who has nephrotic syndrome. Which of the following findings should the nurse expect? a. Proteinuria b. Hyperalbuminemia c. Flank pain d. Hypotension ANS: A 34.A nurse is preparing to administer a 250 mL IV bolus of dextrose 5% in water to infuse over 2 hr for a client. The drop factor is 10 gtt/mL. The nurse should set the pump to administer how many gtt/min? (Round the answer to the nearest whole number. Using a leading zero if it applies, no trailing zeros. ANS: 21 GTT MEDSURG QUESTIONS AND ANSWERS. Download to score 35.A nurse is assessing a client who has right-sided heart failure. Which of the following assessment findings should the nurse expect to find? a. Poor skin turgor b. Pitting edema c. Oliguria d. S3/S4 galloping heart sounds ANS: B MEDSURG QUESTIONS AND ANSWERS. Download to score a. Urine output 150mL over 4 hr b. Pallor in the affected extremity c. Bruising around the incision site d. Temperature of 37.9 C (100.2 F) ANS: B 41.A nurse is caring for an older adult client who has not been eating. Which of the following findings indicates dehydration? a. Capillary refill of 2 seconds b. Engorged neck veins c. Crackles auscultated bilaterally d. Diminished peripheral pulses ANS: D 42.A nurse is preparing to discharge a client who has a halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following prescriptions with the provider? a. May place a pillow under the head when sleeping b. Take tub baths instead of showers c. Increase intake of fiber-rich foods d. May operate motor vehicle when no longer taking analgesics ANS: D 43.A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglass cast. Which of the following findings should the nurse expect? a. Bounding distal pulses b. Intense pain with movement c. Capillary refill less than 2 seconds d. Erythema of the toes ANS: B 44.A nurse is caring for a client who is postoperative following coronary artery bypass surgery and reports shortness of breath. The nurse administers oxygen at 3L/min and MEDSURG QUESTIONS AND ANSWERS. Download to score obtains arterial blood gases 60 min later. Which of the following laboratory findings indicates a positive response to the oxygen therapy? a. Ph 7.32 b. PaCO2 34 mm Hg c. paO2 90 mm Hg d. Bicarbonate 20 mEq/L MEDSURG QUESTIONS AND ANSWERS. Download to score ANS: C 45.A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)? a. Loss of peripheral vision b. Deviation of the tongue from midline c. Disequilibrium with movement d. Inability to smell ANS: C 46.A nurse is caring for a client with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse? a. Bilateral pupil diameter changes from 4 to 2 mm b. Glasgow coma scale score changes from 14 to 9 c. Pulse pressure changes from 30 to 20 mm Hg d. WBC count changes from 9,000 to 16,000/mm3 ANS: B 47.A nurse is caring for a client who presents to the emergency department after experiencing a heat stroke. Which of the following actions should the nurse take? a. Administer antipyretic b. Apply cooling blanket c. Assess axillary temperature every 15 min d. Administer lactated Ringer’s ANS: B 48.A nurse is caring for a client who is taking furosemide.The client has potassium level of 3.1mEq/L. Which of the following should the nurse assess first? a. Muscle weakness b. Urine output MEDSURG QUESTIONS AND ANSWERS. Download to score b. Measure catheter after removal c. Apply slight pressure when resistance is met d. Remove the catheter with one continuous motion ANS: B MEDSURG QUESTIONS AND ANSWERS. Download to score 54.A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions would the nurse take? a. Remove one of the weights b. Increase the elevation of the affected extremity c. Pull the client up in bed d. Tie knots in the ropes near the pulleys to shorten them ANS: C 55.A nurse is caring for a client who has a flail chest. Which of the following actions should the nurse take? a. Implement fluid restriction b. Administer antibiotic medication c. Administer acetaminophen orally d. Provide humidified oxygen ANS: D 56.A nurse is teaching a group of newly licensed nurses about acute respiratory failure. Which of the following manifestations should the nurse include in the teaching? a. Hypocarbia b. Hypoxemia c. Hyperventilation d. Hypervolemi a ANS: B 57.A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first? a. Clear items from the client’s