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MED SURG FINAL EXAM S.G.
BOLD ONES I GOT WRONG
EXAM 1 2025/
1. A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion
does the nurse evaluate first? Irregular blue mole with white specks on the lower
leg
- The nurse is caring for a client with an acute burn injury. Which action should the nurse take
to prevent infection by autocontamination? Change gloves between wound care on
different parts of the client's body.
3. A client has a leg wound that is in the second stage of the inflammatory response. For
what manifestation does the nurse assess?Purulent drainage
4. A nurse is caring for a client with systemic sclerosis. The client’s facial skin is very taut, limiting the client’s ability to open the mouth. After consulting with a registered dietitian for appropriate nutrition, what other consultation should the nurse facilitate?
With limited ability to open the mouth, dental hygiene may be lacking. The
nurse should encourage the client to see a dentist. The other referrals are
not related to the mouth.
- A student nurse asks the nursing instructor what “apoptosis” means. What response by the
instructor is best? Apoptosis is programmed cell death. With this
characteristic, organs and tissues function with cells that are at their peak
of performance. Growth by cells enlarging is hyperplasia. Having the
normal number of chromosomes is euploidy. Inhibition of cell growth is
contact inhibition.
6. A preoperative nurse is assessing a client prior to surgery. Which information would
be most important for the nurse to relay to the surgical team? Use of multiple
herbs and supplements
7. Which statement about carcinogenesis is accurate? Tumor cells need to develop
their own blood supply.
8. A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the
nurse? Report of headache and stiff neck
9. The nurse caring for oncology clients knows that which form of metastasis is the
most common? Bloodborne
10. A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, “Why am I taking this medication?” How should the
nurse respond? "It helps prevent stomach ulcers, which are common after
burns."
11. A nurse is orienting a new client and family to the inpatient unit. What information
does the nurse provide to help the client promote his or her own safety? Encourage
the client and family to be active partners.
- A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which
action should the nurse take next? Place the client in an upright position.
13. A nurse is caring for a client who has a spinal cord injury at level T3. Which
intervention should the nurse implement to assist with bladder dysfunction? Use the
Credé maneuver every 3 hours.
14. A nurse plans care for a client who is immobile. Which interventions should the nurse include in this client’s plan of care to prevent pressure sores? (Select all that apply.)
Place a small pillow between bony surfaces. Use a lift sheet to assist with
re-positioning. Keep the client's heels off the bed surfaces.
15. A nurse assesses an older adult’s skin. Which findings require immediate referral?
(Select all that apply. Lesion with various colors Asymmetric 6-mm dark
lesion on forehead
16. A nurse reads on a hospitalized client’s chart that the client is receiving teletherapy.
What action by the nurse is best? Coordinate continuation of the therapy.
- A nurse cares for a dying client. Which manifestation of dying should the nurse treat first?
Pain
18. A postoperative client vomited. After cleaning and comforting the client, which action by the
nurse is most important? Auscultate lung sounds.
- A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which action should the
nurse take? Assess the IV site at least every 2 hours for thrombophlebitis.
- A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action
should the nurse take first? Assess the right leg for pulses, skin color, and
temperature
- A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which
expected therapeutic effect should the nurse assess? Blood pressure decrease from
180/72 mm Hg to 144/50 mm Hg
- A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of
breath with activity and extreme fatigue. What intervention is best to promote comfort? Pace
activities, allowing for adequate rest.
23. A nurse is assessing clients on a medical-surgical unit. Which adult client should the
nurse identify as being at greatest risk for insensible water loss? Anxious client
who has tachypnea
24. A nurse plans care for a client who has a wound that is not healing. Which focused assessments should the nurse complete to develop the client’s plan of care? (Select
all that apply.) Height, Alcohol use, Prealbumin laboratory results
- A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads in the client’s chart that the cancer classification is TISN 0 M 0. What does the nurse
conclude about this client’s cancer? There are no distant metastases noted in the
report.
26. A nurse is working with a community group promoting healthy aging. What **recommendation is best to help prevent osteoarthritis (OA)? Lose weight if needed
- The nurse working in the orthopedic clinic knows that a client with which factor has**
an absolute contraindication for having a total joint replacement?Severe
osteoporosis
- After teaching a client about advance directives, a nurse assesses the client’s understanding. Which statement indicates the client correctly understands the teaching?
focused assessment should the nurse complete next? Hemoglobin and hematocrit
44. A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team?
Potassium: 2.9 mEq/L
45. A nurse assesses clients on a medical-surgical unit. Which client should the nurse
evaluate for a wound infection? Client with a white blood cell count of
23,000/mm
- A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. What response by the experienced
nurse is best? "Being able to sleep doesn't mean pain doesn't exist."
