Med Surg vati assessment Questions And Answers
A nurse is collecting data from a client who has right-sided heart failure. Which of
the following findings should the nurse expect? (Select all that apply.) - correct
answer Poripheral edema
Hepatomegaly
Abdominal distention
A nurse is caring for a client who has heart failure and a new prescription for
furosemide. The nurse should monitor the client for which of the following
adverse effects of the medication? - correct answer Tinnitus
The nurse should monitor clients who take furosemide for tinnitus and hearing
loss. Audiometry is recommended for clients recelving prolonged IV furosemide.
A nurse is reinforcing teaching with a client who is recovering from severe
diarrhea and is ready to resume eating solid foods. Which of the following food
items should the nurse recommend? - correct answer Yogurt
The nurse should recommend adding yogurt to the diet to provide probiotics and
add substance to the stool, making it more formed. A client who is recovering
from diarrhea should consume a diet that is low in fiber. Taking probiotics can
also help restore the natural gastrointestinal flora.
A nurse is monitoring a client who has a new prescription for furosemide for
peripheral edema. For which of the following adverse effects should the nurse
monitor? - correct answer Muscle weakness
Furosemide is a loop diuretic, which is used to treat hypertension and edema.
Furosemide can cause excess excretion of potassium. The nurse should monitor
,the client for manifestations of hypokalemia such as nausea, muscle weakness,
and spasms.
A nurse is contacting the provider of a client who has heart failure and a
potassium level of 3.4 mEq/L. Which of the following client medications should
the nurse expect the provider to withhold? - correct answer Digoxin
The nurse should expect the provider to withhold digoxin when the client's
potassium level is low to decrease the client's risk of dysrhythrmias due to
digoxin toxicity. Potassium assists in displacing digoxin, because digoxin binds
to potassiurm, and reduces the risk for digoxin toxicity.
A nurse is assisting with the care of a client who has cellulitis and is receiving IV
ceftriaxone. During data collection, the nurse notes the client is flushed and the
client reports urticaria. After stopping the IV infusion, which of the following
actions should the nurse take first? - correct answer Check the client's
respirations.
After stopping the IV infusion, the first action the nurse should take when using
the airway, breathing, circulation approach to client care is to count the client's
respirations and monitor for dyspnea because a client experiencing an allergic
reaction can progress to anaphylactic shock and death.
A registered nurse (RN) in an acute care facility is caring for a group of clients
with the assistance of a licensed practical nurse (LPN). Which of the following
tasks should the RN delegate to the LPN? (Select all that apply.) - correct answer
Inserting an NG tube
Monitoring an IV infusion
Administering IM medications
, A nurse is reinforcing teaching with a young adult client about testicular self-
examination. Which of the following instructions should the nurse include? -
correct answer "Examine your testicles after a warm shower."
After exposure to warm water in a shower or bath, the scrotum relaxes and
becomes easy to palpate. The testicle should feel smooth and round, and the
client should report any lumps to his provider.
A nurse is assisting in the planning of a health education class for a group of
older adult clients. Which of the following recommendations should the nurse
include? - correct answer Obtain a pneumococcal immunization
The pneumococcal immunization should be obtained to prevent pneumonia and
is generally given at or near the age of 65, One dose provides lifelong immunity
A nurse is preparing to administer eardrops to an adult client who has otitis
media. Which of the following actions should the nurse plan to take? - correct
answer Warm the bottle by holding it in the palm for 5 min before administration.
The nurse should plan to warm the bottle of drops slightly by holding it in the
palm of the hand or putting the bottle in a pocket for about 5 min. Administering
cold ear drops can cause the client to experience discomfort or dizziness.
A nurse is reinforcing teaching about the use of an oxygen concentrator in the
home for a client who has end-stage emphysema. Which of the following
instructions should the nurse include to promote client safety? - correct answer
Maintain an electrical backup system.
medical services and the electric company of the The nurse should remind the
client to maintain an electrical backup system to ensure continuity of oxygen
therapy. This includes notifying local emergency use of home oxygen equipment.
