TTT 67777 Med Surg 1_Graded A | TTT67777 Med Surg 1_2020

TTT 67777 Med Surg 1 – California State University 1. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? a. Bradycardia b. Flushed skin c. Frothy sputum – pg.198 d. Jugular vein distention 2. A nurse is assessing a client who is experiencing renal colic from a calculus in left renal pelvis. Identify the area where the nurse should expect the client to have referred pain. (Find “hot spots” in the artwork) - CORRECT 3. A nurse is caring for a client who is receiving peritoneal dialysis and notes a decrease in the dialysate flow rate. Which of the following actions should the nurse take? (Select all the apply.) a. Monitor the access site for drainage. b. Strip the catheter tubing c. Measure the amount of the dialysate outflow d. Raise the client to high fowlers position - pg.370: encourage client to lie Supine with head slightly elevated during CCPD and APD treatment. e. Position the client to her other side. 4. A nurse is providing discharge teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching? a. Wash you’r perineal area two times each day with antimicrobial soap. b. Change your pet’s litter box daily. c. Change the water in your drinking glass every 4 hrs. d. Wash your toothbrush in the dishwasher once each month. 5. A nurse is planning to insert an indwelling catheter for a female client. Which of the following actions should the nurse plan to take? a. Collect urine specimen from the drainage bag 1 hr after insertion b. Raise the head of the bed to 45 degrees prior to insertion c. Secure the catheter to the client's inner thigh d. Attach the bag to the rail of the bed 6. A nurse is providing teaching for a client who has age-related macular degeneration. Which of the following information should the nurse include in the teaching? a. A possible cause of this problem is long-term lack of dietary protein. b. You probably have a Detachment of your retina. c. You probably have noticed a decline in your central vision. – pg.63 d. The doctor can perform surgery to correct the start paying the folds in your retina. 7. A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report? – Expected Findings: fatigue, Wt loss, , ntion, pruritus. a. Platelets 70,000/mm3 - pg.357 b. Distended abdomen c. Alkaline phosphatase 125 units/L d. Clay colored stools 8. A nurse is preparing to discontinue long-term total parenteral nutrition (TPN) therapy for a client for a client. The nurse should plan to discontinue the TPN gradually to reduce the risk of which of the following adverse effects? a. Hyperglycemia – if unavailable, do not attempt to catch up by increasing the infusion rate because client can develop Hyperglycemia. b. Diarrhea c. Constipation d. Hypoglycemia – pg.298 – sudden abruption of infusing rate can cause hypoglycemia. 9. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse plan to take? - CORRECT a. Administer the unit of packed RBC’s over 1 hr. b. Obtain the client’s first set of vital signs 1 hr after initiating the transfusion. c. Initiate venous access with a 21-gauge needle. d. Use Y tubing with 0.9% sodium chloride when administering the transfusion. 10. A nurse is caring for a female who has toxic shock syndrome. Which of the following findings should the nurse expect? a. Elevated platelet count b. Generalized rash ■ Whole body rash c. Decreased total bilirubin d. Hypertension ■ Hypotension 11. A nurse is providing discharge teaching to an older adult client who had an exacerbation of COPD. The client is to start fluticasone by metered-dose inhaler. Which of the following instructions should the nurse include? a. Use fluticasone as needed for shortness of breath. b. Limit fluid intake to 1 L per day. c. Obtain a yearly influenza immunization. d. Assist use of pursed-lip breathing. 12. A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching? a. “You can cross your legs at the ankles when sitting down.” b. “Clean the incision daily with hydrogen peroxide.” c. “Install a raised toilet seat in your bathroom.” d. “You should use an incentive spirometer every 8 hrs.” 13. Missing 14. A nurse is caring for a client who is postoperative following a femur fracture. Which of the following findings should the nurse report to the provider immediately? a. The client reports shortness of breath – sign of surgical complication b. The client has a temperature of 38.1 C (100.5F) c. The client’s incision is red and warm d. The client reports incision pain 15. A nurse is planning care for a client who Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action? a. Place the client in a protective environment b. Obtain a stool specimen with gloves c. Clean surfaces with chlorhexidine-bleach d. Wash hands with alcohol-based hand rub. 16. A nurse is setting up a sterile field before performing a dressing change on client who is postoperative. Which of the following actions should the nurse plan to take to maintain the sterile field? (Select all the apply.) a. Grasp 2.5 cm (1 in) of the outer edge to open the surgical wrap b. Select a work surface at the nurse’s waist level c. Apply sterile gloves before opening the pack d. Open the first flap of the sterile package toward the nurse's body e. Place a surgical pack with a sterile drape on the work surface. 17. A nurse is caring for a client who has acute appendicitis. Which of the findings is the priority to the provider? a. Nausea b. Flank pain c. Fever d. Rigid abdomen 18. A nurse is caring for a client who is receiving radiation. The client reports nauseas since the therapy was initiated. Which of the following considerations should the nurse include when planning the client’s meals? a. Offer frequent, high-carbohydrate meals b. Offer highly seasoned foods c. Offer a snack prior to radiation therapy d. Offer hot beverages with meals 19. A nurse is caring for a client who is receiving mechanical ventilation. Which of the following interventions should the nurse implement? a. Empty water from the ventilator tubing daily. b. Suction the client’s airway every 4 hr. c. Maintain the client in supine position. d. Perform oral care every 2 hr. 20. A nurse in an emergency department is assessing a client who has cirrhosis of the liver. Which of the following is a priority finding? a. Palmar erythema b. Spider angiomas c. Yellow Sclera d. Mental Confusion