surrounding area b. Obtain the client’s vital signs c. Loosen the client’s restrictive clothing d. Lower the client to the floor ANS: D MEDSURG QUESTIONS AND ANSWERS. Download to score 58.A nurse is teaching a client who is receiving total parenteral nutrition at home through a central venous access device about transparent dressing changes. Which of the following instructions should the nurse include in the teaching? a. Use clean technique when changing the dressing b. Wear a mask during the dressing change c. Replace the extension tubing with each dressing change MEDSURG QUESTIONS AND ANSWERS. Download to score 63.A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the following statements should the nurse include in the teaching? a. Exhale fully before bringing the inhaler to your lips b. Do not shake your inhaler before use c. Use peroxide to clean the mouthpiece of your inhaler d. Depress the canister after you inhale ANS: A 64.A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure? a. Initiate beta blocker therapy b. Administer IV fluids to the client c. Insert urinary catheter d. Prepare the client for an intravenous pyelogram ANS: B 65.A nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominences, but the client’s skin is intact. Which of the following interventions should the nurse include in the plan of care? a. Massage the reddened areas three times daily b. Turn and reposition the client every 4 hr c. Support the bony prominences with pillows d. Apply an occlusive dressing ANS: C 66.A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin? a. Thrombocytopenia b. COPD MEDSURG QUESTIONS AND ANSWERS. Download to score c. Thalassemia d. Rheumatoid arthritis ANS: A 67.A nurse is caring for a client who has completed 10 daily cycles of total parenteral nutrition (TPN). Which of the following findings indicates that the client is receiving adequate TPN supplementation? MEDSURG QUESTIONS AND ANSWERS. Download to score a. Weight gain of 9.1 kg (20 lb) b. BUN level of 15 mg/dL c. Improved mobility d. Potassium level of 2.5 mEq/L ANS: C Expected finding is for BUN to be elevated when TPN is being administered. 68.A nurse is providing teaching to a client who is postoperative following a partial glossectomy. Which of the following statements by the client indicates an understanding of the teaching? a. I will inspect my mouth once each week for sores b. I will drink orange juice to increase my vitamin C intake c. I will consume canned soup whenever sores appear in my mouth d. I will rinse my toothbrush with hydrogen peroxide and water after each use ANS: D 69.A nurse is performing an ear irrigation for a client. Which of the following actions should the nurse take? a. Use cool fluid for irrigation b. Insert the tip of the syringe 2.5 cm (1 in) into the ear canal c. Tilt the client’s head 45 degrees d. Point the tip of the syringe towards the top of the ear canal ANS: C 70.A nurse is caring for a client who is receiving continuous irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse take first? a. Administer PRN pain medication b. Check the client’s urine output c. Reposition the client in bed MEDSURG QUESTIONS AND ANSWERS. Download to score b. Administer 0.9% sodium chloride c. Check potassium levels d. Initiate a continuous IV insulin infusion ANS: B; p.538 MEDSURG QUESTIONS AND ANSWERS. Download to score 76.A nurse is reviewing the laboratory results of a female client who asks about acupuncture as treatment for chemotherapy-induced nausea and vomiting. Which of the following laboratory results should the nurse identify as a contraindication to receiving acupuncture? a. Hemoglobin 12/gdL b. C-reactive protein 0.7 mg/dL c. Platelets 160,000 / mm3 d. Absolute neutrophil count 500/mm3 ANS: D? 77.A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level of a 6 on a pain scale of 0 to 10. Which of the following interventions should the nurse take? a. Gently massage the area around the client’s incision b. Apply an ice pack to the client’s knee c. Perform range of motion exercises to the client’s knee d. Place pillows under the client’s knee ANS: B 78.A nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which of the following findings indicates hypokalemia? a. Muscle weakness b. Hypertension c. Positive chvostek’s sign d. Oliguri a ANS: A 79.A nurse at a