Adult Medical Surgical
A nurse is caring for a client who is 3 days postoperative following a total right hip arthroplasty.
Which of the following actions should the nurse take? - ANS-Maintain abduction of the client's
right leg while in bed.
A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think
I can go on any longer." Which of the following responses should the nurse make?
"Are you experiencing abdominal pain?"
"You should talk about this with the people you're closest to."
"Many people who have cancer feel this way."
"You feel like you want to discontinue treatment?" - ANS-"You feel like you want to discontinue
treatment?"
A nurse is contributing to the plan of care for a client who is having difficulty eating following a
stroke. Which of the following actions should the nurse take first?
Collaborate with a dietitian.
Ensure that the client is provided with a high-ber diet.
Implement recommendations from the speech-language pathologist.
Request a referral for an occupational therapist. - ANS-Implement recommendations from the
speech-language pathologist.
A nurse is contributing to the plan of care for a client who was admitted to the neurological unit
following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the
priority? - ANS-Keep the client in a side-lying position.
Greatest risk to the client following a stroke is aspiration. The nurse should position the client in
a lateral, or side-lying, position to allow any secretions to drain out of the mouth, decreasing the
risk for aspiration. Additionally, the nurse should have suction equipment available in the event
that any secretions are present in the oral cavity.
A nurse is participating in a health fair for older adult clients. Which of the following vaccines
should the nurse recommend for this age group? - ANS-Herpes zoster for 60 years of age and
older.
Meningococcal vaccine to college students and military recruits who are living in shared
housing.
HPV vaccine for clients who are 9 to 26 years of age.
MMR vaccine to clients who are 62 years of age.
,A nurse is contributing to the plan of care for a client who has a new prescription for nystatin
suspension for oral candidiasis. Which of the following interventions should the nurse include in
the plan?
Use a commercial mouthwash before taking the medication.
Instruct the client to swish the medication in their mouth.
Discontinue the medication as soon as the lesions are healed.
Combine the medication with applesauce - ANS-Instruct the client to swish the medication in
their mouth.
A nurse is preparing to perform intermittent urinary catheterization for a female client who has
been unable to void following surgery 6 hr ago. Which of the following catheters should the
nurse use to perform this procedure? - ANS-intermittent straight catheter (clear tube with blue
top)
A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel
obstruction in the descending colon. When listening in the left upper quadrant, the nurse should
identify this sound as which of the following? - ANS-Hyperactive bowel sounds
Normal bowel sounds, the nurse should expect to hear 5-35 gurgles and clicks in 1 min.
A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking
dantrolene to manage muscle spasms. Which of the following interventions should the nurse
include?
Apply hot packs to the client's muscles.
Schedule physical therapy in the afternoon
Encourage the client to complete ADLs.
Administer valerian to promote sleep - ANS-Encourage the client to complete ADLs.
A nurse is assisting with the care of a client who had a cardiac catheterization via the right
femoral artery. Which of the following actions should the nurse take to prevent postprocedure
complications?
Monitor the insertion site for bleeding
Position the affected extremity at a 45º
Restrict the client's fluid intake
Maintain the pressure dressing
Check the client's peripheral pulses - ANS-Monitor the insertion site for bleeding is
Maintain the pressure dressing
Check the client's peripheral pulses
A home health nurse is reinforcing teaching about preventing asthma attacks with a client who
has asthma. Which of the following instructions should the nurse include in the teaching?
, "Cover the floor of your bedroom with carpet."
"Do not allow visitors to smoke cigarettes in your home."
"Breathe cold air to ease feelings of shortness of breath."
"Open the windows in your home during the spring to increase air flow." - ANS-"Do not allow
visitors to smoke cigarettes in your home."
A nurse is caring for a client who has a prescription for phenazopyridine. Which of the following
findings should the nurse identify as a therapeutic effect of the medication?
Reduces bacteria in the urinary tract
Suppresses urge to void
Prevents nerve stimulation to the bladder muscle
Decreases pain during urination - ANS-Decreases pain during urination
A nurse is monitoring a client who is taking acarbose. Which of the following findings should the
nurse identify as an adverse effect of the medication?
Polyuria
Abdominal cramps
Renal insufficiency
Insomnia - ANS-Abdominal cramps
A nurse is caring for a client who has a new cast on their left forearm and reports severe pain in
the affected arm with numbness in the ngers. The nurse nds the skin is pale and cold with
sluggish capillary refill. Which of the following fracture complications should the nurse suspect?
Compartment syndrome
Fat embolism
Deep-vein thrombosis
Osteomyelitis - ANS-Compartment Syndrome
A nurse is assisting with the discharge planning for a client who is postoperative following a total
hip arthroplasty. Which of the following instructions should the nurse include in the discharge
plan?
Expect decreased sensation for the rst postoperative week.
Avoid lying on the operative side.
Obtain a raised toilet seat.
Cross legs at the ankles - ANS-Obtain a raised toilet seat.
A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the
following provider prescriptions should the nurse implement first? - ANS-Initiate oxygen at 4
L/min via nasal cannula.
