Medical-Surgical B
1. 1.ID: 310947654
Which method elicits the most accurate information during a physical assessment of an
older client?
o Ask the
... [Show More] client to recount one's health history.
o Obtain the client's information from a caregiver.
o Review the past medical record for medications.
o Use reliable assessment tools for older adults. Correct
Specific assessment tools (D) for an older adult, such as Older Adult Resource Services
Center Instrument (OARS), mini-mental assessment, fall risk, depression (Geriatric
Depression Scale), or skin breakdown risk (Braden Scale), consider age-related
physiologic and psychosocial changes related to aging and provide the most accurate and
complete information. (A and B) are subjective and may vary in reliability based on the
client's memory and caregiver's current involvement. Although (C) is a good resource to
identify polypharmacy, a written record may not be available or currently accurate.
Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 310972705
A client who has just tested positive for human immunodeficiency virus (HIV) does not
appear to hear what the nurse is saying during post-test counseling. Which information
should the nurse offer to facilitate the client's adjustment to HIV infection?
o Inform the client how to protect sexual and needle-sharing partners.
o Teach the client about the medications that are available for treatment.
o Identify the need to test others who have had risky contact with the client.
o Discuss retesting to verify the results, which will ensure continuing contact.
Correct
Encouraging retesting (D) supports hope and gives the client time to cope with the
diagnosis. Although post-test counseling should include education about (A, B, and C),
retesting encourages the client to maintain medical follow-up and management.
Awarded 1.0 points out of 1.0 possible points.
3.ID: 310955083
The nurse hears short, high-pitched sounds just before the end of inspiration in the right
and left lower lobes when auscultating a client's lungs. How should this finding be
recorded?
o Inspiratory wheezes in both lungs. Incorrect
o Crackles in the right and left lower lobes. Correct
o Abnormal lung sounds in the bases of both lungs.
o Pleural friction rub in the right and left lower lobes.
Fine crackles (B) are short, high-pitched sounds heard just before the end of inspiration
that are the result of rapid equalization of pressure when collapsed alveoli or terminal
bronchioles suddenly snap open. Wheezing (A) is a continuous high-pitched squeaking or
musical sound caused by rapid vibration of bronchial walls that are first evident on
expiration and may be audible. Although (C) describes an adventitious lung sound, this
documentation is vague. (D) is a creaking or grating sound from roughened, inflamed
surfaces of the pleura rubbing together heard during inspiration, expiration, and with no
change during coughing.
Awarded 0.0 points out of 1.0 possible points.
3. 4.ID: 310946670
What assessment finding should the nurse identify that indicates a client with an acute
asthma exacerbation is beginning to improve after treatment?
o Wheezing becomes louder. Correct
o Cough remains unproductive.
o Vesicular breath sounds decrease.
o Bronchodilators stimulate coughing. Incorrect
In an acute asthma attack, air flow may be so significantly restricted that wheezing is
diminished. If the client is successfully responding to bronchodilators and respiratory
treatments, wheezing becomes louder (A) as air flow increases in the airways. As the
airways open and mucous is mobilized in response to treatment, the cough becomes more
productive, not (B). Vesicular sounds are soft, low-pitched, gentle, rustling sounds heard
over lung fields (C) and is not an indicator of improvement during asthma treatment.
Bronchodilators do not stimulate coughing (D).
Awarded 0.0 points out of 1.0 possible points.
4. 5.ID: 310944528
The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving
chemotherapy. Laboratory results reveal a platelet count of 10,000/ml. What action
should the nurse implement?
o Encourage fluids to 3000 ml/day.
o Check stools for occult blood. Correct
o Provide oral hygiene every 2 hours.
o Check for fever every 4 hours.
Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common
side effect of chemotherapy. A client with thrombocytopenia should be assessed
frequently for occult bleeding in the emesis, sputum, feces (B), urine, nasogastric
secretions, or wounds. (A) does not minimize the risk for bleeding associated with
thrombocytopenia. (C) may cause increased bleeding in a client with thromobcytopenia.
(D) assesses for infection, not risk for bleeding.
Awarded 1.0 points out of 1.0 possible points.
5. 6.ID: 310982319
Three weeks after discharge for an acute myocardial infarction (MI), a client returns to
the cardiac center for follow-up. When the nurse asks about sleep patterns, the client tells
the nurse that he sleeps fine but that his wife moved into the spare bedroom to sleep when
he returned home. He states, I guess we will never have sex again after this. Which
response is best for the nurse to provide?
o Sexual intercourse can be strenuous on your heart, but closeness and intimacy,
such as holding and cuddling, can be maintained with your wife.
o Sexual activity can be resumed whenever you and your wife feel like it because
the sexual response is more emotional rather than physical.
o You should discuss your questions about your sexual activity with your healthcare
provider because sexual activity may be limited by your heart damage.
o Sexual activity is similar in cardiac workload and energy expenditure as climbing
two flights of stairs and may be resumed like other activities [Show Less]