Verified Answers | Medical-Surgical Nursing
Complete Review
1. A nurse is reviewing the laboratory results of a client who has a history
of aplastic anemia. Which of the following findings indicates that the
client is experiencing pancytopenia?
Potassium 3.3 mEq/L (3.5 to 5 mEq/L)
Platelets 450,000/mm3 (150,000 to 400,000/mm3)
RBC count 6.3 million/mm3 (4.7 to 6.1 million/mm3 male)
WBC count 2,000/mm3 (5000 to 10,000/mm3)
2. If a patient with a nephrostomy tube presents with fever and flank pain
24 hours post-operation, what should the nurse's priority action be?
Notify the physician without further assessment.
Administer pain medication as prescribed.
Assess the nephrostomy site for signs of infection or
obstruction.
Document the findings and continue to monitor.
3. What intervention will the registered nurse (RN) implement while
completing a dressing change procedure for a client receiving
brachytherapy for the treatment of endometrial cancer?
Keep the bed sheet above the client's waist
Position a plastic shield over the client's pelvic area
Wear a lead apron during the procedure
Request the radiation source be removed during the procedure
,4. Describe how a detached retina can affect a patient's vision.
A detached retina results in a gradual loss of peripheral vision.
A detached retina is not related to any visual symptoms.
A detached retina causes only mild discomfort and no visual
changes.
A detached retina can lead to sudden flashes of light and
potential vision loss.
5. Describe the importance of using a pressure bag in the management of
an arterial line.
Using a pressure bag reduces the need for frequent line
changes.
Using a pressure bag allows for easier access to the arterial line
for medication administration.
Using a pressure bag helps to keep the arterial line clean and
free from bacteria.
Using a pressure bag ensures that the flush solution is
delivered at a consistent pressure, preventing clot formation.
6. In a scenario where a patient with a hemothorax is experiencing
decreased oxygen saturation levels, what immediate nursing
intervention should be prioritized?
Prepare the patient for chest tube insertion
Administer supplemental oxygen
Monitor vital signs every hour
Increase the patient's fluid intake
,7. Describe the key indicators a nurse should monitor to assess
improvement in a client with DKA.
The nurse should check for increased urine output only.
The nurse should monitor for normalization of blood glucose
levels and resolution of acidosis.
The nurse should focus solely on the client's weight loss.
The nurse should prioritize monitoring the client's appetite.
8. Edna is a resident who had heart surgery two days ago. the nurse taught
her how to do cough and deep breathing exercises, but she tells you
she doesnt want to do them because she is afraid that it will hurt. you
should
report her refusal to the respiratory therapist
suggest that she wait a few more days before starting the
exercises
encourage her to splint while preforming the exercises
tell her that she can use an incentive spirometer instead
9. The nurse observes a patient having a tonic-clonic seizure. What actions
should the nurse take during the seizure?
Check the patient's pulse oximetry and blood pressure
Remove objects near the patient and observe the patient's
movements
Restrain the patient using soft restraints to prevent injury
Administer a bolus dose of intravenous levetiracetam
10. In a scenario where a patient refuses a recommended treatment, what
should the nurse do to uphold the patient's rights?
, Respect the patient's decision and provide information about
the consequences.
Insist that the patient follows the treatment plan for their own
safety.
Encourage the patient to change their mind by emphasizing the
benefits of the treatment.
Document the refusal and proceed with the treatment anyway.
11. The client is experiencing hypovolemia. Which finding should the nurse
identify as a priority to report to the prescriber?
decreased LOC
fatigue
dry mucous membranes
report of thirst
12. In a scenario where a patient with portal hypertension is found to be
vomiting blood mixed with food, which intervention should the nurse
implement first to ensure patient safety?
Administer antiemetic medication immediately.
Provide the patient with oral fluids.
Notify the physician without any assessment.
Assess the patient's vital signs and level of consciousness.
13. A client has just been admitted to the postanesthesia care unit
following abdominal surgery. As the client begins to awaken, the client
is uncharacteristically restless. The nurse checks the skin, and it is cold,
moist, and pale. The nurse is concerned the client may be at risk for
which condition?
Hemorrhage and shock