47. A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint.
What nonpharmacologic treatment does the nurse apply? Ice packs
48. The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most
appropriate? Inform the surgeon that the sterile field has been broken
49. A client is receiving plasmapheresis as treatment for Goodpasture’s syndrome. When planning care, the nurse places the highest priority on interventions for which client
problem? Potential for infection related to the site for organism invasion
- The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative
clients. Which client should the nurse assess first? Client with a respiratory rate of 6
breaths/min
- The nurse teaches burn prevention to a community group. Which statement by a member of
the group should cause the nurse the greatest concern? "Sometimes I wake up at
night and smoke."
- A client with acquired immune deficiency syndrome is in the hospital with severe diarrhea. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select
all that apply.) Assisting the client to get out of bed to prevent falls, Obtaining
a bedside commode if the client is weak, Providing gentle perianal
cleansing after stools, Reporting any perianal abnormalities
53. A student nurse asks the faculty to explain best practices when communicating with a person from the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ)
community. What answer by the faculty is most accurate? Don't make
assumptions about their health needs.
- A nurse is working with an older client admitted with mild dehydration. What teaching does
the nurse provide to best address this issue? “Have something to drink every 1 to 2
hours.”
55. A nurse suspects a client has serum sickness. What laboratory result would the nurse
correlate with this condition? Creatinine: 3.2 mg/dL
56. A medical-surgical nurse asks the nurse researcher, “What is the difference between qualitative and quantitative questions?” How should the nurse researcher respond?
"Quantitative questions identify relationships between measurable
concepts."
- A nurse administers topical gentamicin sulfate (Garamycin) to a client’s burn injury. Which
laboratory value should the nurse monitor while the client is prescribed this therapy?
Creatinine
58. A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first? Apply oxygen by mask or nasal cannula
- A nurse is caring for a client who has just had a central venous access line inserted. Which
action should the nurse take next? Confirming placement of the catheter by x-ray
60. A nurse working with older adults assesses them for common potential adverse medication effects. For what does the nurse assess? (Select all that apply.)
Constipation, Dehydration, Weakness
- A nursing student learning about antibody-mediated immunity learns that the cell with the
most direct role in this process begins development in which tissue or organ Bone marrow
62. A client has received intravenous anesthesia during an operation. What action by the
postanesthesia care nurse is most important? Place the client on a cardiac monitor
and pulse oximeter.
63. A nurse cares for a client with decreased mobility. Which intervention should the
nurse implement to decrease this client’s risk of fracture? Perform weight-bearing
activities.
- A client with human immune deficiency virus (HIV) has had a sudden decline in status with a
large increase in viral load. What action should the nurse take first Assess the client for
adherence to the drug regimen.
65. The nurse is caring for clients on the medical-surgical unit. What action by the nurse
will help prevent a client from having a type II hypersensitivity reaction? Correctly
identifying the client prior to a blood transfusion
66. A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan?
Decreased orthostatic light-headedness and dizziness
- A nurse cares for clients who have various skin infections. Which infection is paired with the
correct pharmacologic treatment? Fungal infection- Ketoconzole ( Nizoral )
- A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which
question should the nurse ask first? What medications are you taking?
69. A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan
primary teaching? Acetaminophen (Tylenol)
- While assessing a client’s lower extremities, a nurse notices that one leg is pale and cooler to the touch. Which assessment should the nurse perform next? Palpate the client’s pedal pulses bilaterally.
71. A nurse assesses an older adult client with the skin disorder shown below: Petechiae
72. While assessing a client, a nurse detects a bluish tinge to the client’s palms, soles, and
mucous membranes. Which action should the nurse take next? Use pulse oximetry to
assess the client's oxygen saturation
- The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is
most effective? Consistent use of Standard Precautions
74. A client has a platelet count of 9800/mm 3. What action by the nurse is most
appropriate? Instruct the client to call for help to get out of bed.
the student using a pair of scissors to cut a 4x4 gauze pad to make a split dressing that will fit around the tracheostomy tube. What is the nurse’s best action? Direct the student in the correct use of mater and explain the rationale.
