dsfgh
A. “The head of your bed must remain flat
MEDSURG for 24 hours after surgery.”
B. “You should avoid deep breathing and
coughing after surgery.”
C. “You won’t be able to swallow for the
A 78 year old client is first day or two.”
admitted to the emergency D. “You must avoid hyperextending your
neck after surgery.”
department with numbness and
weakness of the left arm and
slurred speech. Which nursing
A nurse in the emergency
intervention is priority? *
department is observing a 4-
1/1
Prepare to administer recombinant tissue year-old child for signs of
plasminogen activator (rt-PA).
Discuss the precipitating factors that
increased intracranial pressure
caused the symptoms. after a fall from a bicycle,
Schedule for A STAT computer
tomography (CT) scan of the head. resulting in head trauma. Which
of the following signs or
Notify the speech pathologist for an
emergency consult.
symptoms would be cause for
concern? *
1/1
Leigh Ann is receiving
Bulging anterior fontanel.
pancrelipase (Viokase) for Repeated vomiting.
chronic pancreatitis. Which
Signs of sleepiness at 10 PM.
observation best indicates the Inability to read short words from a
treatment is effective? * distance of 18 inches.
1/1
A. There is no skin breakdown. For a diabetic male client with
B. Her appetite improves.
C. She loses more than 10 lbs. a foot ulcer, the physician
D. Stools are less fatty and decreased in
frequency. orders bed rest, a wet-to-dry
dressing change every shift, and
blood glucose monitoring before
During preoperative teaching meals and bedtime. Why are
for a female client who will wet-to-dry dressings used for
undergo subtotal thyroidectomy, this client? *
1/1
the nurse should include which
They contain exudate and provide a moist
statement? * wound environment.
They protect the wound from mechanical
1/1 trauma and promote healing.
,They debride the wound and promote
Nurse Ruth is assessing a client
healing by secondary intention.
after a thyroidectomy. The
They prevent the entrance of assessment reveals muscle
microorganisms and minimize wound
discomfort. twitching and tingling, along
with numbness in the fingers,
A 22 year old client suffered toes, and mouth area. The
from his first tonic-clonic nurse should suspect which
seizure. Upon awakening the complication? *
client asks the nurse, “What 1/1
A. Tetany
caused me to have a seizure?
Which of the following would B. Hemorrhage
the nurse include in the C. Thyroid storm
D. Laryngeal nerve damage
primary cause of tonic clonic
seizures in adults more the 20
A female client admitted to an
years? *
acute care facility after a car
1/1
accident develops signs and
Electrolyte imbalance
Head trauma symptoms of increased
intracranial pressure (ICP). The
Epilepsy
Congenital defect client is intubated and placed
on mechanical ventilation to
A 38 year old woman returns help reduce ICP. To prevent a
from a subtotal thryroidectomy further rise in ICP caused by
for the treatment of suctioning, the nurse anticipates
hyperthyroidism. Upon administering which drug
assessment, the immediate endotracheally before
priority that the nurse would suctioning? *
include is: * 1/1
Phenytoin (Dilantin)
1/1 Mannitol (Osmitrol)
Assess for pain Lidocaine (Xylocaine)
Assess for neurological status
Assess fluid volume status
Assess for respiratory distress Furosemide (Lasix)
,A neurological consult has been Dr. Rodriguez prescribes
ordered for a pediatric client glipizide (Glucotrol), an oral
with suspected petit mal antidiabetic agent, for a male
seizures. The client with petit client with type 2 diabetes
mal seizures can be expected to mellitus who has been having
have: * trouble controlling the blood
0/1 glucose level through diet and
Short, abrupt muscle contraction
exercise. Which medication
instruction should the nurse
Quick, bilateral severe jerking movements
Abrupt loss of muscle tone provide? *
A brief lapse in consciousness
Correct answer 1/1
A brief lapse in consciousness “Be sure to take glipizide 30 minutes
before meals.”
A female adult client with a
“Glipizide may cause a low serum sodium
history of chronic level, so make sure you have your sodium
level checked monthly.”
hyperparathyroidism admits to “You won’t need to check your blood
glucose level after you start taking
being noncompliant. Based on glipizide.”
initial assessment findings, the “Take glipizide after a meal to prevent
heartburn.”
nurse formulates the nursing
diagnosis of Risk for injury. To The nurse is formulating a
complete the nursing diagnosis teaching plan for a client who
statement for this client, which has just experienced a transient
“related-to” phrase should the ischemic attack (TIA). Which
nurse add? * fact should the nurse include in
1/1
the teaching plan? *
A. Related to bone demineralization
resulting in pathologic fractures 1/1
TIA symptoms may last 24 to 48 hours.
