Capstone Med Surg Assessment
Capstone Med Surg Assessment
1. A nurse is teaching a client about using a continuous positive airway
pressure (CPAP)
... [Show More] device to treat obstructive sleep apnea. Which of the
following information should the nurse include in the teaching?
2. A nurse is providing discharge teaching to a client following a heart
transplant. Which of the following information should the nurse include in
the teaching?
3. A nurse is caring for a client who has syndrome of inappropriate
antidiuretic hormone (SIADH) and is receiving 3 % sodium chloride via
continuous IV. Which of the following laboratory finding should the nurse
identify as an indication that the SIADH is resolving?
4. A nurse is teaching a client about fecal occult blood testing (FOBT) for the
screening of colorectal cancer. Which of the following statements should
the nurse include in the teaching?
5. A nurse is preparing a client for a colonoscopy. Which of the following
medications should the nurse anticipate the provider to prescribe as an
anesthetic for the procedure?
6. A nurse is planning care for a client who has acute pancreatitis. Which of
the following interventions should the nurse include in the clients plan?
Select all that apply.
7. A nurse is teaching a client who has hypertension about dietary
modifications to help control blood pressure. Which of the following food
choices should the nurse recommend as the client to include in their diet?
8. A nurse is reviewing the medical record of a client who has unstable angina.
Which of the findings should the nurse report to the provider?
9. A nurse is providing discharge instructions to a client who has GERD.
Which of the following statements by the client demonstrates an
understanding of the teaching?
10. A nurse at a provide office is interviewing a client who has multiple
sclerosis and has been taking dantrolone for several months. Which of the
following client statements should the nurse identify as an indication that
the medication is effective?
11.A nurse is assessing a client who reports a possible exposure to HIV. Which
of the following finding should the nurse identify as an early manifestation
of HIV infection?
12.A nurse is teaching a client who has type 1 diabetes mellitus about
hypoglycemia .which of the following statements by the client indicates an
understanding of the teaching?
13.A nurse is providing discharge teaching to a client who has heart failure and
a prescription for furosemide 20 mg PO two times daily. Which of the
following instructions should the nurse include in the teaching?
14.A nurse is caring for a client who has burn injuries covering their upper
body and is concerned about their altered appearance .Which of the
following statements should the nurse make?
15.A nurse is developing a plan of care for a client who will be placed in halo
traction following surgical repair of the cervical spine .Which of the
following interventions should the nurse include in the plan?
16.A nurse is caring for a client who has a traumatic brain injury. Which of the
following finding should indicate to the nurse the need for immediate
intervention?
17.A nurse is assessing a client who has meningitis. The nurse should identify
which of the following finding as a positive Kerning s sign?
18.A nurse is teaching a group of assistive personnel (AP) about caring for
client who have Alzheimer’s disease. Which of the following information
should the nurse include in the teaching?
19.A home health nurse is providing teaching to the family of a client who has
a seizure disorder. Which of the following interventions should the nurse
include in the teaching?
Keep a padded tongue blade near the bedside.
Place a pillow under the client's head while in bed during a seizure.
Administer diazepam orally at the onset of seizures.
Position the client on their side during a seizure.
20.A nurse is contributing to the plan of care for a client who has
pyelonephritis. Which of the following interventions should the nurse
include?
Encourage the client to consume caffeinated beverages
Avoid the use of acetaminophen for discomfort
Monitor the clients the urine for color changes
Begin antibiotic therapy after culture and sensitivity results are obtained
21. Nurse is assessing a client who has a herniated lumbar disc. Which of the
following findings should the nurse expect?
The client reports relief from pain when lying in the prone position.
The client reports that her low-back pain radiates upward toward one scapula.
The client reports tingling and a burning sensation in one foot.
The client reports decreased pain when the affected leg is raised and straightened
22.A nurse is caring for a client who has acute gastritis and is NPO. The client
has a new prescription to resume oral intake. Which of the following items
should the nurse offered the client?
