9. Medical Surgical-Physical Assessment/Respiratory-Pneumonia-priority
assessment
Patient with pneumonia ABG ph 7.24, CO2 65, CO3 24. Which
... [Show More] intervention…plan
of care daily
A. Hypertension
B. Maintain IV
C. Check electrocardiogram daily
D. Assess lung for increase pulmonary secretion
TestBankWorld.org
*The nurse is preparing to administer an oral antibiotic to a client with unilateral
weakness, mouth drooping, and aspiration pneumonia. What is the priority nursing
assessment that she will be done before administering the medication.
A- Determine which side of the body is weak
B- Auscultate and breathe sounds
C- Obtain and record client vital sign
D- Ask the client about soft food preferences
100. Medical Surgical-Renal-Acute kidney injury (AKI)-POC
A female client with chronic pyelonephritis expresses concern that she may have to
undergo dialysis. What is the best initial response by the nurse?
a. Offer to introduce the client to a dialysis nurse who can provide teaching
about dialysis
b.
c. Provide assurance that dialysis is not the usual treatment for kidney infections
d. Assist the client to reduce anxiety and gain control by using guided imagery
exercise
101. Medical Surgical-Renal-Chronic renal insufficiency
Which symptoms is a characteristic of urethral colic in the client diagnosed with
renal calculi?
a. symptoms of irritation associated with urinary tract infection
b. Acute, excruciating pain, wave-like pain radiating to the gemnitalia
c. intense, deep ache in the cost vertebral region
d. chills, fever and dysuria
TestBankWorld.org
Explain the relationship between chronic kidney infection renal failure and
dialysis
102. Medical Surgical-Reproductive-Endometriosis
A young adult female client with recurred pelvic pain for 3 years returns to the
clinic for relief of severe dysmenorrheal. The nurse reviews her medical record
which indicates that the client has endometriosis. Based on this finding, what
information should the nurse provide this client?
A- Oral contraceptives increase the symptoms of endometriosis
B- An option to diagnose disease extent and provide therapeutic treatment is
laparoscop
y
C- Infertility is successfully treated with removal of intra-abdominal endometrial lesions
D- The symptoms of endometriosis can increase with menopause
103. Medical Surgical-Respiratory-Chest tube-respiratory distress
The UAP find a patient (chest tube) with shortness of breath call the RN. What is
the first thing that the nurse implements?
A- 2 L Oxygen
B- Check the tube connection
104. Medical Surgical-Respiratory-Pulmonary function test
A client with a 40 pack year history of smoking does not want to have a pulmonary
function test conducted. Which of the following should the nurse explain to the
client regarding this diagnostic test?
A- ¨It is used to diagnose lung cancer so treatment can be started
B- ¨It is used to determine the amount of oxygen that is in your lungs with every
breath¨.
C- ¨It measures your lung functioning¨.
D- ¨It identifies the best interventions to help you quit smoking.
TestBankWorld.org
105. Medical Surgical-Respiratory-TB precautions
ANSWER: AIRBORNE PRECAUTION
106. Medical Surgical-Respiratory-TB activated
A male client recently release from a correctional facility arrives at the clinic with a
cough, fever, and chills, active tuberculosis (TB) 10 years ago. What action should
the nurse implement? (Select all that apply)
A- Administer a purified protein derivate (PPD) test
B- Schedule the client for a chest
radiograph
C- Obtain sputum for acid fast bacillus (AFB)
testing
D- Place a mask on the client until he is moved to
isolation
E- Send client home with instructions for a prescribed antibiotic
107. Medical Surgical-Sensory-Cataract extraction-nausea
ANSWER: ZOFRAN OR ANTIEMETIC
108. Medical Surgical-Sensory-Pilocarpine-action
A client is newly diagnosed with open-angle glaucoma and receives a prescription
for the meiotic pilocarpin. The client asks how the eyes pressure will be controlled
when the eyes drops are used on the surface. What explanation should the nurse
offer when teaching about the therapeutic action of the ophthalmic drops?
A- Once the pupil gets smaller, the amount of liquid made inside the eyes is
reduced
B- It is necessary to open the pupil to allow movement of the fluid from behind
the iris
C- The drops will reduce eye swelling which is causing increased ocular pressure DTestBankWorld.org
The iris will constrict and contract away from the opening, thereby allowing
it to
drain
109. Pathophysiology-Neurological/Physical Assessment-Craniotomy-GCS When
assessing a client who had a supratentorial craniotomy, what action should the nurse
implement when determining the client’s Glasgow coma scale (GCS) rating?
A- Determine the intracranial pressure.
B- Check the patellar and radial reflexes.
C- Inject cold water into the client’s ear.
D- Instruct the client to raise an arm.
110. Pathophysiology/Medical Surgical-Immune/HematologyAntihistamines
Which conditions are most likely to respond to the treatment with antihistamines?
(Select all that apply)
A) Otitis media
B) Allergy rhinitis
C) Contact dermatitis
D) Myocarditis
E) Bronchitis
111. Pathophysiology/Medical Surgical-Immune/Hematology-WBC
levelpatho
A female adult who is undergoing chemotherapy tells the nurse that she plans to
volunteer at elementary school this winter. Which question is best for the nurse to
ask this client?
a) “Do you realize that you will be exposed to many different kinds of germs?”