15. A patient has an endotracheal tube and requires frequent suctioning for copious secretions. What is a complication of tracheal suctioning? Hypoxia 16. A patient required emergency intubation and currently has an artificial airway in place. Oxygen is being administered directly from the wall source. Why would warmed and humidified oxygen be more appropriate choice for this patient? Helps prevent drying damage to mucous membranes 17. A patient with an endotracheal tube in place has dry mucous membranes and lips related to the tube and the partial open mouth position. What techniques does the nurse use to provide this patient with frequent oral care? Uses oral swabs or a soft bristle brush moistened in water 18. The nurses is caring for a patient with a nasal fracture. The patient has clear secretions that react positively when tested for glucose. Which complication does the nurse suspect? Skull fracture 19. The patient with a nasal fracture has clear fluid draining from the nose which dries on a piece of filter paper and leaves a yellow “halo” ring at the dried edge of the fluid. What is the nurse’s best first action? Notify the healthcare provider 20. The nurse is caring for several patients who are at risk because of problems related to the upper airway. Which are the priority assessments and actions for these patients? Adequacy of oxygenation; ensure an unobstructed air passageway 21. On postoperative assessment, the nurse notes that the patient with a rhinoplasty repeatedly swallows. What is the nurse’s best first action? Examine the throat for bleeding 22. A patient has been diagnosed with sleep apnea. Which assessment findings indicate that the patient is having complications associated with sleep apnea? Side effects of hypoxemia, hypercapnia, and sleep deprivation 23. The patient with laryngeal trauma develops stridor. What is the nurse’s highest priority intervention? Call the Rapid Response Team 24. Which factors contributes to sleep apnea?(select all that apply) 25. The patient with laryngeal trauma develops stridor. What is the nurse’s highest priority intervention? Call the rapid response team 26. Which are characteristics of asthma?(select all that apply) Narrowed airway lumen due to inflammation, increased eosinophils, intermittent bronchospasm, situation of disease process by allergies. 27. The nurse is caring for an older adult patient with a chronic respiratory disorder. Which interventions are best to use in caring for this patient?(select all that apply) Provide rest periods between activities, schedule drug administration around routine activities, arrange chairs in strategic locations to allow patient to walk and rest, encourage the patient to have an annual flu vaccination. 28. An adult patient diagnosed with rhinitis medicamentosa reports chronic nasal congestion.What does the nurse instruct the patient to do? Discontinue the use of the current nose drop or sprays. 29. Which description best defines the cardiovascular concept afterload? Amount of pressure or resistance that the ventricles must overcome to eject blood through this semilunar valves and into the peripheral blood vessels 30. The nurse is providing health teaching for a patient at risk for heart disease. Which factor is the most modifiable, controllable risk factor? Obesity
31. Which statement about blood pressure are accurate? (Select all that apply) pulse pressure is the difference between the systolic and diastolic pressures, diastolic blood pressure is primarily determined by the amount of peripheral vasoconstriction, to maintain adequate blood flow to the coronary arteries mean arterial pressure must be at least 60 MM HG 32. Which category of cardiovascular drugs block the sympathetic stimulation to the heart and increase the heart rate? Beta blockers 33. What term describes the difference between systolic and diastolic values, which is an indirect measure of cardiac output? Pulse pressure 34. Patient comes to the clinic stating “ my right foot turns a darkish red color when i sit too long, and when i put my foot up, it turns pale.” Which conditions does the nurse suspect? Arterial insufficiency 35. The patient has smoked half a pack of cigarettes per day for two years. How many pack- years has this patient smoked? 36. In assessing a patient who has come to the clinic for a physical exam, the nurse sees that the patient has parlor. What is the find the most indicat in assessing a patient who has come to the clinic for physical exam, the nurse sees that the patient has pallor. What is the find the most indicative of? Anemia 37. The nurse is performing a cardiac assessment on older adults. What is a common assessment finding for this patient? S4 heart sound 38. A patient’s chart notes that the examiner has heard S1 and S2 auscultation of the heart. What does the documentation refer to? First and second heart sounds 39. The nurse is assessing a patient with suspected CVD. When assessing the precordium, which assessment technique does the nurse begin? Inspection 40. While