Lemonade
Tomato soup
Gelatin
Black coffee
23.A triage nurse nds a school-age child lying in the road following a school
bus crash with multiple casualties. The child has a respiratory rate of 8/min,
is unresponsive to verbal commands, and groans to painful stimuli. The
nurse should assign the client which of the following triage tags?
Red
Yellow
Green
Black
24.A nurse is teaching a client who has a new diagnosis of polycystic kidney
disease. Which of the following statements should the nurse include in the
teaching?
"Take aspirin as needed to reduce your pain."
"Reduce your dietary beer intake."
"Apply dry heat to your abdomen when needed."
"Check your weight once per week."
25. A nurse is assessing a client who has right lower lobe pneumonia. Which of
the following findings should the nurse expect?
Dull percussion sounds
Increased anterior posterior chest diameter
Distended neck veins
Pitting edema
26.A nurse is providing teaching to the caregivers of a client who has
Alzheimer's disease. Which of the following instructions should the nurse
give? (Select all that apply.)
Install safety locks and alarm systems.
Place nightlights throughout the home.
Replace carpeted flooring with tile.
Establish a predictable daily routine for the client.
Remind the client of scheduled activities 1 day in advance.
27.A nurse is caring for a client who is hyperventilating and has the following
ABG results: pH 7.50, PaCO 29 mm Hg, and HCO 25 mEq/L. The nurse
should recognize that the client has which of the following acid-base
imbalances? 2 3 –
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis
28.A nurse is providing discharge teaching for a client who has COPD about
nutrition. Which of the following instructions should the nurse include?
Eat three large meals daily.
Consume high-calorie foods.
Limit caffeinated drinks to two per day.
Drink fluids during mealtime
29.A nurse is caring for a client who has a right-sided pneumothorax.
Following chest tube insertion, which of the following findings indicates
that the chest drainage system is functioning correctly?
Gentle bubbling in the suction chamber
Crepitus around the insertion site
Constant bubbling in the water seal chamber
Absence of breath sounds on the right side
30.A nurse is caring for client who has a new diagnosis of tuberculosis. Which
of the following precautions should the nurse initiate to present
transmission of the disease?
Contact precautions
Airborne precautions
Droplet precautions
Protective environment
31.A nurse is planning care for a client who has Ménière's disease and is
experiencing episodes of vertigo. Which of the following interventions
should the nurse include in the plan?
Maintain strict bed rest.
Restrict uid intake to the morning hours.
Administer aspirin.
Provide a low-sodium diet.
32.A nurse reviewing laboratory reports for client who is taking NSAISs for
rheumatoid arthritis. Which of the following results should the nurse
recognize as a possible adverse effect of NSAID therapy?
Increased erythrocyte sedimentation rate
Elevated creatinine clearance
Increased serum potassium
Positive fecal occult blood test
33.A nurse is assessing a client who is receiving a blood transfusion. Which of
the following findings indicates the client might be experiencing a
hemolytic transfusion reaction.
Hypertension
Report of urticarial
Distended neck veins
Report of chest pain
34.A nurse is caring for a client who had surgery 2 days ago and reports
incisional pain. Which of the following actions should the nurse take first?
Determine the time the last dose of pain medication was administered.
Reposition the client to assist with reduction of pain.
Ask the client to describe the pain and rate it on a scale of 0 to 10. Para mi
Check the client's medical record for type of PRN pain medication.
35.A nurse is teaching strategies to prevent carpal tunnel syndrome to a group
of oce workers. Which of the following instructions should the nurse
include? (Select all that apply.)
"Raise your chair height so that you lean over to type."
"Use a wrist rest when working at a computer station."
"Stretch your ngers and wrists periodically while working."
"Position your keyboard at shoulder height."
"Take breaks from the repetitive activity."
