Adult Medical Surgical Assessment 2
Question: 1 of 50
A nurse is caring for a client who is hyperventilating and has the following results: pH 7.50, PaCo2 29mm Hg, and HCO2 25mEq/L. The nurse should recognise that the client has which of the follow -
ing acid-base imbalance?
a.Respiratory acidosis
b.Respiratory alkalosis
c.Metabolic acidosis
d.Metabolic alkalosis
Answer: b
Question 2 of 50
A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include?
a.Eat three large meals daily. b.Consume high calorie foods.
c.Limit caffeinated drinks to two per day.
d.Drink fluids during meal time
Answer: b
Question 3 of 50
A nurse is caring for a client who has a right sided pneumothorax. Following chest tube insertion, which of the following findings indicates that the chest drainage system is functioning correctly?
a.Circle bubbling in the suction chamber
b.Crepitus around the insertion site
c.Constant bubbling in the water seal chamber
d.Absence of breath sounds on the right side
Answer: a
Question 4 of 50
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention? a.Auxiliary temperature 37.3 degrees Celsius (99 f)
b.Apical pulse 100mm
c.Respiratory rate 30/min
d.Blood pressure 140/34 mm Hg
Answer: c
Question 5 of 50
A nurse is developing a plan of care for a client who will be placed in halo traction following surgi -
cal repair of the cervical spine. Which of the following intervention should he nurse include in the plan?
a.Inspect the pin site every 48 hr
b.Monitor the client’s skin under the halo vest
c.Ensure two personnel hold the halo device when repositioning the chest
d.Apply powder frequently to the cline’s skin under the vest to decrease aching. Answer: b
Question 6 of 50
A nurse is providing discharge teaching to a client who has heart failure and a prescription for furosemide 20 mg PO two times daily. Which of the following instructions should the nurse include
in the teaching?
a.Monitor for increased blood pressure.
b.Increase intake of high potassium foods. c.Expect an increase in swelling in the heads and feet.
d.Take off the second dose at bedtime.
Answer: b
Question 7 of 50
A nurse is teaching a client about feral occult blood testing (FOBT) for the screening of colorectal cancer. Which of the following statements should the nurse include in the teaching?
a.“Your provider will use stool from your digital rectal examination to perform the test.”
b.“Your provider will prescribe a stimulant laxative prior to the procedure to evacuate the bowel.”
Question: 1 of 50
A nurse is caring for a client who is hyperventilating and has the following results: pH 7.50, PaCo2 29mm Hg, and HCO2 25mEq/L. The nurse should recognise that the client has which of the follow -
ing acid-base imbalance?
a.Respiratory acidosis
b.Respiratory alkalosis
c.Metabolic acidosis
d.Metabolic alkalosis
Answer: b
Question 2 of 50
A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include?
a.Eat three large meals daily. b.Consume high calorie foods.
c.Limit caffeinated drinks to two per day.
d.Drink fluids during meal time
Answer: b
Question 3 of 50
A nurse is caring for a client who has a right sided pneumothorax. Following chest tube insertion, which of the following findings indicates that the chest drainage system is functioning correctly?
a.Circle bubbling in the suction chamber
b.Crepitus around the insertion site
c.Constant bubbling in the water seal chamber
d.Absence of breath sounds on the right side
Answer: a
Question 4 of 50
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention? a.Auxiliary temperature 37.3 degrees Celsius (99 f)
b.Apical pulse 100mm
c.Respiratory rate 30/min
d.Blood pressure 140/34 mm Hg
Answer: c
Question 5 of 50
A nurse is developing a plan of care for a client who will be placed in halo traction following surgi -
cal repair of the cervical spine. Which of the following intervention should he nurse include in the plan?
a.Inspect the pin site every 48 hr
b.Monitor the client’s skin under the halo vest
c.Ensure two personnel hold the halo device when repositioning the chest
d.Apply powder frequently to the cline’s skin under the vest to decrease aching. Answer: b
Question 6 of 50
A nurse is providing discharge teaching to a client who has heart failure and a prescription for furosemide 20 mg PO two times daily. Which of the following instructions should the nurse include
in the teaching?
a.Monitor for increased blood pressure.
b.Increase intake of high potassium foods. c.Expect an increase in swelling in the heads and feet.
d.Take off the second dose at bedtime.
Answer: b
Question 7 of 50
A nurse is teaching a client about feral occult blood testing (FOBT) for the screening of colorectal cancer. Which of the following statements should the nurse include in the teaching?
a.“Your provider will use stool from your digital rectal examination to perform the test.”
b.“Your provider will prescribe a stimulant laxative prior to the procedure to evacuate the bowel.”