TestBankWorld.org
b) “Have you considered that you are putting yourself at risk for developing
infections?”
c) “Are you aware that you do not have a fully functioning immune system?”
d) “Is it possible that you will be in direct contact with the children at the school?”
OJO CON ESTA DE ABAJO
A client’s morning laboratory test results include leukocytes 3,500/mm3 or 3.5 x
10???/L (SI). Based on this laboratory result, which complaint is this client most
likely to report to the nurse?
a) Inability to walk without shortness of breath.
b) Superficial cuts do not readily stop bleeding.
c) A red streak and pain in right calf muscle.
d) Persistent cough with yellow-colored sputum.
112. Pathophysiology/Medical Surgical-Musculoskeletal-Osteoarthritis-risk
factor
The nurse is assessing a middle-aged adult who is diagnosed with osteoarthritis.
Which factor in the client’s history is a contributor to the osteoarthritis?
a. Lactose intolerant since childhood.
b. Recently treated for deep vein thrombosis.
c. Long distance runner since high school.
d. Photosensitive to a drug currently taking.
113. Pathophysiology/Medical SurgicalNeurological/Trauma/EmergencyHead injury-diabetes insipidus
Polyuria can be defined as a urine output exceeding 3 L/24 h in adults and 2
L/m2 in children. It must be differentiated from the more common complaints
of frequency or nocturia, which are not associated with an increase in the total
urine output. Differential diagnosis has to be kept in mind when TBI patients
undergoing neurosurgery have huge amounts of urine output because most
cases of polyuria, at this time, are not caused by DI (Seckl and Dunger 1989).
TestBankWorld.org
The more common causes are excretion of excess fluid administered during
surgery and an osmotic diuresis, resulting from treatment aimed at
minimizing cerebral edema using mannitol or glucocorticoids (Bohn, Davids
et al. 2005).
114. Pathophysiology/Professional Issues/Medical Surgical-Nursing
ProcessResp acidosis-pneumonia
PNEUMONIA IS DIAPHORETIC AND CONFUSED:
ANSWER: OBSERVE FREQUENTLY
ESTA NO SALIO PERO HAY QUE VERLA
A client with a history of upper respiratory symptoms is admitted to the unit with
chest tightness, productive cough and difficult breathing. The client ABG is
respiratory acidosis. What lab the nurse expects to be high?
a. Ph
b. Arterial ph.
c. HCO3
d. Paco2
115. Pediatrics-Cardiovascular-Left sided heart failure
A nurse is assessing a 2 year-old child with left sided heart failure. Which
assessment finding should the nurse report to the healthcare provider immediately?
a. Penorbital edema noted bilaterally after napping
b. Crackles heard in lower lobes of lungs bilaterally
c. An apical heart rate of 120 beats per minute
d. Liver palpated 2 cm below right costal margin
TestBankWorld.org
116. Pediatrics-GI/Hepatic-Diarrhea-specimen
Stool Specimens
Stool specimens are frequently collected in children to identify parasites and
other organisms that cause diarrhea, to assess gastrointestinal function, and to
check for occult (hidden) blood. Ideally, stool should be collected without
contamination with urine, but in children wearing diapers this is difficult
unless a urine bag is applied. Children who are toilet trained should urinate
first; flush the toilet; and then defecate in the toilet, a bedpan (preferably one
that is placed on the toilet to avoid embarrassment), or a commercial potty
hat.
Stool specimens should be large enough to obtain an ample sampling, not
merely a fecal fragment. Specimens are placed in an appropriate container,
which is covered and labeled. If several specimens are needed, the containers
are marked with the date and time and kept in a specimen refrigerator.
Special care is exercised in handling the specimen because of the risk of
contamination.
No creo q es la rest*A child with diarrhea: Antibiotics
117. Pediatrics-Gwth & Devlp/Physical Assessment-Child interview-school
age
Child 9 years old:
A- Talk directly to the child
B- Ask the child if the parents are saying the true
C- Tell the parents to get out of the room
118. Pediatrics-Immune/Hematology- von Willebrand’s disease-POC
(Bleeding disorder)
A- Decrease exposure to infection
B- Decrease contact with other children
C- Decrease contact with cold graft
TestBankWorld.org
D- Guard against bleeding injuries
119. Pediatrics-Integumentary-Burns-hydrotherapy
*Answer: Let the child touch the water
120. Pediatrics-Musculoskeletal- Congenital hip-1st action
2 days old infant legs flexed with limited abduction, what is the next action that the
nurse take:
A- Range of motion exercise
B- Notify MD
C- Document as an normal finding D- Continue with the care
121. Pediatrics-Neurological-Vegetative state-adolescent
Un Nino en estado vegetative hace 5 meses. RN q hacer
*Answer: Talk to the child
122. Pediatrics- Renal-Nephrotic syndrome-I&O
2 year old child with nephrotic syndrome taking corticosteroids is edematous and
fatigue. What action the nurse implement first.
A- Sign and symptom of Cushing
B- Restrict sodium
C-…
D- Measure abdominal girth for 2 days [Show Less]