long-term care facility is assessing an older adult client. Which of the following findings should the nurse identify as an indication that the client has a recall memory impairment? a. Inability to state his current age b. Inability to name the members of his family MEDSURG QUESTIONS AND ANSWERS. Download to score c. Inability to count backwards from 10 d. Inability to state what he had for dinner last night ANS: D 80.A nuse on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury. Which of the following IV medications should the nurse plan to administer? MEDSURG QUESTIONS AND ANSWERS. Download to score d. Tell me why it’s important to have your CD4+ count checked ANS: D (pg. 556) 85.A nurse is caring for a client who has an endotracheal tube. Which of the following actions should the nurse take to verify tube placement? a. Deflate the cuff to check for tube placement b. Place the client’s head and neck in a flexed position c. Document the tube length where it passess the chin d. Observe for symmetry of chest expansion ANS: D 86.A nurse in an emergency department is caring for a client who is receiving treatment for excessive ingestion of antacids. The nurse should identify that this client is at risk for which of the following acid-base imbalances? a. Metabolic acidosis b. Respiratory acidosis c. Respiratory alkalosis d. Metabolic alkalosis ANS: D 87.A nurse is assessing a client for a positive Chvostek’s sign following a thyroidectomy. Which of the following areas on the client’s head should the nurse tap to assess the client for tetany? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) MEDSURG QUESTIONS AND ANSWERS. Download to score a. ANS: right in front of the ear MEDSURG QUESTIONS AND ANSWERS. Download to score 88.A nurse is caring for a client who has advanced liver disease. Which of the following laboratory results should the nurse monitor when assessing this client? a. Phosphate level b. Serum troponin c. Serum ammonia d. Glucose level ANS: C 89.A nurse is caring for a client who has pneumothorax and a chest tube with a closed water-seal drainage system. Which of the following actions should the nurse take? a. Strip or clear the chest tube every 8 hr. b. Change the chest tube site dressing every 24 hr. c. Empty the system at least every 8 hr. d. Refill the water chamber if the fluid level is low. ANS: D Pg.104 “Check the water seal level every 2 hr, and add fluid as needed” Pg. 103 “Monitor the fluid level and add fluid as needed to maintain the prescribed level of suctioning.” 90.A nurse in an emergency department is reviewing a client’s ECG reading. Which of the following findings should the nurse identify as an indication that the client has first-degree heart block? a. Prolonged PR intervals b. More P waves than QRS complexes c. Nondiscernible P waves d. No correlation between P and QRS waves ANS: A 91.A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify the sequence of steps the nurse should follow. (Move the steps into the box on MEDSURG QUESTIONS AND ANSWERS. Download to score c. Indomethacin d. Oxycodone ANS: D 96.A nurse is caring for a client who has Haemophilus influenza type B. Which of the following types of isolation should the nurse implement? a. Droplet b. Airborne c. Protective MEDSURG QUESTIONS AND ANSWERS. Download to score d. Contact ANS: A 97.A nurse is providing discharge teaching to a client who has pulmonary tuberculosis. Which of the following findings should the nurse include as an indication the client is no longer infectious? a. Negative sputum cultures for acid-fast bacillus b. Positive Quantiferon-TB Gold test c. Mantoux skin test revealing an induration of less than 1 mm d. Client no longer coughing up blood-tinged sputum ANS: A 98.A nurse working in the emergency department is caring for a client who has burn injury. After securing the client’s airway, which of the following interventions should the nurse take first? a. Cleanse the client’s wounds. b. Administer analgesic medication. c. Start an IV with a large-bore needle. d. Increase the room temperature. ANS: C 99.A nurse is caring for a client who has central venous access device and notes the tubing has become disconnected. The client develops dyspnea and tachycardia. Which of the following actions should the nurse take first? a. Obtain ABG values. b. Perform an