Most clients have residual effects after
B. Related to exhaustion secondary to an having a TIA.
accelerated metabolic rate TIA may be a warning that the client may
C. Related to edema and dry skin have cerebrovascular accident (CVA)
secondary to fluid infiltration into the
interstitial spaces
D. Related to tetany secondary to a The most common symptom of TIA is the
decreased serum calcium level inability to speak.
, Michael, a 42 y.o. man is
admitted to the med-surg floor A client with type 1 DM calls
with a diagnosis of acute the nurse to report recurrent
pancreatitis. His BP is 136/76, episodes of hypoglycemia with
pulse 96, respirations 22 and exercise. Which statement by
temp 101. His past history the client indicated an
includes hyperlipidemia and inadequate understanding of
alcohol abuse. The doctor the peak action of NPH insulin
prescribes an NG tube. Before and exercise? *
inserting the tube, you explain 1/1
A. “The best time for me to exercise is
the purpose to patient. Which
every afternoon.”
of the following is a most
accurate explanation? * B. “The best time for me to exercise is
right after I eat.”
1/1 C. “The best time for me to exercise is
A. “It empties the stomach of fluids and after breakfast.”
gas.” D. “The best time for me to exercise is
after my morning snack.”
B. “It prevents spasms at the sphincter of
Oddi.”
C. “It prevents air from forming in the The physician orders laboratory
small intestine and large intestine.” tests to confirm
D. “It removes bile from the gallbladder.”
hyperthyroidism in a female
client with classic signs and
After undergoing a subtotal
symptoms of this disorder.
thyroidectomy, a female client
Which test result would confirm
develops hypothyroidism. Dr.
the diagnosis? *
Smith prescribes levothyroxine
1/1
(Levothroid), 25 mcg P.O. daily.
No increase in the thyroid-stimulating
For which condition is hormone (TSH) level after 30 minutes
during the TSH stimulation test
levothyroxine the preferred
agent? * A decreased TSH level
1/1 An increase in the TSH level after 30
minutes during the TSH stimulation test
A. Primary hypothyroidism Below-normal levels of serum
triiodothyronine (T3) and serum thyroxine
(T4) as detected by radioimmunoassay
B. Graves’ disease
C. Thyrotoxicosis
D. Euthyroidism
A. “The head of your bed must remain flat
MEDSURG for 24 hours after surgery.”
B. “You should avoid deep breathing and
coughing after surgery.”
C. “You won’t be able to swallow for the
A 78 year old client is first day or two.”
admitted to the emergency D. “You must avoid hyperextending your
neck after surgery.”
department with numbness and
weakness of the left arm and
slurred speech. Which nursing
A nurse in the emergency
intervention is priority? *
department is observing a 4-
1/1
Prepare to administer recombinant tissue year-old child for signs of
plasminogen activator (rt-PA).
Discuss the precipitating factors that
increased intracranial pressure
caused the symptoms. after a fall from a bicycle,
Schedule for A STAT computer
tomography (CT) scan of the head. resulting in head trauma. Which
of the following signs or
Notify the speech pathologist for an
emergency consult.
symptoms would be cause for
concern? *
1/1
Leigh Ann is receiving
Bulging anterior fontanel.
pancrelipase (Viokase) for Repeated vomiting.
chronic pancreatitis. Which
Signs of sleepiness at 10 PM.
observation best indicates the Inability to read short words from a
treatment is effective? * distance of 18 inches.
1/1
A. There is no skin breakdown. For a diabetic male client with
B. Her appetite improves.
C. She loses more than 10 lbs. a foot ulcer, the physician
D. Stools are less fatty and decreased in
frequency. orders bed rest, a wet-to-dry
dressing change every shift, and
blood glucose monitoring before
During preoperative teaching meals and bedtime. Why are
for a female client who will wet-to-dry dressings used for
undergo subtotal thyroidectomy, this client? *
1/1
the nurse should include which
They contain exudate and provide a moist
statement? * wound environment.
They protect the wound from mechanical
1/1 trauma and promote healing.
,They debride the wound and promote
Nurse Ruth is assessing a client
healing by secondary intention.
after a thyroidectomy. The
They prevent the entrance of assessment reveals muscle
microorganisms and minimize wound
discomfort. twitching and tingling, along
with numbness in the fingers,
A 22 year old client suffered toes, and mouth area. The
from his first tonic-clonic nurse should suspect which
seizure. Upon awakening the complication? *
client asks the nurse, “What 1/1
A. Tetany
caused me to have a seizure?