listening to a patient's heart sounds, the nurse detects a murmur. What does the nurse understand about the cause of murmurs? A murmur is caused when there is turbulent blood flow through normal or abnormal valves 41. In assessing a patient, the nurse finds that the PMI appears in more than one intercostal space, and has shifted laterally to the midclavicular line. How does the nurse interpret this data? Left ventricular hypertrophy 42. The primary pacemaker of the heart, the SA node, is functional if a pt.s pulse is at what regular rate? 60 to 100 beats/min 43. What is the normal measurement of the PR interval in a ECG? 0.12-0.20 second 44. What is the QRS complex in an ECG normally? Less than 0.12 seconds 45. What is the ST segment in a ECG normally? Isoelectric 46. What is the total time required for ventricular depolarization and repolarization as represented on the ECG? QT interval 47. The nurses were viewing ECG results of a patient admitted for fluid and electrolyte in balances. The T waves are tall and peaked. The nurse reports this finding to the provider obtains an order for which Serum level test? Potassium 48. The nursing notified by the telemetry monitor technician about a patient’s heart rate. Which Method to confirm the technicians report? Assess the patient’s heart rate directly by taking apical pulse. 49. Atherosclerosis affects which large arteries? (select all that apply) 50. A patient is amid it with a vascular problem. Based on the pathophysiology of systemic arterial pressure, what is the systemic arterial pressure a product off?(select all that apply) cardiac output, peripheral vascular resistance 51. A patient is prescribed Atovastin(Lipitor). The nurse instructs the patient to watch for and
73. The nurse is performing the immediate post procedure care for a bone marrow donor. What is the priority assessment that the nurse will perform? Monitor for infection 74. An older patient has been receiving frequent blood transfusions without any complications or adverse reactions; however, the nurse carefully monitor is the patient during the current transfusion. Which signs/symptoms suggest that the patient is experiencing circulatory overload? 75. The patient reports fatigue, bone pain, and frequent bacterial infections. Further investigation reveals anemia, hypercalcemia, X-Ray findings show bone thinning with areas of bone loss that resembles Swiss cheese. The signs/symptoms and diagnostic findings are consistent with which disorder? Multiple Myeloma EXAM 3 1. The nurse is assessing a clients abdomen. Identify the area where the nurse’s hand should be placed to palpate the liver. Upper Right Quadrant of Abdomen
- After several diagnostic tests, a client is diagnosed with diabetes insipidus. The nurse preforms an assessment an assessment on the client, knowing that which symptoms is most indicative of this disorder? Polydipsia 3. Which client statement alerts the nurse to the possibility of hypothyroidism? “I am always tired even with 10 to 12 hours of sleep”
- Which dietary modification does the nurse provide for a client with hyperthyrodism? Increased calories, proteins, and carbohydrates 5. Which client is at highest risk for hearing loss? A client with osteomyelitis receiving IV gentamicin (Garamycin) 6. A client’s chart indicate anisocoria. For what should the nurse assess? Difference in pupil size 7. The nurse is caring for a client with otitis media. The client reports that the pain was severe during the night but was gone upon awakening in the morning. Which finding does the nurse expect to observe during the client’s physical assessment? Purulent fluid is present in the ear canal
- The nurse is caring for a client with ulcerative colitis and severe diarrhea. Which nursing assessment is the highest priority? Heart rate and rhythm 9. Which nursing actions are appropriate following a liver biopsy? Select all that apply. Immediately assist client to turn on right side. Check vital signs every 10-15 minutes for 1 - 2 hours. Place a pillow under the right costal margin. Instruct the client to avoid heavy lifting for 1 week after biopsy.
- A client is scheduled for an ultrasound to rule out bile duct obstruction. What preparation is required for an ultrasound test? Explanation about the procedure 11. Twelve hours after a total thyroidectomy, the client develops stridor. Which is the nurse’s priority intervention? Prepare for emergency tracheostomy and call the health care provider
- What isolation precautions are necessary for a client with a history of hepatitis C who is “anti-HCV positive”? Standard precautions 13. The most important nursing assessment to make before a client is started on indomethacin is: Asking if there is a history of gastric bleeding
- The nurse is caring for a client who has just been diagnosed with end-stage pancreatic cancer. The nurse assesses the client’s emotional response to the diagnosis. Which is the nurse’s initial action for the assessment? Determine whether the client feels like
talking about his or her feelings.
