Adult Medical Surgical Practice A
A nurse is reviewing the medical record of a client who has systemic lupus erythematosus.
Which of the following findings should the nurse expect? - ANS-Facial butterfly rash.
R: A butterfly rash is a manifestation of SLE. It appears as a dry red rash on the clients cheeks
and nose and can disappear during times of remission.
A nurse is caring for a client who is receiving plasmapheresis through a venous access site.
Which of the following actions should the nurse take? - ANS-Check electrolyte levels before
and after therapy.
R: Plasmapheresis can cause citrate induced hypocalcemia. Therefore the nurse should
monitor the clients electrolyte levels before and after therapy.
A nurse is assessing a client who has Graves disease. Which of the following images should
indicate to the nurse that the client has exophthalmos? - ANS-The nurse should identify an
outward protrusion of the eyes is exophthalmos a common finding of graves disease. An
overproduction of the thyroid hormone causes edema of the extraocular muscle and increases
fatty tissue behind the eye which results in the eyes protruding outward. Exophthalmos can
cause the client to experience problems with vision including focusing on objects as well as
pressure on the optic nerve.
A nurse is performing a cardiac assessment for a client who had a myocardial infarction 2 days
ago. Which of the following actions should the nurse take first after hearing the following sound?
- ANS-Listen with the client on his left side. When providing nursing care the nurse should first
use the least invasive intervention. Therefore after auscultating a murmur the first action the
nurse should take is to place the client on his left side and listen to his heart again.
A nurse is providing teaching to an older adult female client who has stress incontinence and a
BMI of 32. Which of the following statements by the client indicates an understanding of the
teaching question mark - ANS-I am dieting to lose weight. Excess weight cut creates increased
abdominal pressure that can result in stress incontinence.
A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the
following results should the nurse expect? - ANS-Paco2 of 56. A client who has COPD retains
paco2 due to the weakening and the collapse of the alveolar sacs which decreases the area
and lungs for gas exchange and causes the paco2 to increase above the expected reference
range.
, A nurse is providing teaching to a client who is perimenopausal and has a prescription for
hormone replacement therapy. For which of the following adverse effects should the nurse
instruct the client to notify the provider? Select all that apply. - ANS-Calf pain, numbness in the
arms and intense headache. Calf pain is an indication of DVT and the client should report this
finding to the provider immediately. Numbness in the arms can indicate cerebrovascular
accident which is an adverse effect of hormone replacement therapy and an intense headache
can indicate a cerebrovascular accident.
A nurse is providing teaching to a client who has chronic kidney disease and a new prescription
for erythropoietin. Which of the following statements by the client indicates an understanding of
the teaching? - ANS-I am taking this medication to increase my energy level. The goal of
erythropoietin therapy is to increase the level of hematocrit and clients who have anemia. When
the medication is effective the client should have a decreasing fatigue and an improvement and
activity tolerance.
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 teaching? -
ANS-I will wear clean graduated compression stockings everyday. The client should apply a
clean pair of graduated compression stockings each day and clean soiled stockings with mild
detergent and warm water by hand.
A nurse is preparing to present a program about atherosclerosis at a health fair. Which of the
following recommendations should the nurse plan to include? Select all that apply. -
ANS-Follow a smoking cessation program maintain an appropriate weight eat a low-fat diet and
increase fluid intake. Smoking cessation is an important lifestyle modification to prevent Arthur
sclerosis and preventing obesity through diet and exercise can help prevent atherosclerosis.
Eating a low fat diet decreases LDL cholesterol and can prevent atherosclerosis.
A nurse is caring for a client who is 12 hours post-operative following a total hip arthroplasty.
Which of the following actions should the nurse take? - ANS-Place a pillow between the clients
legs. The nurse should place a pillow between the clients legs to prevent hip dislocation.
A nurse is reviewing the medication history of a client who is to undergo allergy testing. The
nurse should instruct the client to discontinue which of the following medications before the
testing? - ANS-...
A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the
following actions should the nurse take first? - ANS-Check for the type and number of units of
blood to administer. According to evidence based practice the nurse should first confirm that the
type and number of units of blood to administer matches what is indicated in the clients
medication administration record.