ECG. c. Turn the client to his left side. d. Clamp the catheter. ANS: C MEDSURG QUESTIONS AND ANSWERS. Download to score 100. A nurse is providing discharge teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching? a. “Change your pet’s litter box daily.” b. “Wash your perineal area two times each day with antimicrobial soap.” c. “Change the water in your drinking glass every 4 hours.” d. “Wash your toothbrush in the dishwasher once each month.” ANS: B Pg 556 and 580 MEDSURG QUESTIONS AND ANSWERS. Download to score c. “ I will have my liver function tested while I am taking this medication d. “ This medication may cause my blood pressure to increase” ANS: C 8. A nurse is planning care for a client who has pulmonary embolism and a prescription for enoxaparin via subcutaneous injection. Which of the following interventions should the nurse include? a. Massage the injection site for 1 min b. Assess the clients stools for occult blood c. Instruct the client to limit vitamin K intake d. Monitor the clients PT levels ANS: B 9. A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse? a. The client reports a pain level of 7 on a scale from 0 to 10 at the operative site b. The client has 100 mL blood in the closed-suction drain c. The clients capillary refill in the left toe is 6 seconds d. The client has an oral temperature of 38.3° C (100.9° F) ANS: C 10. A community health nurse is reviewing home care instructions with an older adult client who has a new diagnosis of heart failure. Which of the following is the priority topic to review with the client? a. Daily exercise routine b. Daily sodium restrictions c. Fluid intake record d. Changes in weight ANS: D 11. A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by MEDSURG QUESTIONS AND ANSWERS. Download to score the client indicates an understanding of the teaching? a. “ I will have to wait 2 months before additional saline can be added to by breast expander” b. “ I will perform strength-building arm exercises using a 15-pound weight” c. “ I will keep my left arm flexed at the elbow as much as possible” d. “ I should expect less than 25 mL of secretions per day in the drainage devices” MEDSURG QUESTIONS AND ANSWERS. Download to score ANS: D 12. A nurse is planning care for a client who has a chest drainage system set to low suction following a thoracotomy. Which of the following nursing actions is appropriate to include in the plan of care? a. Loop excess tubing below chest wall b. Keep the water seal chamber at chest level c. Check for bubbling in the water seal chamber d. Empty collection chamber every 8 hr ANS: C 13. A nurse is assessing a client following the insertion of a central venous catheter. Which of the following findings indicates a pneumothorax? a. Distended neck veins b. Diminished breath sounds c. Irregular heart rate d. Itching over the incision site ANS: B 14. A nurse is obtaining a medication history from a client who is to start therapy with naproxen for rheumatoid arthritis. Which of the following medications places the client at risk for bleeding? a. Ibuprofen b. Phenytoin c. Captopril d. Digoxi n ANS: A 15. A nurse is caring for a client who is receiving total parenteral nutrition through a central line. The current bag is nearly empty, and a new bag is unavailable from the pharmacy. Which of the following actions should the nurse take? MEDSURG QUESTIONS AND ANSWERS. Download to score d. “ I will need to take my clothes to the dry cleaners to sterilize them” ANS: B 20. A nurse is preparing instructions for a client who is prescribed metoprolol. Which of the following should the nurse plan to include in the teaching? a. Notify the provider if hearing loss occurs b. Expect excess production of saliva after taking the medication MEDSURG QUESTIONS AND ANSWERS. Download to score c. Take a radial pulse before administering the medication d. Monitor for hyperglycemia when taking the medication ANS: C Pharm ATI book p.158 it just says to monitor pulse but not radial or apical specifically. 