15. Blood sugar management for a client who has Type 2 Diabetes with nausea and decreased appetite should include: Continuing insulin even if the client is vomiting
- The client with obstructive jaundice asks the nurse why his skin is so itchy. Which is the nurse’s best response? “Bile salts accumulate in the skin and cause the itching.” 17. The nurse is caring for a client with acute pancreatitis. During the physical assessment the nurse notes a grayish-blue discoloration of the client’s flanks. WHich is the nurse’s priority action? Ensure that the client has a patent large-bore IV site 18. What would be allowed in the diet of a client with Peptic Ulcer Disease (PUD)? Tomato juice 19. The nurse is reviewing recent laboratory values for a client who is being treated for malnutrition. Which laboratory finding indicates that the client is not receiving adequate iron supplement? Hematocrit 31%
- Which statement made by a diabetic client who has a urinary tract infection indicates that teaching was effective regarding antibiotic therapy? Even if I completely well, I should take the medication until it is gone.”
- A client has newly diagnosed diabetes. To delay the onset of microvascular and macrovascular complications in this client, the nurse stresses that the client take which action? Control hyperglycemia
- A male client reports fluid secretion from his breasts. What does the nurse assess next in this client? Anterior pituitary hormones 23. THe nurse is obtaining the history of a client with a sliding hernia. Which symptoms does the nurse expect to see in this client? (Select all that apply) Belching, Dysphagia, reflux
- The nurse is caring for a postoperative parathyroidectomy client. Which client complaint would indicate that a life threatening complication may be developing, requiring notification of the health care provider immediately? Laryngeal stridor
- The nurse notes a bulge in a client’s groin that is present when the client stands and disappears when the client lies down. Which conclusion does the nurse draw from these assessment findings? Reducible inguinal hernia
- A client has been educated about activities that can increase intraocular pressure. Which statement indicates that the client requires further teaching? “I will not put my arms above my head.”
- The nurse is caring for a client who is hospitalized with exacerbation of Crohn’s disease. What does the nurse expect to find during the physical assessment? High-pitched, rushing bowel sounds in the right lower quadrant
- What is a common problem that older clients experience more frequently as they age? Decrease hydrochloric acid 29. The client has chronic hypercortisolism. Which intervention is the highest priority for the nurse? Wash the hands when entering the room 30. A client is scheduled to receive Novolog insulin. When should it be administered? 15 minutes before the meal 31. A nurse instructs a client to eat a low-iodine diet before a thyroid study. A client should be told to avoid: Shellfish
- A client is scheduled for a colonoscopy. What does the nurse tell the client to do before the procedure is performed? Begin a clear liquid diet 12 to 24 hours before the test
- A client with a history of diabetes mellitus has new onset of microalbuminauria. Which
output has decreased from the previous day. Which intervention does the nurse expect to provide for the client? Add colloids to the client’s IV solutions
48. Which dietary alterations does the nurse make for a client with CUshing’s disease? Low carbohydrate, low sodium
- Which assessment alerts the nurse to the possible presence of a cataract in a client? Blurred vision and reduced color perception 50. A client on an intensified insulin regimen consistently has a fasting blood glucose level between 70 and 80 mg/dL, a postprandial blood glucose level below 200 mg/dL, and a hemoglobin A1c level of 5.5%. Which is the nurse’s interpretation of these findings? Good control of blood glucose
- A client has abnormal calcium levels. Which hormone does the nurse anticipate testing for? Thyrocalcitonin (calcitonin) 52. A nurse is assessing a client who had an esophagogastroduodenoscopy (EGD). THe first priority for the nurse should be: Monitoring or the return of the gag reflex
- A client is being discharged after having a thyroidectomy. Which of the following discharge instructions would be appropriate for the client? Select all that apply Watch for changes in body functioning, such as lethargy, restlessness, sensitivity to cold, and dry skin, and report these changes to the physician. Take thyroid replacement medication as ordered.
- A client with macular degeneration would like to watch television. Where does the nurse place the television for best visualization of the screen? On either side of the client
- Which substance produced in the stomach facilitates the absorption of Vitamin B12? Intrinsic factor 56. A client is brought to the emergency department after being shot in the abdomen and is hemorrhaging heavily. Which action by the nurse is the priority? Assess and maintain a patent airway.
