RETAKE 2 RN MEDSURG - LATEST GUIDE 1. A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of
... [Show More] the following findings indicates that the client is experiencing increased ICP?SATA. a. Flat jugular veins b. GCS score of 15 c. Sleepiness exhibited by the client d. Widening pulse pressure e. Decerebrate posturing f. Flat jugular veins is incorrect 2. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the clients to withhold for 48hr prior to cardioversion? a. Enoxaparin b. Metformin c. Diazepam d. Digoxin 4. A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the client’s bedside? a. Suction machine b. Wire cutters c. Padded clamp d. Communication board 3. A nurse is assessing a client who has acute cholecystitis. which of the following findings is the nurse’s priority? a. Anorexia b. Abdominal pain radiating to the right shoulder c. Tachycardia d. Rebound abdominal tenderness 6. A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication? a. Ginkgo biloba b. Glucosamine c. Calcium d. Vitamin C 7. A nurse is planning to irrigate and dress a clean, granulation wound for a client who has a pressure injury. Which of the following actions should the nurse take? a. Apply a wet-to-dry gauze dressing b. Irrigate with hydrogen peroxide solution c. Use a 30-ml syringe d. Attach a 24-gauge angiocatheter to the syringe. the nurse is providing teaching to a female client who has a history of UTI’s. which of the following information should the nurse include in the teaching? a. Avoid foods that are high in ascorbic acid b. Add oatmeal to the water when taking a tub bath c. Urinate every 6 hours d. Take daily cranberry supplements? 10. A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which off the following statements should the nurse identify as an indication that the client understands the teaching? A.“ I will wash the ink markings off the radiation area after each treatment.” B.“I will use my hands rather than a washcloth to clean the radiation area.” C.“I will be able to be out in the sun 1 month after my radiation treatments are over.” D.“I will use a heating pad on my neck it if becomes sore during the radiation therapy.” A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse’s priority? A.Initiate oxygen at 2 L via nasal cannula B.Apply firm pressure to the insertion site C.Take the client’s vital signs D.Obtain a stat order for an aPTT 12. A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? a. Obtain ABGs b. Administer propofol to the client c. Instruct the client to allow the machine to breathe for them d. Disconnect the machine and manually ventilate the client. 13. A nurse is reviewing the lab results of a client who has cirrhosis. Which of the following laboratory values should the nurse expect? a. Decreased prothrombin time b. Elevated bilirubin level c. Decreased ammonia level d. Elevated albumin level 14. A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching? a. “ I should avoid walking as much as possible.” b. “I should sit down and read for several hours a day” c. “I will wear clean graduatied compression stockings every day.” d. “I will keep my legs level with my body when I sleep at night.” 15. A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following laboratory values should the nurse report to the provider? a. Potassium 4 mEq/L b. WBC count 10,000/mm3 c. Hct 45% d. Hgb 8 g/dL 16. A nurse is caring for a client who has a stage III pressure injury. Which of the following findings contributes to delayed would healing? a. WBC count 6K b. BMI 24 c. Urine output 25ml/hr d. Albumin 4 a nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which of the following actions should the nurse include in the client’s plan of care? a. Collect and place the client’s urine or feces in a biohazard bag b. Limit the client’s ambulation to their own room c. Wear a lead apron while providing care to the client d. Limit each visitor to 1 hr per day. nurse is caring for a client who has a potassium level of 3 mEq/L/ Whichh of the following assessment findings should the nurse expect? a. Positive trousseaus sign b. 4+ deep tendon reflexes c. Deep respirations d. Hypoactive bowel sounds A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client avoid? a. Shellfish b. Aged cheese: Aged cheese A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing FVD? a. HR 110/min b. BP 138/90 c. Urine Specific Gravity 1.020 d. BUN 15 mg/dL nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates and understanding of the teaching? a. “I will monitor my blood sugar carefully because the medication increases the secretion of insulin.” b. I should take the medication with a meal c. I can expect to gain weight while taking this medication d. While taking this medication, I will experience flushing of my skin.” A nurse is caring for a client who has anorexia, low grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first? nurse is assessing a male client for an inguinal hernia. Which of the following areas should the nurse palpate to verify that the client has an inguinal hernia? A nurse is performing a cardiac assessment for a client who has a MIM 2 days ago. Which of the following actions should the nurse take first after hearing the following sound? A nurse is caring for a client who as ALS and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse’s priority? a. Temp 38.4 C b. Increased respiratory secretion c. Fluid intake of 200ml in the prior 8 hr d. Limited range of motion A nurse is conduction and admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify which of the following findings requires further assessment? A.Hx of asthma B.Appendectomy 1 year ago C.Penicillin allergy D.TKA 6 months ago A nurse is providing discharge instruction to a client who has a partial thickness burn on the hand. Which of the following instructions should the nurse include? a. Change the dressing every 72 hr b. Immobilize the hand with a pressure dressing c. Take pain medication 30 minutes after changing the dressing d. Wrap fingers with individual dressings The nurse should instruct the client to change the dressing every 12 to 24 hr to allow for wound inspection. The client should observe the wound closely for manifestations of increased redness, warmth, drainage, edema, or foul odor, which can indicate an infection. A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client has dyspnea with a productive cough and is using accessory muscles to breathe. Which of the following actions should the nurse take first? A.Obtain a prescription for ABGs B.Administer IV Abx to the client C.Instruct the client to use the incentive spirometer D.Place the client in high fowler’s position. A nurse is providing teaching for a female client who has recurrent UTI’s/ which of the following information should the nurse include in the teaching? A.Take tub baths daily B.Drink at least 