QUESTION BANK Exam Study Guide –
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Medical-Surgical Nursing, 7th Edition
by Adrianne Dill Linton
,
,An 81-year-old male client has emphysema. He lives at home with his cat and
manages self-care with no difficulty. When making a home visit, the nurse notices
that this client's tongue is somewhat cracked and his eyeballs appear sunken into
his head. Which nursing intervention is indicated?
A.Help the client determine ways to increase his fluid intake.
B.Obtain an appointment for the client to have an eye examination.
C.Instruct the client to use oxygen at night and increase the humidification.
D.Schedule the client for tests to determine his sensitivity to cat hair.
A
Clients with COPD should ingest 3 L of fluids daily but may experience a fluid
deficit because of shortness of breath. The nurse should suggest creative
methods to increase the intake of fluids (A), such as having fruit juices in
disposable containers readily available. (B) is not indicated. Humidified oxygen
will not effectively treat the client's fluid deficit, and there is no indication that
the client needs supplemental oxygen at night (C). These symptoms are not
indicative of (D) and may unnecessarily upset the client, who depends on his pet
for socialization.
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, A postoperative client receives a Schedule II opioid analgesic for pain. Which
assessment finding requires the most immediate intervention by the nurse?
A.Hypoactive bowel sounds with abdominal distention
B.Client reports continued pain of 8 on a 10-point scale
C.Respiratory rate of 12 breaths/min, with O2 saturation of 85%
D.Client reports nausea after receiving the medication
C
Administration of a Schedule II opioid analgesic can result in respiratory
depression (C), which requires immediate intervention by the nurse to prevent
respiratory arrest. (A, B, and D) require action by the nurse but are of less
priority than (C).
Which instruction should the nurse teach a female client about the prevention of
toxic shock syndrome?
A."Get immunization against human papillomavirus (HPV)."
B."Change your tampon frequently."
C."Empty your bladder after intercourse."
D."Obtain a yearly flu vaccination."
B
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