- The nurse is caring for a female client who is 5 feet, 7 inches tall and weighs 115 pounds. The client asks the nurse if she needs to lose weight. Which response by the nurse is best? No, in fact, your body mass index suggest that you are already underweight
- The nurse is caring for a client with Menieres disease. The client asks the nurse how to prevent another acute episode from occuring. Which is the nurse’s best response? Stop or reduce cigarette smoking 59. Radioactive iodine is administered to a client with hyperthyroidism to: Limit secretion of thyroid hormone by destroying thyroid tissue 60. The nurse is caring for an older client who presents with dizziness and difficulty hearing. Which of the nurse’s assessment findings will require collaboration with the client’s primary health care provider? Select all that apply Clear watery drainage is present in the ear canal and is positive for glucose. The client reports dizziness after taking naproxen (Aleve) for arthritis pain. Tympanic membrane is retracted, with multiple air bubbles.
- The nurse conducts a physical assessment for a client with abdominal pain. WHich finding leads the nurse to suspect appendicitis? Severe, steady right lower quadrant (RLQ) pain 62. How does a tropic hormone differ from other hormones? Tropic hormones stimulate other endocrine glands to secrete hormones
63. A client with Crohn’s disease is scheduled to receive an infusion of infiximab (Remicade). What intervention by the nurse will determine the effectiveness of treatment? Checking the frequency and consistency of bowel movements
- The nurse is caring for a client who is being discharged from the hospital after an attack of acute pancreatitis. Which discharge instructions does the nurse provide for the client to help prevent a recurrence? (selective all that apply) Attend local alcoholics anonymous (AA) meetings weekly. Use cooking spray when you cook rather than margarine or butter. We can talk to your doctor about a prescription for nicotine patches.
- A client has been admitted to the emergency with severe right upper quadrant pain. Based on the signs and symptoms and laboratory data documented on the chart below, the nurse would expect the client to have which diagnosis? Pancreatitis
- On the second postoperative day after a subtotal thyroidectomy, the client tells the nurse that he feels numbness and tingling around his mouth. Which is the nurse’s priority intervention? Assess Chvostek’s sign
- The nurse is caring for a client who was started on total parenteral nutrition (TPN) 2 days previously. The client reports blurred vision, dry mouth, and frequent urination. Which is the nurse’s priority action? Assess the client’s blood sugar
- A client is using an ophthalmic beta-blocking agent for the treatment of glaucoma. Which instruction does the nurse give to the client to prevent orthostatic hypotension? Apply pressure to the inside corner of your eye when administering the drops.
- A client with diabetes has a serum creatinine of 1.9 mg/dL. The nurse correlates which urinalysis finding with this client? Protein in the urine during a random urinalysis 70. The nurse reads on a client’s chart that the client has exophthalmos. What assessment finding is consistent with this diagnosis? Bulging eyes
- A client presents with elevations in triiodothyronine (T3) and thyroxine (T4) and with normal thyroid-stimulating hormone (TSH) levels. Which is the nurse’s priority intervention? Monitor the apical pulse
- The nurse is caring for a client with cholecystitis. Which assessment finding indicates to the condition is chronic rather than acute? Clay-colored stools and dark amber urine 73. Which safety measure is most important for the nurse to institute for a client who has Cushings disease? Use a lift sheet to change the client’s position
- Which situation of condition is likely to result in increased production of thyroid hormones? Starvation 75. A client who has undergone Nissen fundoplication for gastroesophageal reflux disease (GERD) is ready for discharge home. Which statement made by the client indicates understanding of the disease? I will need to continue to watch my diet and may still need medication EXAM 4 1. During a neurologic assessment of a client, the nurse notes that the client’s arms, wrists, and fingers have become flexed, and an internal rotation plantar flexion of the legs are evident. How does the nurse document these findings? Decorticate posturing
- The nurse is assessing a client with a spinal injury at the T5 level. Which clinical manifestation alerts the nurse to the presence of a complication of this injury? Agitation and restlessness
- A woman is being treated in the emergency department after being sexually assaulted.
receptor antibody levels
18. The nurse is assessing a client with a history of migraines. Which clinical manifestation is an early sign of a migraine with aura? Visual disturbances
- The nurse is obtaining a health history for a client admitted to the hospital after experiencing a brain attack. Which disorder does the nurse identify as a predisposing factor for an embolic stroke? Atrial fibrillation
- The nurse is caring for a client with prostate cancer. Which laboratory finding indicated to the nurse that the cancer has metastasized to the bone? Serum calcium 21.6 mg/dL 21. The nurse is caring for a client with a history of epilepsy who suddenly begins to experience a tonic-clonic seizure and loses consciousness. What is the nurse’s priority action? Turn the client’s head to the side.