1 L of fluid daily C.Wear underwear made of nylon D..Void before and after intercourse A nurse in and emergency department is reviewing the provider’s prescription for a client who sustained a rattlesnake bite to the lowe leg. Which of the following prescription should the nurse expect? A.Apply ice to the client’s puncture wounds B.Initiate corticosteroid therapy for the client C.Keep the client’s leg above the heart level D.Administer an opioid analgesic to the client A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instruction should the nurse include? A.Keep the clients personal care items in the bathroom B.Keep the overhead lights on in the client’s bedroom while the client is sleeping C.Remind the client to scan their complete range of vision during ambulation D.Secure the client’s extension cords under carpeting. A nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients? A.A client who is receiving preoperative teaching for a right knee arthroplasty B.A client who states they will have difficulty obtaining a walker for home use C.A client who reports an increase in pain following a left hip arthroplasty D.A client who is having emotional difficulty accepting they have a prosthetic leg. 40. A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take? a. Maintain adduction of the client’s legs b. Encourage ROM of the hip up to a 120 degree angle c. Place a pillow between the client’s legs d. Keep the client’s hip internally rotated 41. A nurse and an AP are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions? a. Wear a mask b. Wear a gown c. Keep the client’s room well lit d. Maintain the HOB at a 45 degree elevation 42. A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client is experiencing excessive stools. Which of the following findings is an adverse effect of this medication a. Hypokalemia b. Hypercalcemia c. Gastrointestinal bleeding d. Confusion 43. A nurse in an emergency dept is caring for a client who has full-thickness burns over 20% of their total body surface area. After ensuring a patent airway and administering oxygen, which of the following items should the nurse prepare to administer first? a. IV fluids b. Analgesia c. Antibiotics d. Tetanus toxoid 44. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take? a. Keep the line open with 0.9% sodium chloride until the new bag arrives b. Administer dextrose 10% in water until the new bag arrives c. Flush the line and cap the port until the new bag arrives d. Decrease the infusion rate until the new bag arrives. 45. A nurse is caring for a client in an acute care facility who is at risk for seizures. Which of the following precautions should the nurse implement? a. Place a padded tongue blade at the client’s bedside b. Keep the side rails lowered on the client’s bed. c. Maintain the client’s bed at hip level or above d. Ensure that the client has a patent IV 46. A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend? a. Add full-fat yogurt to the diet b. Add cabbage to the diet c. Replace butter with coconut oil d. Replace shellfish with red meat. 47. A nurse in a provider’s office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should Identify what which of the following client medications interacts with feverfew? a. Meoprolol b. Bupropion c. Naproxen d. Atorvastatin 48. A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching? 49. A nurse is caring for a client who has a prescription for enalapril. The nurse should identify which of the following findings as an adverse effect of the medication a. Bradycardia b. Tremors c. Orthostatic hypotension d. drowsiness 50. An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? 51. a nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? 53. A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first? 54. A nurse is providing discharge teaching to a client who has heart failure and a new prescriptions for a potassium- sparing diuretic. Which of the following information should the nurse include in the teaching? 55. A nurse is providing discharge instructions to a client following an upper GI series with barium contrast. Which of the following information should the nurse provide? 56. A nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analgesic for pain management. Which of the following information should the nurse include with the teaching? 57. A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take? 58. A nurse in in the emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report? 58. A nurse in in the emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report? 60. A nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis for the past 3 days. Which of the following statements should the nurse include when instructing a client? 61. A nurse is caring for a client who has a new prescription for TPN. The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/l. the IV pump should be set at how many ml/hr? 62. A nurse is assessing a client who had extracorporeal show wave lithotripsy (ESWL) 6 hr ago. Which of the following findings should the nurse expect? 63. A nurse has received change of shift report for a group of clients. Which of the following should the nurse assess first? 64. A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hrs ago. Which of the following actions should the nurse take? 66. A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider? 67. A nurse is caring for a client who is experiencing superventricular tachycardia. Upon assessing the client, the nurse observes the following findings: heart rate 200/min, BP 78/40, RR 30/min. Which of the following actions should the nurse take? 68. A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates and understanding of the teaching? 69. A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan? 70. A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent Pseudomonas aeruginosa infection? 71. A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements should the nurse include in the teaching? 72. A nurse is teaching a young adult client how to perform testicular self-examination. Which of the following instructions should the nurse include? 73. A nurse is assessing a client following the administration of magnesium sulfate 1g IV bolus. For which of the following adverse effect should the nurse monitor? 74. A nurse is caring for a client who has diabetic ketoacidosis DKA. Which of the following laboratory findings should the nurse expect? 75. A nurse is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate that the client is having an adverse reaction to this medication? 76. A nurse is caring for a client who has viral pneumonia. The client’s pulse oximeter readings have fluctuated between 79% and 88% for the last 30 minutes. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen? CONTINUED .....DOWNLOAD FOR BEST REVISION TO BEST SCORES [Show Less]