A nurse is caring for a client who is 3 days postoperative following a total right hip arthroplasty.
Which of the following actions should the nurse take? - ANS-Maintain abduction of the client's
right leg while in bed.
A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think
I can go on any longer." Which of the following responses should the nurse make?
"Are you experiencing abdominal pain?"
"You should talk about this with the people you're closest to."
"Many people who have cancer feel this way."
"You feel like you want to discontinue treatment?" - ANS-"You feel like you want to discontinue
treatment?"
A nurse is contributing to the plan of care for a client who is having difficulty eating following a
stroke. Which of the following actions should the nurse take first?
Collaborate with a dietitian.
Ensure that the client is provided with a high-ber diet.
Implement recommendations from the speech-language pathologist.
Request a referral for an occupational therapist. - ANS-Implement recommendations from the
speech-language pathologist.
A nurse is contributing to the plan of care for a client who was admitted to the neurological unit
following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the
priority? - ANS-Keep the client in a side-lying position.
Greatest risk to the client following a stroke is aspiration. The nurse should position the client in
a lateral, or side-lying, position to allow any secretions to drain out of the mouth, decreasing the
risk for aspiration. Additionally, the nurse should have suction equipment available in the event
that any secretions are present in the oral cavity.
A nurse is participating in a health fair for older adult clients. Which of the following vaccines
should the nurse recommend for this age group? - ANS-Herpes zoster for 60 years of age and
older.
Meningococcal vaccine to college students and military recruits who are living in shared
housing.
HPV vaccine for clients who are 9 to 26 years of age.
MMR vaccine to clients who are 62 years of age.
,A nurse is contributing to the plan of care for a client who has a new prescription for nystatin
suspension for oral candidiasis. Which of the following interventions should the nurse include in
the plan?
Use a commercial mouthwash before taking the medication.
Instruct the client to swish the medication in their mouth.
Discontinue the medication as soon as the lesions are healed.
Combine the medication with applesauce - ANS-Instruct the client to swish the medication in
their mouth.
A nurse is preparing to perform intermittent urinary catheterization for a female client who has
been unable to void following surgery 6 hr ago. Which of the following catheters should the
nurse use to perform this procedure? - ANS-intermittent straight catheter (clear tube with blue
top)
A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel
obstruction in the descending colon. When listening in the left upper quadrant, the nurse should
identify this sound as which of the following? - ANS-Hyperactive bowel sounds
Normal bowel sounds, the nurse should expect to hear 5-35 gurgles and clicks in 1 min.
A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking
dantrolene to manage muscle spasms. Which of the following interventions should the nurse
include?
Apply hot packs to the client's muscles.
Schedule physical therapy in the afternoon
Encourage the client to complete ADLs.
Administer valerian to promote sleep - ANS-Encourage the client to complete ADLs.
A nurse is assisting with the care of a client who had a cardiac catheterization via the right
femoral artery. Which of the following actions should the nurse take to prevent postprocedure
complications?
Monitor the insertion site for bleeding
Position the affected extremity at a 45º
Restrict the client's fluid intake
Maintain the pressure dressing
Check the client's peripheral pulses - ANS-Monitor the insertion site for bleeding is
Maintain the pressure dressing
Check the client's peripheral pulses
A home health nurse is reinforcing teaching about preventing asthma attacks with a client who
has asthma. Which of the following instructions should the nurse include in the teaching?
, "Cover the floor of your bedroom with carpet."
"Do not allow visitors to smoke cigarettes in your home."
"Breathe cold air to ease feelings of shortness of breath."
"Open the windows in your home during the spring to increase air flow." - ANS-"Do not allow
visitors to smoke cigarettes in your home."
A nurse is caring for a client who has a prescription for phenazopyridine. Which of the following
findings should the nurse identify as a therapeutic effect of the medication?
Reduces bacteria in the urinary tract
Suppresses urge to void
Prevents nerve stimulation to the bladder muscle
Decreases pain during urination - ANS-Decreases pain during urination
A nurse is monitoring a client who is taking acarbose. Which of the following findings should the
nurse identify as an adverse effect of the medication?
Polyuria
Abdominal cramps
Renal insufficiency
Insomnia - ANS-Abdominal cramps
A nurse is caring for a client who has a new cast on their left forearm and reports severe pain in
the affected arm with numbness in the ngers. The nurse nds the skin is pale and cold with
sluggish capillary refill. Which of the following fracture complications should the nurse suspect?
Compartment syndrome
Fat embolism
Deep-vein thrombosis
Osteomyelitis - ANS-Compartment Syndrome
A nurse is assisting with the discharge planning for a client who is postoperative following a total
hip arthroplasty. Which of the following instructions should the nurse include in the discharge
plan?
Expect decreased sensation for the rst postoperative week.
Avoid lying on the operative side.
Obtain a raised toilet seat.
Cross legs at the ankles - ANS-Obtain a raised toilet seat.
A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the
following provider prescriptions should the nurse implement first? - ANS-Initiate oxygen at 4
L/min via nasal cannula.