21. A nurse is caring for a client who has atrial fibrillation. Which of the following medications should the nurse expect to administer? a. Atropine b. Amiodarone c. Lidocaine d. Dobutamine ANS: B Page 171, Box 28.4 22. A nurse is caring for a client who is admitted with heart failure. Which of the following laboratory findings should the nurse report to the provider? a. Hematocrit 24% b. Sodium 137 mEq/L MEDSURG QUESTIONS AND ANSWERS. Download to score c. BUN 19 mg/dL d. Glucose 112 mg/dL ANS: A. (Page 245) Only abnormal lab. 23. A nurse is teaching a client who has Grave’s disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching? MEDSURG QUESTIONS AND ANSWERS. Download to score d. Oatmeal ANS: A (Page 337) Educate the client to eat high protein, high calories, and low-fiber foods. 27. A nurse is caring for a client who develops third-degree heart block with a heart rate of 30/min. Which of the following actions should the nurse take? a. Perform carotid sinus massage b. Administer digoxin by IV bolus c. Instruct client to perform valsalva maneuver d. Prepare the client for temporary pacing ANS: D (Page 176) Indications for pacemaker: symptomatic bradycardia, complete heart block. A is regarding to high blood pressure and tachycardia. B and C are regarding tachycardia. 28. A nurse in the emergency department admitted a client who is having a myocardial infarction. The client has been placed on the heart monitor. Which of the following electrocardiogram strips is indicative of a myocardial infarction? MEDSURG QUESTIONS AND ANSWERS. Download to score ANS: D ST elevation. No need to look up book. 29. A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching? a. “ I will eat a high-fiber diet” b. “ I will take a laxative when im confused” MEDSURG QUESTIONS AND ANSWERS. Download to score c. “ I will empty my bag when it is full” d. “ I will expect my stools to be loose” ANS: D Page 303 and 305. Ileostomy is frequent and liquid since large intestine is bypassed. 30. A nurse is caring for a client who has bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suctioning. The nurse should recognize these assessment findings as indicating which of the following? a. Aspiration b. Fluid volume excess c. Increased cardiac output d. Pleural effusion ANS: B (or D, but most likely B). Page 267-268 for B and Page 202 for D 31. A nurse is caring for a client who is 5 days postoperative following a total abdominal hysterectomy. Which of the following findings indicates wound dehiscence? a. Inflammation of incision edges b. Serous crusting along the incision site c. Increased serosanguineous drainage from the wound d. Incisional pain when coughing or breathing deeply ANS: C ATI Fundamentals book p.331 manifestations says “a significant increase in the flow of serosanguineous fluid on the wound dressing” but also “immediate history of sudden straining (coughing, sneezing, vomiting)” i agree lol :0 All other answers are expected findings (Page 648). Page 650 states coughing can cause MEDSURG QUESTIONS AND ANSWERS. Download to score 36. A nurse is caring for a client who has been diagnosed with myxedema coma. Which of the following assessment findings indicates that the prescribed interventions have been effective? a. Heart rate 56/min b. Respiratory rate 18/min c. PaCO2 49 mm Hg d. Blood pressure 80/50 mm Hg ANS: B Page 515 - Myxedema (severe hypothyroidism) is swelling of the face, hands, and feet. Manifestations include respiratory failure, hypotension, bradycardia, dysrhythmia, and respiratory acidosis MEDSURG QUESTIONS AND ANSWERS. Download to score 37. A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the admission diagnosis, which of the following clients requires a private room? a. A client who has diabetes mellitus and is presenting with acute ketoacidosis b. A client who reports having fever, night sweats, and cough for 2 days c. A client who has a compound fracture of the right femur d. An older adult client who was admitted with aspiration pneumonia ANS: B. S/S of TB 38. A nurse is caring for a female client who has toxic shock syndrome. Which of the following findings should the nurse expect? a. Elevated platelet count b. Generalized rash c. Decreased total bilirubin d. Hypertension ANS: B Not in book. Google toxic shock syndrome = Rash 39. A nurse is caring for a client who has thrombocytopenia. Which of the following laboratory results should the nurse expect? a. INR of 1.0 b. PT 11 seconds c. aPPT 40 seconds d. Platelets 70,000/mm³ ANS: D Only abnormal lab results MEDSURG QUESTIONS AND ANSWERS. Download to score 40. A nurse is assessing a client who has an arteriovenous (AV) fistula in the left forearm. Which of the following findings should the nurse identify as an indication of complication at the vascular access site? a. Absence of a bruit b. 2+ left radial pulse c. Dilated appearance of the AV site d. Presence of palpable thrill ANS: A Obviously MEDSURG QUESTIONS AND ANSWERS. Download to score ANS: B, D, C, E, A 45. