MEDICAL SURGICAL EXAM DETAILED ANSWER KEY - QUESTIONS WITH COMPLETE SOLUTIONS

A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? - CORRECT ANSWERS -Instruct the client to allow the machine to breathe for them. A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend? - CORRECT ANSWERS -Add cabbage to the diet. A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric stroke. Which of the following neurologic deficits should the nurse expect to find when assessing the client? (Select all that apply.) - CORRECT ANSWERS -- Visual spatial deficits - Left hemianopsia - One-sided neglect A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen? - CORRECT ANSWERS -Nonrebreather mask A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client has dyspnea with a productive cough and is using accessory muscles to breathe. Which of the following actions should the nurse take first? - CORRECT ANSWERS -Place the client in high-Fowler's position. A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client is experiencing excessive stools. Which of the following findings is an adverse effect of this medication? - CORRECT ANSWERS -Hypokalemia A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent a Pseudomonas aeruginosa infection? - CORRECT ANSWERS -Avoid placing plants or flowers in the client's room. An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? - CORRECT ANSWERS -Urine specific gravity 1.045 A nurse in an emergency department is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse expect? - CORRECT ANSWERS -Administer an opioid analgesic to the client. A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings? - CORRECT ANSWERS -Dysphagia A nurse is teaching a young adult client how to perform testicular self-examination. Which of the following instructions should the nurse include? - CORRECT ANSWERS -Roll each testicle between the thumb and fingers. A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching? - CORRECT ANSWERS -"I should take this medication with a meal." A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching? - CORRECT ANSWERS -"I will wear clean graduated compression stockings every day." A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority? - CORRECT ANSWERS -Tachycardia A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings? - CORRECT ANSWERS -Current medications