36.A nurse is assessing a client who has a tension pneumothorax following
blunt chest trauma. Which of the following findings should the nurse
expect?
Tracheal deviation to the unaffected side
Pleural friction rub
Frothy, pink-tinged sputum
Increased breath sounds on the affected side
37.A nurse is caring for an adult client who asks about vaccinations against
communicable diseases. The nurse should inform the client that which of
the following vaccines are available? (Select all that apply)
Hepatitis A vaccine
Hepatitis B vaccine
Pneumococcal vaccine
Hepatitis C vaccine
Helicobacter pylori vaccine
38.A nurse is teaching a client who has angina pectoris about nitroglycerin
sublingual tablets. Which of the following statements should indicate to the
nurse that the client understands the teaching?
"I will keep the tablets in the original container."
"I should keep the container in my shirt or pants pocket."
"I should begin to feel relief within 20 minutes of taking the medication."
"I will drive myself to the emergency room if three nitroglycerin tablets do
not relieve my pain."
39.A nurse is preparing to administer epoetin to a client who has anemia due to
chemotherapy. Which of the following actions should the nurse plan to
take?
Review the client's Hgb level prior to administration.
Use the Z-tract method when administering the medication.
Shake the vial for 30 seconds prior to withdrawing the medication.
Ensure the client is not taking iron supplements while on this medication.
40.A nurse is assessing a client who has Guillain-Barré syndrome. Which of
the following findings should the nurse report to the provider immediately?
Decreasing leg strength
Decreasing voice volume
Decreased deep tendon reflexes
Decreased sensation in the arm
41. A nurse is assessing a client who has Addison's disease. Which of the
following manifestations should indicate to the nurse that the client is
experiencing an Addisonian crisis?
Hypothermia
Increased deep tendon reflexes
Hypotension
Erythema of the neck and chest
42.A nurse is caring for a client who has a cerebellar tumor. Which of the
following actions is the nurse's priority?
Provide assistance with ambulation.
Facilitate retention of facts by repeating instructions.
Place the client in a darkened room.
Speak slowly and clearly.
43.A nurse is providing teaching to a newly licensed nurse about caring for a
client who is receiving a ealed radioactive implant. Which of the following
information should the nurse include in the teaching?
Place soiled linens in a lead container. •
Allow children who are over 10 years old to visit.
Limit visitors to 1 hr per day.
Wear a lead apron during care
44.A nurse is assessing a client who is postoperative following a kidney
transplant. Which of the following findings indicates the client is
experiencing a transplant rejection?
Polyuria •
Hypothermia
Hypertension
Hypovolemia
45.A nurse is providing teaching to a client who is scheduled for a bone
marrow biopsy taken from the iliac crest. Which of the following
information should the nurse include?
"Avoid taking warm baths following the procedure." •
"You will lie on your back during the procedure."
"You will receive general anesthesia for the procedure."
"Take acetaminophen as prescribed for pain relief after the procedure."
46.A nurse is providing discharge instructions to a client who has a peptic
ulcer. Which of the following dietary modications should the nurse include?
Provide a snack at bedtime. •
Choose decaeinated coee.
Restrict intake of fried foods.
Avoid drinking liquids with meals
47.A nurse is assessing a client following a hypophysectomy. Which of the
following findings indicates the client might be developing diabetes
insipidus?
Urine ketones
Hyperglycemia •
Halo or ring-shaped dressing drainage
Low urine specic gravity
48.A nurse is assessing a client who has a history of migraine headaches with
aura and reports feeling "a migraine coming on." The nurse should expect
the client to report which of the following manifestations?
Visual disturbances •
Photophobia
Nasal congestion
Phonophobia
49.A nurse is reviewing laboratory values for a client who has Cushing's
disease. Which of the following
values should the nurse expect?
Blood glucose 65 mg/dL •
Serum calcium 12.2 mg/dL
Potassium 5 mEq/L
Sodium 150 mEq/L [Show Less]