Medical-Surgical LPN/RN Assessment 1ShiftKey {25 Questions and Answers}

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1. A nurse is reviewing the laboratory results of a client who is scheduled for a
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CT scan with an IV contrast agent. Which of the following laboratory findings s
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hould the nurse report to the provider prior to the procedure?
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A) Sodium 136 mEq/L v v


B) Potassium 4.8 mEq/L v v


C) Creatinine 1.9 mg/dL v v


D) Calcium 10 mg/dL: C) Creatinine 1.9 mg/dL v v v v v v




Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse
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should report the finding to the provider before the client has a CT scan with an IV cont
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rast agent. This finding places the client at risk for developing contrast-
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induced nephropathy. v


2. A nurse is monitoring a client who is taking acarbose. Which of the following
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findings should the nurse identify as an adverse effect of the medication?
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A) Polyuria
B) Abdominal cramps v


C) Renal insufficiency v


D) Insomnia: B) Abdominal cramps v v v




Acarbose affects the gastrointestinal system. Therefore, the nurse should monitor the
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vclient for abdominal cramping, rumbling bowel sounds, and diarrhea as adverse effec
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ts of this medication.
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3. A nurse is assisting with the care of a client who had a cardiac catheterizatio
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n via the right femoral artery. Which of the following actions should the nurse ta
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ke to prevent postprocedure complications? (Select all)
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A) Monitor the insertion site for bleeding v v v v v


B) Position the affected extremity at a 45 degree angle v v v v v v v v


C) Restrict the client's fluid intake v v v v


D) Maintain the pressure dressing v v v


E) Check the client's peripheral pulses: A) Monitor the insertion site for bleeding
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The nurse should monitor the client's insertion site for manifestations of hemorrhagin
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g.

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D) Maintain the pressure dressing.
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The nurse should maintain the client's pressure dressing to prevent hemorrhaging a
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nd allow for the cannulation site to heal. E) Check the client's peripheral pulses.
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The nurse should assess the client's peripheral pulses to help identify signs of arterial
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occlusion.
4. A nurse is contributing to the plan of care for a client who has chronic obstru
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ctive pulmonary disease (COPD) and is dyspneic. Which of the following interv
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entions should the nurse include in the plan?
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A) Encourage abdominal breathing v v


B) Direct the client to inhale with pursed lips
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C) Set the oxygen therapy at 5L/min
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D) Instruct the client to lean back while coughing: A) Encourage abdominal breat
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hing

The nurse should encourage abdominal breathing, which reduces the workload on th
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e accessory muscles of respiration during dyspneic episodes.
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5. A nurse is preparing to administer phytonadione 7 mg subcutaneously to
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a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many m
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L should the nurse administer? (Round the answer to the nearest tenth. Use a l
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eading zero is it applies. Do not use a trailing zero.: 7mg/10 mg *1mL= 0.7 mL
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6. A nurse is examining a client's IV site and notes a red line up his arm. The c
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lient reports a throbbing, burning pain at the IV site. The nurse should identify t
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hat the client's manifestations indicate which of the following complications of
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vIV therapy?v




A) Thrombophlebitis
B) Infiltration
C) Hematoma
D) Venous spasms: A) Thrombophlebitis v v v




The nurse should identify pain, warmth, and a red streak up the arm as indications of t
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hrombophlebitis.



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7. A nurse is reinforcing teaching about management of constipation with a cl
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ient who has hypothyroidism. Which of the following should the nurse includ
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e in the teaching?
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A) Increase intake of fiber-rich foods v v v v


B) Take a laxative every morning
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C) Maintain a fluid intake of 1200 mL per day v v v v v v v v


D) Limit activity to preserve energy: A) Increase intake of fiber-rich foods
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The nurse should instruct the client to increase the amount of fiber-
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rich foods in his diet. Dried beans and brown rice are examples of fiber-rich foods.
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8. A nurse is caring for a client who has a compound fracture of the femur and w
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as placed in balanced suspension skeletal traction 4 days ago. Which of the foll
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owing actions should the nurse take?
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A) Perform pin site care daily v v v v


B) Remove the overbed trapeze v v v


C) Remove the boot every 2 hr v v v v v


D) Keep the weights on a stable, flat surface: A) Perform pin site care daily
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The nurse should perform pin site care daily with chlorhexidine solution or use a soluti
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on according to facility protocol. The nurse should also monitor the pin sites for manife
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stations of infection. v v


9. A nurse observes a client who is lying in bed experiencing a tonic-
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clonic seizure. Which of the following actions should the nurse take?
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A) Lower the side rails of the client's bed
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B) Apply wrist restraints to the client
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C) Position the client in the semi-Fowler's position v v v v v v


D) Loosen clothing around the client's neck: D) Loosen clothing around the client'
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s neck v




The nurse should loosen clothing around the client's neck to maintain an open airway
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and prevent aspiration.
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10. A nurse is contributing to the plan of care for a client who has multiple scler
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osis and is taking dantrolene to manage muscle spasms. Which of the followin
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g interventions should the nurse include?
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A) Apply hot packs to the client's muscles v v v v v v


B) Schedule physical therapy in the afternoon v v v v v


C) Encourage the client to complete ADLs v v v v v


D) Administer valerian to promote sleep: C) Encourage the client to complete ADL v v v v v v v v v v v


s

The nurse should encourage the client to complete ADLs and provide assistance as n
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eeded. Performing self- v v


care increases the client's independence, strength, and level of functioning.
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11. A nurse is reinforcing discharge teaching to prevent dumping syndrome for
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a client following a partial gastrectomy for ulcers. Which of the following infor
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mation should the nurse include in the teaching?
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A) Avoid liquids at mealtimes v v v


B) Exclude eating starchy vegetables v v v


C) Avoid eating high-protein meals v v v


D) Plan to increase intake of sweetened fruits: A) Avoid liquids at mealtimes
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The nurse should remind the client to avoid drinking liquids at mealtimes to prevent th
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e food from emptying into the small bowel too quickly.
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12. A nurse is collecting data from a client who has heart failure and is taking di
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goxin. Which of the following outcomes from the medication should the nurse
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expect?

A) Increased weight v


B) Increased heart rate v v


C) Decreased urinary output v v


D) Decreased shortness of breath: D) Decreased shortness of breath v v v v v v v v




The nurse should expect the client to have decreased shortness of breath. Digoxin inc
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reases the contractility of the heart, which decreases pulmonary congestion.
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