NURS 307 MED SURG CMS

1 A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglass cast. Which of the following findings should the nurse expect? A. Capillary refill less than 2 seconds B. Bounding distal pulses C. Intense pain with movement d. Erythema of the toes 2 A nurse is monitoring a client who is receiving 2 units packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction? A. Chills B. Hypertension C. Bradycardia D. Back pain 3 A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions should thenurse take to prevent hip dislocation? A. Remove the wedge device when turning B. Place two bed pillows between the legs when in bed C. Encourage the client to lean forward when attempting to stand D. Elevate the knees higher than the hips when sitting 4 A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the following substances A. Povidone-iodine B. Adhesive tape C. Latex D. Anesthetics 5 A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching? A. Place hands on the upper abdomen during inhalation. B. Position the mouthpiece 2.5 cm (1 in) from the mouth C. Exhale slowly through pursed lips D. Hold breaths about 3 to 5 seconds before exhaling 6 A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8mEq/L. Which of the following interventions should the nurse implement first? A. Check the clients hand grasps B. Administer an IV potassium drip C. Listen to the client's bowel sounds D. Initiate cardiac monitoring for the clients Priority question remember, what can I do first, you can start a K+ drip without knowing how their heart is affected. 7 A nurse is preparing to administer peritoneal dialysis to a client. Which of the following actions should the nurse take? A. Chill the dialysate before administration B. Hang the drainage bag below the client's abdomen C. Place the client in high-Fowlers position D. Use clean technique to access the catheter 8 A nurse is preforming a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)? A. Inability to smell B. loss of peripheral vision C. Disequilibrium with movement D. Deviation of the tongue from midline 9 A nurse is planning care for a client who is one day postoperative Following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care? A. Place pillows under the clients knees B. Avoid use of anticoagulants C. Discourage leg exercises while in bed D. apply compression stockings to the lower extremities 10 A nurse is providing a discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching? A. "I will keep my left arm flexed at the elbow as much as possible" ? B. " I should expect less than 25 mL of secretions per day in the drainage devices " C. "I will perform strength building arm exercises using a 15 pound weight" D. " I will have to wait 2 months before additional saltine can be added to my breast expander" b11 A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the following statements should the nurse include I the first teaching? A. "Do not shake your inhaler before use" B. "Exhale Fully before bringing the inhaler to your lips " C. "Use Peroxide to clean the mouthpiece of your inhaler" D. "Depress the canister after you inhale" 12 A nurse is caring for a client who has been receiving total parental nutrition (TPN) for 1 week. For which of the following findings should the nurse notify the provider? A. Calcium level 11.5 mg/dL B. Serum albumin level 3.9g/dl C. Output 200 mL more than intake over the past 12 hr. D. Fasting blood glucose level 105 mg/dL 13 A nurse is setting up a sterile field before preforming a dressing change on a client who is postoperative. Which of the following actions should the nurse plan to take to maintain the sterile field? (Select all that apply) A. Grasp 2.5 cm (1 in) of the outer edge to open the surgical wrap B. Open the first flap of the sterile package toward the nurse's body C. Place a surgical pack with a sterile drape on the work surface D. Select a work surface at the nurse's waist level E. Apply sterile gloves before opening the pack 14 A nurse is an emergency department is preparing a client for emergency surgery. The clients blood alcohol level is 180mg/dL. Which of the following actions is the nurse's priority? A. Obtain consent for surgery B. Insert an indwelling urinary catheter C. Insert an NG tube D. Apply antiembolic stoking's 17 A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the first sign of deteriorating neurological status? A. Pupillary dilation B. Cheyne-Strokes respirations C. Decorticate posturing D. Altered level of Consciousness 18 A nurse is performing skin cancer screening on a group of clients. Which of the following findings should the nurse Identify as an indication of melanoma? A. Flat lesion with irregular borders B. Raised lesion with a rolled border C. Scaly lesion with the crusted appearance D. Reddened lesion with dilated blood vessels 19 A nurse is caring for a client who has diabetes insipidus. Which Of the following medications should the nurse plan to administer. A. Lithium B. Desmopressin C. Regular insulin D. Furosemide 20 A nurse is preparing to assist with the insertion of a non-tunneled Central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take. A. Cleanse the site with a hydrogen peroxide solution B. instruct the client to cough as the catheter is inserted C. confirm the correct position of the line by obtaining a blood sample D. place the head of the client's bed lower than the foot 21 A nurse is providing discharge teaching to a client who has chronic urinary tract infections. The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following instructions should the nurse include in the teaching? A. Monitor heart rate once daily. B. Take a laxative to prevent constipation. C. Drink 2 to 3 L of fluids daily. D. Take an antacid 30 min before taking the medication. 22 A nurse is providing discharge teaching for a client who has HIV. Which of the following information is the priority for the nurse to review with the client? A. "List some ways you can cope with the stress of your illness" B. "Name a few things you will change about your diet." C. "Tell me why it's important to have your CD4+ count checked" D. "Describe your daily medication schedule." 23 A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea10 min after the infusion begins. Which of the following actions should the nurse take first ? A. Stop the infusion. B. Collect a urine sample. C. Check the client's vital signs. D. Administer oxygen to the client. 24 A nurse is preparing to assist the provider with a thoracentesis for a client who has a left pleural effusion. Which of the following interventions is the priority for the nurse? A. Reinfo