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports bladder spasms and the nurse observes decreased urinary output. Which of the following actions should the nurse take? a. Administer ibuprofen 400 mg for pain relief b. Decrease traction of the catheter c. Flush the catheter manually with 0.9% sodium chloride d. Remove the indwelling urinary catheter ANS: C ; p.426 46. A nurse is caring for a client in the emergency department following a myocardial infarction. Which to the following actions should the nurse anticipate if the client develops asystole? a. Start continuous lidocaine infusion b. Begin cardiopulmonary resuscitation c. Administer atropine via IV bolus d. Defibrillate with 200 joules ANS: B 47. A nurse is caring for an older adult client who is prescribed packed RBCs. Which of the following actions is appropriate for the nurse to take? a. Infuse lactated ringers solution while transfusing blood product b. Obtain vital signs every hour during transfusion c. Administer the transfusion over a 4 hr period d. Use a 24-gauge needle for the transfusion ANS: C p.250 48. A nurse is teaching a group of young adult clients about risk factors for hearing loss. MEDSURG QUESTIONS AND ANSWERS. Download to score Which of the following factors should the nurse include in the teaching? (Select all that apply) a. Frequent exposure to low-volume noise b. Use of loop diuretics c. Chronic infections of the middle ear d. Born with a high birth weight e. Perforation of eardrum MEDSURG QUESTIONS AND ANSWERS. Download to score ANS: B, C, E pg 71 ototoxic medications like furosemide, gentamicin, erythromycin, NSAIDs, aspirin 49. A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. Which of the following routine medications to give at 0800 should the nurse withhold? a. Valproic acid b. Metoprolol c. Fluticasone d. Metformi n ANS: D 50. A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse? a. “ The elastic bandage will keep the sutures from loosening” b. “ The elastic bandage will keep you from seeing the surgical site” c. “ The elastic bandage will prevent a postoperative wound infection” d. “ The elastic bandage will prevent excess edema” ANS: D 51. A nurse in the intensive care unit is caring for client who has the following ABG results: pH 7.30; HCO3 19 mEq/L; PaCO2 and PaCO2 within the expected reference ranges. The nurse should expect to provide treatment for which of the following conditions? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis ANS: A MEDSURG QUESTIONS AND ANSWERS. Download to score b. PaO2 95 mm Hg c. PaCO2 50 mm Hg d. HCO3 20 mEq/L ANS: C; p.130 57. A nurse is instructing a client who has a new diagnosis of type 1 diabetes mellitus about the sick-day rules. Which of the following statements by the client indicates an understanding of the teaching? a. “ I will not take my diabetes medications while I am sick” MEDSURG QUESTIONS AND ANSWERS. Download to score b. “ I will consume 250 grams of carbohydrates daily while I’m sick” c. “ I will monitor my blood glucose every 8 hours” d. “ I will check my urine for ketones if my blood glucose is greater than 240 mg/dL” ANS: D (Found on course hero); also p.539 58. A nurse on an acute care unit is receiving change of shift report for four clients. Which of the following clients should the nurse assess first? a. A client who had total hip arthroplasty and is reporting a pain level of 5 on a scale of 0 to 10 b. A client who received morphine 10 mg IV bolus 30 min ago and has a respiratory rate of 14/min c. A client who had a colon resection 24 hr ago and has a hemoglobin level of 14 g/dL d. A client who had an acute kidney injury and has a potassium level of 6.5 mEq/L ANS: D p.380 59. A nurse is reviewing medications taken at home who has angina. Which of the following statements by the client indicates an understanding of the teaching? a. “ I should lie down before taking a dose of isosorbide dinitrate” b. “ I should take my daily aspirin on an empty stomach” c. “ I should withhold