2022 MED SURGE AND PHARM FOR NEW EXAM SOLUTION
The nurse is caring for an older adult client with a history of stroke who has been
prescribed several medications and expresses reluctance to take them because of his
difficulty swallowing. Which of the following actions is the nurse's priority?
- CORRECT ANSWER Observe for symmetry of the client's soft palate and uvula
The nurse on a medical -surgical unit is providing care for a client who is a hospital
employee. Several nurses have called seeking information about the client. Which of
the following actions should the nurse take in response to inquires from the nurses?
- CORRECT ANSWER Refer questions to the nursing supervisor
The nurse is caring for a client who is postoperative immediately following a
tonsillectomy. Which of the following snacks should the nurse offer the client?
- CORRECT ANSWER orange ice pop
The nurse is caring for a client who has heart failure and has been taking digoxin
0.25mg daily. The client refuses breakfast and reports nausea. Which of the following
actions should the nurse take first?
- CORRECT ANSWER Check the client's vital signs
The nurse is collecting data from a client who has scleroderma. Which of the following
findings should the nurse expect?
- CORRECT ANSWER Hardened skin
The nurse is assisting with the care of a client who is postoperative and has a closed-
wound drainage system in place. Which of the following actions should the nurse take?
- CORRECT ANSWER Fully recollapse the reservoir after emptying it
The nurse is caring for a client who has multiple myeloma and has a WBC count of
2,200/mm3. Which of the following food items brought by the family should the nurse
prohibit from being given to the client?
- CORRECT ANSWER fresh fruit basket
The nurse is preparing to administer heparin intravenously to a client. Which of the
following actions should the nurse take?
- CORRECT ANSWER Obtain an infusion pump to regulate the continuous flow of the
medication
The nurse is caring for an older client who has dysphagia and left-sided weakness
following a stroke. Which of the following actions should the nurse take?
- CORRECT ANSWER Add thickener to fluids
The nurse is checking for paradoxical blood pressure on a client who has constrictive
pericarditis. Which of the following findings should the nurse expect?
- CORRECT ANSWER Drop in systolic BP more than 10 mm Hg on inspiration
, The nurse is reviewing the prescription for a newly admitted client who is to undergo
cardiac testing. For which of the following procedures should the nurse verify that the
client has given written informed consent?
- CORRECT ANSWER Exercise ECG stress test
The nurse is caring for a child who has disseminated intravascular coagulation and is
experiencing epistaxis. Which of the following actions should the nurse take?
- CORRECT ANSWER Insert cotton into both of the child's nostrils.
The nurse is reinforcing discharge reaching with a client about how to care a newly
created ileal conduit. Which of the following instructions should the nurse include int eh
teaching?
- CORRECT ANSWER Empty the ostomy pouch when its 2/3 full
The nurse is caring for a client receiving IV therapy in the left forearm and notices that
the site is red, swollen, and warm. Which of the following actions should the nurse
perform first?
- CORRECT ANSWER Discontinue the existing IV infusion
The nurse is reviewing the laboratory results of a client who is postoperative and has a
respiratory rate of 7/min. The arterial blood gas (ABG) values include:
pH- 7.22
PaCO2- 68 mm Hg
Base excess-2
PaO2- 78 mm Hg
Oxygen saturation- 80%
Bicarbonate- 28 mEq/L
Which of the following interpretations of the ABG values should the nurse make?
- CORRECT ANSWER Respiratory Acidosis
The nurse is caring for an older adult client who is 5 day postoperative following a total
hip arthroplasty and is receiving meperidine for pain. While the nurse is taking morning
vital signs, the client begins to experience a seizure. Which of the following should the
nurse recognize as the possible cause for this seizure?
- CORRECT ANSWER Cumulative effect
The nurse is collecting data from a client who has open-angle glaucoma. Which of the
following findings should the nurse expect?
- CORRECT ANSWER Loss of peripheral vision
The nurse is assisting in the care of a client who is 2 hours postoperative following a
wedge resection of the left lung and has a chest tube to suction. Which of the following
is the priority finding the nurse should report to the provider?