Which of the following would B. Hemorrhage
the nurse include in the C. Thyroid storm
D. Laryngeal nerve damage
primary cause of tonic clonic
seizures in adults more the 20
A female client admitted to an
years? *
acute care facility after a car
1/1
accident develops signs and
Electrolyte imbalance
Head trauma symptoms of increased
intracranial pressure (ICP). The
Epilepsy
Congenital defect client is intubated and placed
on mechanical ventilation to
A 38 year old woman returns help reduce ICP. To prevent a
from a subtotal thryroidectomy further rise in ICP caused by
for the treatment of suctioning, the nurse anticipates
hyperthyroidism. Upon administering which drug
assessment, the immediate endotracheally before
priority that the nurse would suctioning? *
include is: * 1/1
Phenytoin (Dilantin)
1/1 Mannitol (Osmitrol)
Assess for pain Lidocaine (Xylocaine)
Assess for neurological status
Assess fluid volume status
Assess for respiratory distress Furosemide (Lasix)
,A neurological consult has been Dr. Rodriguez prescribes
ordered for a pediatric client glipizide (Glucotrol), an oral
with suspected petit mal antidiabetic agent, for a male
seizures. The client with petit client with type 2 diabetes
mal seizures can be expected to mellitus who has been having
have: * trouble controlling the blood
0/1 glucose level through diet and
Short, abrupt muscle contraction
exercise. Which medication
instruction should the nurse
Quick, bilateral severe jerking movements
Abrupt loss of muscle tone provide? *
A brief lapse in consciousness
Correct answer 1/1
A brief lapse in consciousness “Be sure to take glipizide 30 minutes
before meals.”
A female adult client with a
“Glipizide may cause a low serum sodium
history of chronic level, so make sure you have your sodium
level checked monthly.”
hyperparathyroidism admits to “You won’t need to check your blood
glucose level after you start taking
being noncompliant. Based on glipizide.”
initial assessment findings, the “Take glipizide after a meal to prevent
heartburn.”
nurse formulates the nursing
diagnosis of Risk for injury. To The nurse is formulating a
complete the nursing diagnosis teaching plan for a client who
statement for this client, which has just experienced a transient
“related-to” phrase should the ischemic attack (TIA). Which
nurse add? * fact should the nurse include in
1/1
the teaching plan? *
A. Related to bone demineralization
resulting in pathologic fractures 1/1
TIA symptoms may last 24 to 48 hours.
Most clients have residual effects after
B. Related to exhaustion secondary to an having a TIA.
accelerated metabolic rate TIA may be a warning that the client may
C. Related to edema and dry skin have cerebrovascular accident (CVA)
secondary to fluid infiltration into the
interstitial spaces
D. Related to tetany secondary to a The most common symptom of TIA is the
decreased serum calcium level inability to speak.
, Michael, a 42 y.o. man is
admitted to the med-surg floor A client with type 1 DM calls
with a diagnosis of acute the nurse to report recurrent
pancreatitis. His BP is 136/76, episodes of hypoglycemia with
pulse 96, respirations 22 and exercise. Which statement by
temp 101. His past history the client indicated an
includes hyperlipidemia and inadequate understanding of
alcohol abuse. The doctor the peak action of NPH insulin
prescribes an NG tube. Before and exercise? *
inserting the tube, you explain 1/1
A. “The best time for me to exercise is
the purpose to patient. Which
every afternoon.”
of the following is a most
accurate explanation? * B. “The best time for me to exercise is
right after I eat.”
1/1 C. “The best time for me to exercise is
A. “It empties the stomach of fluids and after breakfast.”
gas.” D. “The best time for me to exercise is
after my morning snack.”
B. “It prevents spasms at the sphincter of
Oddi.”
C. “It prevents air from forming in the The physician orders laboratory
small intestine and large intestine.” tests to confirm
D. “It removes bile from the gallbladder.”
hyperthyroidism in a female
client with classic signs and
After undergoing a subtotal
symptoms of this disorder.
thyroidectomy, a female client
Which test result would confirm
develops hypothyroidism. Dr.
the diagnosis? *
Smith prescribes levothyroxine
1/1
(Levothroid), 25 mcg P.O. daily.
No increase in the thyroid-stimulating
For which condition is hormone (TSH) level after 30 minutes
during the TSH stimulation test
levothyroxine the preferred
agent? * A decreased TSH level
1/1 An increase in the TSH level after 30
minutes during the TSH stimulation test
A. Primary hypothyroidism Below-normal levels of serum
triiodothyronine (T3) and serum thyroxine
(T4) as detected by radioimmunoassay
B. Graves’ disease
C. Thyrotoxicosis
D. Euthyroidism