- The nurse notes reddened areas over the hips and sacrum of a client with paraplegia from a spinal cord injury. Which action does the nurse implement? Reposition the client so that the reddened area does not bear weight
- A client is having a routine prostate examination. An important question that the nurse would ask at this time is: “Do you have difficulty with urination?” 24. The nurse is caring for the client experiencing a possible hospital-acquired bladder infection. Which nursing action should the nurse perform first? Obtain a urine specimen for culture and sensitivity
- During a routine physical examination, a 49 - year-old patient voices concerns about developing BPH. He is interested in actions he can take to promote prostate health and potentially avoid the development of the disorder. What information can be provided to the patient? Encourage the patient to limit alcohol intake
- The nurse assesses a client with a below-knee amputation. Which assessment of the skin flap requires immediate action? Pale and cool to the touch 27. The nursing assistant reports that the client with chronic renal failure (CRF) has “white crystals” and dry, itchy skin. Based on this information, which instruction should the nurse give to the nursing assistant? Prepare a tepid-water bath for the client
- Which instruction does the nurse give to the client before he or she has electromyography (EMG)? “Do not take your cyclobenzaprine (Flexeril) on the 2 days before the test.” 29. A client is actively experiencing status epilepticus. Which prescribed medication does the nurse prepare to administer? Lorazepam (Ativan)
- The nurse is caring for a client receiving hemodialysis. Which of the following assessments would be necessary to detect complications of disequilibrium syndrome? Level of consciousness
- An older woman is admitted after falling down the stairs. Which assessment findings require immediate intervention?(Select all that apply) Potassium 6.0 mEq/L, Dark brown urine, blood pressure 80/50 mm Hg
- A client who has been experiencing dysmenorrhea has come to the ambulatory care clinic. The health care provider has diagnoses the presence of endometriosis. The client asks how this condition is responsible for her pain. What information should be included in the teaching provided? The endometrial tissue located outside of the uterus responds to the hormones responsible for the menstrual period.
- A 32 - year-old African American woman has just been diagnosed with uterine fibroid tumors. The woman is upset and has several questions about the condition. After providing education to her, the nurse will recognize the need for further education when the woman makes which of the following statements? The growth of my tumors is directly linked to my progesterone levels
34. The nurse is performing a medical history and physical assessment on an older client. Which common findings in the older client are related to the musculoskeletal system? (Select all that apply) Decrease in bone density, Atrophy of the muscle tissue, Reduced range of motion of the joints, Degeneration of cartilage
- The nurse is caring for four clients. Which client requires further nursing assessment due to the risk of prerenal failure? The client who has congestive heart failure 36. A patient reports to the emergency department with complaints of scrotal swelling. During the assessment, the patient reports his pain level at “2”. When asked to discuss the characteristics of his pain, he reports feeling a dull ache associated with prolonged standing or walking. The physical assessment reveals a “bag of worms” appearance to the scrotum. Which of the following disorders is likely presented? Varicocele
- Emergency medical services arrive to the emergency department with a client who has a cervical spinal cord injury. Which priority assessment does the emergency department nurse perform at this time? Respiratory pattern and airway
- After performing a physical assessment on a 75 - year old client, the nurse notes that the client has a hypoactive response to a test of deep tendon reflexes. Which intervention does the nurse include in this client’s plan of care? Assist the client with ambulation
- The nurse assesses a client who has trauma to the cerebrum. Which clinical manifestation does the nurse expect to observe? Memory loss 40. The nurse is caring for a client following a knee arthroscopy. What information should the nurse teach? Select all that apply Elevate the involved extremity on pillows for 24- 48 hours, report severe joint pain immediately to the health care provider, treat pain with a mild analgesic such as acetaminophen
- The nurse is assessing the client receiving peritoneal dialysis. Which finding suggests that the client may be developing peritonitis? Cloudy dialysis output. 42. A client who experienced a spinal cord injury 1 year ago is brought to the emergency department. Which prescribed medication does the nurse prepare to administer to this client. Methylprednisolone (Medrol)
- Which postoperative order does the nurse clarify with the surgeon before discharging the client who just had an arthroscopic surgery on the right knee? Administer two tablets of oxycodone/APAP (Tylox) every 4 hours for pain
- A chronic renal failure client is exhibiting signs of metabolic acidosis. Upon assessment of the client’s respiratory status, the nurse would expect: Kussmaul respirations 45. The wife of a man diagnosed with prostate cancer appears disheveled and anxious during her visit to her husband. When the patient leaves the floor for testing, the nurse uses the opportunity to approach her. Which of the following approaches by the nurse is most therapeutic? Would you like to talk about your concerns?