my metoprolol if my heart rate is above 100 beats per minute” d. “ I should place a nitroglycerin tablet under my tongue every 10 minutes for up to four doses” ANS: A ; aspirin shouldn’t be taken on an empty stomach, metoprolol helps lower HR, nitroglycerin is every 5 minutes 60. A nurse is planning care for a client who is 12 hr postoperative following a kidney transplant. Which Of the following actions should the nurse include in the plan of care? a. Monitor for hypokalemia as a manifestation of acute rejection b. Administer opioids PO MEDSURG QUESTIONS AND ANSWERS. Download to score c. Check the client blood pressure every 8 hr d. Assess urine output hourly ANS: D p.374 61. A nurse is providing teaching to a client who has diabetes mellitus. Which of the following instructions should the nurse provide to the client to help prevent the development of nephropathy? a. Controlling hypertension b. Voiding every 2 hr MEDSURG QUESTIONS AND ANSWERS. Download to score ANS: A 66. A nurse is caring for a client who has rheumatoid arthritis and reports increasing fatigue. The nurse should instruct the client to take which of the following actions to conserve energy? a. Determine priority activities to accomplish b. Limit iron intake c. Avoid using large muscle groups d. Allow others to perform her self care activities ANS: A 67. A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE inhibitor and reports a nagging cough. Which of the following responses by the nurse is appropriate? a. “ Sucking on a lozenge may reduce the frequency of your cough” b. “ Your cough should go away in time” c. “ Your cough may require that you stop or change your medication” d. “ Increasing your daily fluid intake may eliminate your cough” ANS: C 68. A nurse is providing discharge teaching to a client who has autoimmune system due to chemotherapy. Which of the following information should the nurse include in the teaching? a. “ Change the water in your drinking glass every 4 hours” b. “ Change your pets litter box daily” c. “ Wash your perineal area two times each day with antimicrobial soap” d. “ Wash your toothbrush in the dishwasher once each month” ANS: C 69. A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take? a. Hold the transfusion if the client is actively bleeding MEDSURG QUESTIONS AND ANSWERS. Download to score b. Administer the plasma immediately after thawing c. Administer the transfusion through a 25 gauge saline lock d. Transfuse the plasma over 4 hr ANS: B 70. A nurse is providing teaching to a client who has tuberculosis. Which of the following is appropriate for the nurse to include in the teaching? MEDSURG QUESTIONS AND ANSWERS. Download to score a. “ You should expect to take prescribed medication therapy for 2 months” b. “ You will need to continue to have yearly tuberculosis skin tests” c. “ You should avoid consuming fresh fruits and vegetables during therapy” d. “ You will no longer be contagious after three consecutive negative sputum specimens” ANS: D (P.138) 71. A nurse in the emergency department is reviewing the medical record of a client who is experiencing chest pain. Which of the following findings should the nurse recognize as an indication the client recently experienced a myocardial infarction? (Click on the exhibit button for additional information about the client. There are three tabs that contain separate categories of data) a. Serum markers b. Serum lipid c. Echocardiogram d. 12 lead ECG ANS: D? 72. A nurse is caring for a client who has dumping syndrome following a gastrectomy. Which of the following actions should the nurse take? a. Encourage the client to drink at least 360 mL (12 oz) of fluids with meals b. Provide the client with four full meals a day c. Have the client lie down for 30 min after meals d. Offer the client high carbohydrate meal options ANS: C Rationale: Eat small, frequent meals. Eat at least 6 times a day. Lie down as soon as you finish eating. This reduces the symptoms of dumping syndrome by slowing the emptying of food from the stomach. MEDSURG QUESTIONS AND ANSWERS. Download to score following assessment findings should the nurse report to the provider? a. Blood glucose of 120 mg/dL b. RBC count of 4.7 million/mm c. WBC count of 16,000/mm d. BUN 22 mg/dL ANS: C MEDSURG QUESTIONS AND ANSWERS. Download to score 79. 