A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron
supplement. Which of the following statements by the client indicates an understanding of the
A nurse is reviewing the medical record of a client who has systemic lupus erythematosus.
Which of the following findings should the nurse expect? - ANS-Facial butterfly rash.
R: A butterfly rash is a manifestation of SLE. It appears as a dry red rash on the clients cheeks
and nose and can disappear during times of remission.
A nurse is caring for a client who is receiving plasmapheresis through a venous access site.
Which of the following actions should the nurse take? - ANS-Check electrolyte levels before
and after therapy.
R: Plasmapheresis can cause citrate induced hypocalcemia. Therefore the nurse should
monitor the clients electrolyte levels before and after therapy.
A nurse is assessing a client who has Graves disease. Which of the following images should
indicate to the nurse that the client has exophthalmos? - ANS-The nurse should identify an
outward protrusion of the eyes is exophthalmos a common finding of graves disease. An
overproduction of the thyroid hormone causes edema of the extraocular muscle and increases
fatty tissue behind the eye which results in the eyes protruding outward. Exophthalmos can
cause the client to experience problems with vision including focusing on objects as well as
pressure on the optic nerve.
A nurse is performing a cardiac assessment for a client who had a myocardial infarction 2 days
ago. Which of the following actions should the nurse take first after hearing the following sound?
- ANS-Listen with the client on his left side. When providing nursing care the nurse should first
use the least invasive intervention. Therefore after auscultating a murmur the first action the
nurse should take is to place the client on his left side and listen to his heart again.
A nurse is providing teaching to an older adult female client who has stress incontinence and a
BMI of 32. Which of the following statements by the client indicates an understanding of the
teaching question mark - ANS-I am dieting to lose weight. Excess weight cut creates increased
abdominal pressure that can result in stress incontinence.
A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the
following results should the nurse expect? - ANS-Paco2 of 56. A client who has COPD retains
paco2 due to the weakening and the collapse of the alveolar sacs which decreases the area
and lungs for gas exchange and causes the paco2 to increase above the expected reference
range.
, A nurse is providing teaching to a client who is perimenopausal and has a prescription for
hormone replacement therapy. For which of the following adverse effects should the nurse
instruct the client to notify the provider? Select all that apply. - ANS-Calf pain, numbness in the
arms and intense headache. Calf pain is an indication of DVT and the client should report this
finding to the provider immediately. Numbness in the arms can indicate cerebrovascular
accident which is an adverse effect of hormone replacement therapy and an intense headache
can indicate a cerebrovascular accident.
A nurse is providing teaching to a client who has chronic kidney disease and a new prescription
for erythropoietin. Which of the following statements by the client indicates an understanding of
the teaching? - ANS-I am taking this medication to increase my energy level. The goal of
erythropoietin therapy is to increase the level of hematocrit and clients who have anemia. When
the medication is effective the client should have a decreasing fatigue and an improvement and
activity tolerance.
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 teaching? -
ANS-I will wear clean graduated compression stockings everyday. The client should apply a
clean pair of graduated compression stockings each day and clean soiled stockings with mild
detergent and warm water by hand.
A nurse is preparing to present a program about atherosclerosis at a health fair. Which of the
following recommendations should the nurse plan to include? Select all that apply. -
ANS-Follow a smoking cessation program maintain an appropriate weight eat a low-fat diet and
increase fluid intake. Smoking cessation is an important lifestyle modification to prevent Arthur
sclerosis and preventing obesity through diet and exercise can help prevent atherosclerosis.
Eating a low fat diet decreases LDL cholesterol and can prevent atherosclerosis.
A nurse is caring for a client who is 12 hours post-operative following a total hip arthroplasty.
Which of the following actions should the nurse take? - ANS-Place a pillow between the clients
legs. The nurse should place a pillow between the clients legs to prevent hip dislocation.
A nurse is reviewing the medication history of a client who is to undergo allergy testing. The
nurse should instruct the client to discontinue which of the following medications before the
testing? - ANS-...
A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the
following actions should the nurse take first? - ANS-Check for the type and number of units of
blood to administer. According to evidence based practice the nurse should first confirm that the
type and number of units of blood to administer matches what is indicated in the clients
medication administration record.
A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron
supplement. Which of the following statements by the client indicates an understanding of the