- The nurse is admitting a hospitalized client who has a renal calculi. Which should be the nurse’s priority? Assess the location and the severity of the client’s pain 47. The nurse is caring for a client with a fractured femur. Which factor in the client’s history may impede healing of the fracture? Paget’s disease
- The nurse is caring for several clients with fractures. Which client does the nurse consider at highest risk for developing deep vein thrombosis? Older man who smokes and has a fractured pelvis
- A client has a fracture and is being treated with skeletal traction. Which assessment causes the nurse to take immediate action? The traction weights are resting on the floor. 50. The nurse is assessing the deep tendon reflexes of a client with long-standing diabetes mellitus. Which clinical manifestation does the nurse expect to see? Bilateral hypoactive
by the healthcare provider
67. The nurse is assigned to provide care for a client who had laparoscopy performed to determine the extent of her endometriosis. Which of the findings in the first 4 hours after the procedure by the nurse will indicate the need to contact the health care provider? Restlessness
- A male client states that he is having problems with impotence. Which of the following diseases should the nurse question as part of the client’s past medical history? Select All that Apply Hypertension, Alcoholism, Diabetes
- The nurse is assessing a client with a frontal lobe brain injury. Which clinical manifestation does the nurse plan to see? Impaired Judgement 70. A client is admitted with acute glomerulonephritis. The nurse inspects the clients urine and expects to find: Tea- colored urine
- The nurse is assessing a client with trigeminal neuralgia. Which clinical manifestation does the nurse expect to observe? Controllable facial twitching 72. A woman reports to the health care provider with complaints of urinary incontinence and abdominal/ pelvic pressure. The health care provider examines the patient and diagnoses her condition as a cystocele. Upon hearing the diagnosis, the patient reports that she has heard about this condition. When receiving education about the condition, she states she is relieved the condition is only the result of the weakening of the structures that support her uterus. What response by the nurse is indicated? The cystocele has occured because the bladder is pressing downward on the uterus
- The nurse is caring for a client with a fractured fibula. Which assessment prompts immediate action by the nurse? Numbness and tingling in the extremity 74. The health care provider prescribes cyclobenzaprine (flexeril) 30 mg orally TID for the client hospitalized with acute cervical neck pain. The pharmacy supplied 10 mg tablets. Which action by the nurse is best? Call the health care provider to question the dose prescribed
- The nurse is caring for the client who had continent urinary diversion surgery with creation of a kock pouch. Which intervention should the nurse include in the care? Insert a catheter in the pouch every 4 to 6 hours to drain the urine
- The nurse is assessing a client who had a discectomy 6 hours ago. Which client complaint requires priority action by the nuree? I am unable to urinate 77. A 40 - year-old client undergoes a total abdominal hysterectomy. After the procedure, the patient voices an interest in hormone replacement therapy. What information should be provided to the client? Hormone replacement therapy is not indicated after this particular procedure
- The nurse is assessing the client who is to have a closed reduction for a right elbow dislocation. Which should be the nurse's priority? Sensation and pulse of the right forearm
- A female client is experiencing hot flashes. The client asks the nurse how long will these last. The nurse would respond by stating that hot flashes: May last up to 5 years 80. A 44 - year-old man has sought treatment for erectile dysfunction. The patient asks specifically to be considered for sildenafil (Viagra) therapy. Which of the following factors in the patient’s medical history must be taken into consideration for this particular medication? Select all that Apply The patient has angina, The patient has a history of hypotension
- During a routine breast examination of a client, the nurse notes a small amount of nipple discharge. The nurse would: Select all that Apply Send the specimen to the lab, Ask the client if this has occured before, Collect specimen on slide, Document the finding
82. The nurse is completing a health assessment for primary amenorrhea caused by hyperthyroidism. Which finding during a clinic visit should indicate to the nurse that treatment was effective? States just started having her menses