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 current coming from your heart” 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” ANS: A 80. 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 teaching? a. “ I will expect swelling in my feet and ankles” b. “ I will keep an exercise diary” c. “ I will take ibuprofen for mild pain” d. “ I will weigh myself every other day” ANS: B 81. A nurse is caring for a client who has deep partial-thickness burns over 15% of her body. Which of the following laboratory findings should the nurse expect during the first 24 hr? a. Hypoalbuminemia b. Hypoglycemia c. Decreased hematocrit d. Decreased BUN ANS: A- page 481 82. A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse? a. Check potassium levels b. Begin bicarbonate continuous IV infusion c. Initiate a continuous IV insulin infusion d. Administer 0.9% sodium chloride ANS: D MEDSURG QUESTIONS AND ANSWERS. Download to score PG 538- always treat underlying cause, provide rapid isotonic fluid replacement to maintain perfusion of vital organs 83. A nurse is caring for a client who has severe burn injury. The nurse should recognize which of the following findings as an indication of hypovolemic shock? a. PaCO2 37 mm Hg MEDSURG QUESTIONS AND ANSWERS. Download to score 88. A nurse is providing discharge teaching about foot care to a client who is newly diagnosed with type 1 diabetes mellitus. Which of the following information should the nurse include? a. Apply lotion between toes b. Soak the feet twice a day c. Inspect the feet every other day d. Trim toenail straight across ANS: D 89. A nurse is reviewing the medical record of a client who has heat exhaustion with nausea and vomiting. Which of the following prescriptions should the nurse expect to administer? (Click on the exhibit button for additional information about the client) a. Dextrose 5% in water b. 0.9% sodium chloride IV solution c. Spironolactone d. Metoprolol ANS: B? The prognosis is optimal when HS is diagnosed early and management with cooling measures and fluid resuscitation and electrolyte replacement begins promptly. Not sure tho because their no exhibit but this would make most sense 90. A nurse is caring for a client who has a peripherally inserted central catheter. The client is receiving an antibiotic via intermittent IV bolus. Which of the following actions should the nurse take? a. Verify placement with an x-ray prior to the initial dose b. Change the transparent membrane dressing daily c. Administer 20 mL of 0.9% sodium chloride after each dose of medication d. Flush the catheter using a 5-mL syringe ANS: A MEDSURG QUESTIONS AND ANSWERS. Download to score x ray verification prior to use Use 10mL or < syringe Tape cath hub to minimize manipulation Remove dressing from distal to proximal note length to help detect cath. migration 91. A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain? a. A client who has peritonitis report generalized abdominal pain b. A client who has angina reports substernal chest pain c. A client who has pancreatitis reports pain in the left shoulder MEDSURG QUESTIONS AND ANSWERS. Download to score d. A client who is postoperative reports incisional pain ANS: C pg 25 92. 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. Sodium 130 mg/dL b. WBC count 15,000/mm c. BUN 8 mg/dL d. Hematocrit 35% ANS: B page 120 93. A nurse is preparing to assist the provider with a thoracentesis for a client who has a left pleural effusion. Which of the following interventions is the priority of the nurse? a. Administer a sedative medication b. Describe the sensation the client will feel during the procedure c. Reinforce the importance of lying still during the procedure d. Determine whether the client has an allergy to local anesthetics ANS: D 94. A critical care nurse is assessing a client who has 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 ANS: B 95. A nurse is caring for a client who is receiving epidural analgesia. Which of the following assessment findings is the nurse's priority? a. Bladder distention b. Weakness in lower extremities MEDSURG QUESTIONS AND ANSWERS. Download to score d. Lymphedema ANS: D 100. A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client? a. Side-lying MEDSURG QUESTIONS AND ANSWERS. Download to score b. Reverse trendelenburg c. Feet elevated d. High- fowler's ANS: C