Medical Surgical Assessment A Exam - Questions, Answers and Rationales A nurse is reviewing the laboratory results of a client who is scheduled for a CT
... [Show More] scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure? A) Sodium 136 mEq/L B) Potassium 4.8 mEq/L C) Creatinine 1.9 mg/dL D) Calcium 10 mg/dL Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse should report the finding to the provider before the client has a CT scan with an IV contrast agent. This finding places the client at risk for developing contrast-induced nephropathy. A nurse is monitoring a client who is taking acarbose. Which of the following findings should the nurse identify as an adverse effect of the medication? A) Polyuria B) Abdominal cramps C) Renal insufficiency D) Insomnia Acarbose affects the gastrointestinal system. Therefore, the nurse should monitor the client for abdominal cramping, rumbling bowel sounds, and diarrhea as adverse effects of this medication. A nurse is assisting with the care of a client who had a cardiac catheterization via the right femoral artery. Which of the following actions should the nurse take to prevent postprocedure complications? (Select all) A) Monitor the insertion site for bleeding B) Position the affected extremity at a 45 degree angle C) Restrict the client's fluid intake D) Maintain the pressure dressing E) Check the client's peripheral pulses A) Monitor the insertion site for bleeding - The nurse should monitor the client's insertion site for manifestations of hemorrhaging. D) Maintain the pressure dressing - The nurse should maintain the client's pressure dressing to prevent hemorrhaging and allow for the cannulation site to heal. E) Check the client's peripheral pulses - The nurse should assess the client's peripheral pulses to help identify signs of arterial occlusion. A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary disease (COPD) and is dyspneic. Which of the following interventions should the nurse include in the plan? A) Encourage abdominal breathing B) Direct the client to inhale with pursed lips C) Set the oxygen therapy at 5L/min D) Instruct the client to lean back while coughing The nurse should encourage abdominal breathing, which reduces the workload on the accessory muscles of respiration during dyspneic episodes. A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero is it applies. Do not use a trailing zero. 7mg/10 mg *1mL= 0.7 Ml A nurse is examining a client's IV site and notes a red line up his arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy? A) Thrombophlebitis B) Infiltration C) Hematoma D) Venous spasms The nurse should identify pain, warmth, and a red streak up the arm as indications of thrombophlebitis. A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. Which of the following should the nurse include in the teaching? A) Increase intake of fiber-rich foods B) Take a laxative every morning C) Maintain a fluid intake of 1200 mL per day D) Limit activity to preserve energy The nurse should instruct the client to increase the amount of fiber-rich foods in his diet. Dried beans and brown rice are examples of fiber-rich foods. A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take? A) Perform pin site care daily B) Remove the overbed trapeze C) Remove the boot every 2 hr D) Keep the weights on a stable, flat surface The nurse should perform pin site care daily with chlorhexidine solution or use a solution according to facility protocol. The nurse should also monitor the pin sites for manifestations of infection. A nurse observes a client who is lying in bed experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? A) Lower the side rails of the client's bed B) Apply wrist restraints to the client C) Position the client in the semi-Fowler's position D) Loosen clothing around the client's neck The nurse should loosen clothing around the client's neck to maintain an open airway and prevent aspiration. A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should the nurse include? A) Apply hot packs to the client's muscles B) Schedule physical therapy in the afternoon C) Encourage the client to complete ADLs D) Administer valerian to promote sleep The nurse should encourage the client to complete ADLs and provide assistance as needed. Performing self-care increases the client's independence, strength, and level of functioning. A nurse is reinforcing discharge teaching to prevent dumping syndrome for a client following a partial gastrectomy for ulcers. Which of the following information should the nurse include in the teaching? A) Avoid liquids at mealtimes B) Exclude eating starchy vegetables C) Avoid eating high-protein meals D) Plan to increase intake of sweetened fruits The nurse should remind the client to avoid drinking liquids at mealtimes to prevent the food from emptying into the small bowel too quickly. A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect? A) Increased weight B) Increased heart rate C) Decreased urinary output D) Decreased shortness of breath The nurse should expect the client to have decreased shortness of breath. Digoxin increases the contractility of the heart, which decreases pulmonary congestion. A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take with communicating with the client? A) Rephrase client instructions when not understood B) Cup hands around the mouth and direct speech toward the client C) Accentuate vowel sounds by using a higher pitch when speaking D) Sit to the side of the client and speak instructions into her best eat When communicating with a client who has hearing loss, the nurse should rephrase, rather than repeat, discharge instructions when they are not understood. A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk of aspiration? A) Instill 10mL of air through the NG tube B) Place the client in supine position C) Irrigate the NG tube D) Pinch the NG tube The nurse should pinch the NG tube to prevent secretions from draining into the client's throat, which can cause aspiration. A nurse is contributing to the plan of care for an older adult client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss? A) Increase fluid intake B) Encourage range of motion exercises C) Massage bony prominences D) Encourage weight-bearing exercises Weight-bearing exercises, such as walking, can maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis. A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions? A) "I apply rubbing alcohol to my feet every day to prevent infection" B) "I will wear clean, knee-high wool socks every day to help improve my circulation" C) "I use hot water bottles to keep my feet warm at night" D) "I don't cross my legs anymore" Clients who have peripheral vascular disease should not cross their legs because it can impede circulation. A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching? A) "The HbA1c test should be performed 2 hr after I eat a meal that is high in carbohydrates" B) "The HbA1c test can help detect the presence of ketones in my body" C) "I will have my HbA1c checked twice per year" D) "I will plan to fast before I have my HbA1c tested" An HbA1c test provides the client's average glucose level for the preceding 3 months. The nurse should instruct the client to have her HbA1c tested twice yearly to manage her glucose. A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include? A) Restrict the time pregnant women are allowed in the client's room to 15 min B) Pick up a radiation implant with a double-gloved hand if it becomes dislodged C) Limit time spent in the client's room to 2 hr during an 8 hr shift D) Dispose of radiation implants in a lead container Lead impairs the emission of radiation. Therefore, the nurse should dispose of radiation implants in a lead container in accordance with facility protocol. A nurse is caring for a client who had an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration? A) Allow for 30 min of rest before meals B) Provide a straw for drinking liquids C) Serve foods at room temperature D) Place 2 tsp of food in the client's mouth at a time [Show Less]