The nurse is caring for an older adult client with a history of stroke who has been
prescribed several medications and expresses reluctance to take them because of his
difficulty swallowing. Which of the following actions is the nurse's priority?
- CORRECT ANSWER Observe for symmetry of the client's soft palate and uvula
The nurse on a medical -surgical unit is providing care for a client who is a hospital
employee. Several nurses have called seeking information about the client. Which of
the following actions should the nurse take in response to inquires from the nurses?
- CORRECT ANSWER Refer questions to the nursing supervisor
The nurse is caring for a client who is postoperative immediately following a
tonsillectomy. Which of the following snacks should the nurse offer the client?
- CORRECT ANSWER orange ice pop
The nurse is caring for a client who has heart failure and has been taking digoxin
0.25mg daily. The client refuses breakfast and reports nausea. Which of the following
actions should the nurse take first?
- CORRECT ANSWER Check the client's vital signs
The nurse is collecting data from a client who has scleroderma. Which of the following
findings should the nurse expect?
- CORRECT ANSWER Hardened skin
The nurse is assisting with the care of a client who is postoperative and has a closed-
wound drainage system in place. Which of the following actions should the nurse take?
- CORRECT ANSWER Fully recollapse the reservoir after emptying it
The nurse is caring for a client who has multiple myeloma and has a WBC count of
2,200/mm3. Which of the following food items brought by the family should the nurse
prohibit from being given to the client?
- CORRECT ANSWER fresh fruit basket
The nurse is preparing to administer heparin intravenously to a client. Which of the
following actions should the nurse take?
- CORRECT ANSWER Obtain an infusion pump to regulate the continuous flow of the
medication
The nurse is caring for an older client who has dysphagia and left-sided weakness
following a stroke. Which of the following actions should the nurse take?
- CORRECT ANSWER Add thickener to fluids
The nurse is checking for paradoxical blood pressure on a client who has constrictive
pericarditis. Which of the following findings should the nurse expect?
- CORRECT ANSWER Drop in systolic BP more than 10 mm Hg on inspiration
, The nurse is reviewing the prescription for a newly admitted client who is to undergo
cardiac testing. For which of the following procedures should the nurse verify that the
client has given written informed consent?
- CORRECT ANSWER Exercise ECG stress test
The nurse is caring for a child who has disseminated intravascular coagulation and is
experiencing epistaxis. Which of the following actions should the nurse take?
- CORRECT ANSWER Insert cotton into both of the child's nostrils.
The nurse is reinforcing discharge reaching with a client about how to care a newly
created ileal conduit. Which of the following instructions should the nurse include int eh
teaching?
- CORRECT ANSWER Empty the ostomy pouch when its 2/3 full
The nurse is caring for a client receiving IV therapy in the left forearm and notices that
the site is red, swollen, and warm. Which of the following actions should the nurse
perform first?
- CORRECT ANSWER Discontinue the existing IV infusion
The nurse is reviewing the laboratory results of a client who is postoperative and has a
respiratory rate of 7/min. The arterial blood gas (ABG) values include:
pH- 7.22
PaCO2- 68 mm Hg
Base excess-2
PaO2- 78 mm Hg
Oxygen saturation- 80%
Bicarbonate- 28 mEq/L
Which of the following interpretations of the ABG values should the nurse make?
- CORRECT ANSWER Respiratory Acidosis
The nurse is caring for an older adult client who is 5 day postoperative following a total
hip arthroplasty and is receiving meperidine for pain. While the nurse is taking morning
vital signs, the client begins to experience a seizure. Which of the following should the
nurse recognize as the possible cause for this seizure?
- CORRECT ANSWER Cumulative effect
The nurse is collecting data from a client who has open-angle glaucoma. Which of the
following findings should the nurse expect?
- CORRECT ANSWER Loss of peripheral vision
The nurse is assisting in the care of a client who is 2 hours postoperative following a
wedge resection of the left lung and has a chest tube to suction. Which of the following
is the priority finding the nurse should report to the provider?
