Medsurg Capstone Pre-assessment quiz with all answers correct

A nurse is reinforcing discharge teaching with a client who has undergone a transurethral resection of the prostate (TURP). Which of the following statements should the nurse include in the teaching? "Increase fluid intake if urine becomes blood tinged" Rationale: The nurse should reinforce that strenous activity, straining to have a bowel movement, and coughing may cause the urine to become blood tinged. If this should occur, the client should be instructed to stop the activity, rest, and increase fluid intake. If urine becomes increasingly blood tinged or does not clear, or the client has difficulty voiding, he should be instructed to notify the provider. A nurse is caring for a client who is suspected to have active laryngeal tuberculosis (TB). Which of the following actions should the nurse plan to take to safely care for this client? Place the client in a private room with a special ventilation system Rationale: Clients suspected to have active laryngeal tuberculosis are placed in private rooms with negative-pressure airflow via HEPA filtration systems. Negative pressure pulls air away from the hallway and exhausts it out of the room to areas away from the intake vents. A nurse is reinforcing teaching with a client who has a family history of hypertension. The nurse should inform the client that his blood pressure reading of 124/84 mm Hg places him in which of the following categories? Prehypertension Rationale: a blood pressure reading of 124/84 mm Hg places this client in the prehypertension category. This includes a systolic pressure of 120-130 mm Hg and diastolic pressure of 80-89 mm Hg A nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse administer first? Albuterol Rationale: Albuterol is considered a rescue medication due to its rapid onset of action. Albuterol is a beta2 adrenergic agonist used for the treatment of acute exacerbations of asthma. Albuterol promotes broncho dilation and suppresses histamine release in the lungs A nurse is reinforcing teaching with a client who has neutropenia. Which of the following instructions should the nurse include in the teaching? Avoid crowded places Rationale: The nurse should inform the client to avoid crowds due to a suppressed immune system A nurse is collecting data from an older adult client who had a femoral head fracture 24 hr ago and is in Buck's traction. Which of the following findings is an indication of fat embolism syndrome? petechiae on the chest Rationale: a red rash on the clients abdomen, chest, neck or upper arms is a manifestation of fat embolism A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching? Breathe in through her nose and out through pursed lips rationale: The nurse should reinforce that pursed-lip breathing slows expiration, prevents collapse of alveoli, and helps the client to control the rate and depth of respirations A nurse is caring for a client who has cirrhosis and a prescription for lactulose. Following administration, the nurse should monitor the client for which of the following adverse effects? Diarrhea Rationale: The nurse should monitor for diarrhea. Lactulose is a synthetic disaccharide that the small intestine cannot utilize. It causes diarrhea by lowering the pH, so the bacterial flora are changed in the bowel A nurse is caring for a client who is postoperative following a thyroidectomy. Which of the following is a priority for the nurse to monitor during the first 24 hr of care for this client? Airway patency Rationale: when using the airway, breathing, circulation approach to client care, the nurse determines that the priority to monitor is airway patency. A thyroidectomy can result in edema or bleeding that can obstruct the airway. provide humidification and elevate the client's head of bed to reduce swelling A nurse is assisting with the care of a client who is 2 days postoperative following the creation of a tracheostomy. Which of the following actins should the nurse plan to take? Provide humidified air Rationale: the nurse should provide humidified air or oxygen as appropriate to the client's condition. Humidification prevents drying of pulmonary secretions and will facilitate keeping the client's airway clear A nurse is collecting data on a client who has acute pancreatitis. Which of the following factors should the nurse anticipate in the clients history? Gallstones Rationale: the nurse should identify the presence of gallstones as a causative factor in the development of acute pancreatitis. This occurs because a stone blocks the outflow of pancreatic enzymes and bile from the gall bladder and into the duodenum resulting in autodigestion and inflammation of the pancreas. An additional causative factor is an excessive use of alcohol A nurse finds a client who has type 1 diabetes mellitus lying in bed, sweating, tachycardic, and reporting feeling lightheaded and shaky. Which of the following complications should the nurse expect? Hypoglycemia Rationale: the client who has hypoglycemia manifests sweating, tachycardia, tremors, palpitations, hunger and lightheadedness