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? - Answers -
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? - Answers -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? - Answers -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? - Answers -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 - Answers -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? - Answers -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. - Answers -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? - Answers -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? - Answers -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. - Answers -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? - Answers -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? - Answers -...
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? - Answers -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
A nurse is reviewing the medical record of a client who has systemic lupus
erythematosus. Which of the following findings should the nurse expect? - Answers -
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? - Answers -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? - Answers -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? - Answers -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 - Answers -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? - Answers -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. - Answers -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? - Answers -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? - Answers -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. - Answers -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? - Answers -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? - Answers -...
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? - Answers -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