A nurse is collecting data from a client who has right-sided heart failure. Which of
the following findings should the nurse expect? (Select all that apply.) - correct
answer Poripheral edema
Hepatomegaly
Abdominal distention
A nurse is caring for a client who has heart failure and a new prescription for
furosemide. The nurse should monitor the client for which of the following
adverse effects of the medication? - correct answer Tinnitus
The nurse should monitor clients who take furosemide for tinnitus and hearing
loss. Audiometry is recommended for clients recelving prolonged IV furosemide.
A nurse is reinforcing teaching with a client who is recovering from severe
diarrhea and is ready to resume eating solid foods. Which of the following food
items should the nurse recommend? - correct answer Yogurt
The nurse should recommend adding yogurt to the diet to provide probiotics and
add substance to the stool, making it more formed. A client who is recovering
from diarrhea should consume a diet that is low in fiber. Taking probiotics can
also help restore the natural gastrointestinal flora.
A nurse is monitoring a client who has a new prescription for furosemide for
peripheral edema. For which of the following adverse effects should the nurse
monitor? - correct answer Muscle weakness
Furosemide is a loop diuretic, which is used to treat hypertension and edema.
Furosemide can cause excess excretion of potassium. The nurse should monitor
,the client for manifestations of hypokalemia such as nausea, muscle weakness,
and spasms.
A nurse is contacting the provider of a client who has heart failure and a
potassium level of 3.4 mEq/L. Which of the following client medications should
the nurse expect the provider to withhold? - correct answer Digoxin
The nurse should expect the provider to withhold digoxin when the client's
potassium level is low to decrease the client's risk of dysrhythrmias due to
digoxin toxicity. Potassium assists in displacing digoxin, because digoxin binds
to potassiurm, and reduces the risk for digoxin toxicity.
A nurse is assisting with the care of a client who has cellulitis and is receiving IV
ceftriaxone. During data collection, the nurse notes the client is flushed and the
client reports urticaria. After stopping the IV infusion, which of the following
actions should the nurse take first? - correct answer Check the client's
respirations.
After stopping the IV infusion, the first action the nurse should take when using
the airway, breathing, circulation approach to client care is to count the client's
respirations and monitor for dyspnea because a client experiencing an allergic
reaction can progress to anaphylactic shock and death.
A registered nurse (RN) in an acute care facility is caring for a group of clients
with the assistance of a licensed practical nurse (LPN). Which of the following
tasks should the RN delegate to the LPN? (Select all that apply.) - correct answer
Inserting an NG tube
Monitoring an IV infusion
Administering IM medications
, A nurse is reinforcing teaching with a young adult client about testicular self-
examination. Which of the following instructions should the nurse include? -
correct answer "Examine your testicles after a warm shower."
After exposure to warm water in a shower or bath, the scrotum relaxes and
becomes easy to palpate. The testicle should feel smooth and round, and the
client should report any lumps to his provider.
A nurse is assisting in the planning of a health education class for a group of
older adult clients. Which of the following recommendations should the nurse
include? - correct answer Obtain a pneumococcal immunization
The pneumococcal immunization should be obtained to prevent pneumonia and
is generally given at or near the age of 65, One dose provides lifelong immunity
A nurse is preparing to administer eardrops to an adult client who has otitis
media. Which of the following actions should the nurse plan to take? - correct
answer Warm the bottle by holding it in the palm for 5 min before administration.
The nurse should plan to warm the bottle of drops slightly by holding it in the
palm of the hand or putting the bottle in a pocket for about 5 min. Administering
cold ear drops can cause the client to experience discomfort or dizziness.
A nurse is reinforcing teaching about the use of an oxygen concentrator in the
home for a client who has end-stage emphysema. Which of the following
instructions should the nurse include to promote client safety? - correct answer
Maintain an electrical backup system.
medical services and the electric company of the The nurse should remind the
client to maintain an electrical backup system to ensure continuity of oxygen
therapy. This includes notifying local emergency use of home oxygen equipment.
