Medical Surgical Assessment A exam with
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precise detailed answers
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A |nurse |is |reviewing |the |laboratory |results |of |a |client |who |is |scheduled |for |a |CT |scan |with |an |IV |
contrast |agent. |Which |of |the |following |laboratory |findings |should |the |nurse |report |to |the |provider |
prior |to |the |procedure?
A) |Sodium |136 |mEq/L
B) |Potassium |4.8 |mEq/L
C) |Creatinine |1.9 |mg/dL
D) |Calcium |10 |mg/dL |- |correct |answer |C) |Creatinine |1.9 |mg/dL
Creatinine |1.9 |mg/dL |is |not |within |the |expected |reference |range. |Therefore, |the |nurse |should |report |
the |finding |to |the |provider |before |the |client |has |a |CT |scan |with |an |IV |contrast |agent. |This |finding |
places |the |client |at |risk |for |developing |contrast-induced |nephropathy.
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?
A) |Polyuria
B) |Abdominal |cramps
C) |Renal |insufficiency
D) |Insomnia |- |correct |answer |B) |Abdominal |cramps
Acarbose |affects |the |gastrointestinal |system. |Therefore, |the |nurse |should |monitor |the |client |for |
abdominal |cramping, |rumbling |bowel |sounds, |and |diarrhea |as |adverse |effects |of |this |medication.
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?
|(Select |all)
,A) |Monitor |the |insertion |site |for |bleeding
B) |Position |the |affected |extremity |at |a |45 |degree |angle
C) |Restrict |the |client's |fluid |intake
D) |Maintain |the |pressure |dressing
E) |Check |the |client's |peripheral |pulses |- |correct |answer |A) |Monitor |the |insertion |site |for |bleeding
The |nurse |should |monitor |the |client's |insertion |site |for |manifestations |of |hemorrhaging.
D) |Maintain |the |pressure |dressing.
The |nurse |should |maintain |the |client's |pressure |dressing |to |prevent |hemorrhaging |and |allow |for |the |
cannulation |site |to |heal.
E) |Check |the |client's |peripheral |pulses.
The |nurse |should |assess |the |client's |peripheral |pulses |to |help |identify |signs |of |arterial |occlusion.
A |nurse |is |contributing |to |the |plan |of |care |for |a |client |who |has |chronic |obstructive |pulmonary |disease
|(COPD) |and |is |dyspneic. |Which |of |the |following |interventions |should |the |nurse |include |in |the |plan?
A) |Encourage |abdominal |breathing
B) |Direct |the |client |to |inhale |with |pursed |lips
C) |Set |the |oxygen |therapy |at |5L/min
D) |Instruct |the |client |to |lean |back |while |coughing |- |correct |answer |A) |Encourage |abdominal |breathing
The |nurse |should |encourage |abdominal |breathing, |which |reduces |the |workload |on |the |accessory |
muscles |of |respiration |during |dyspneic |episodes.
,A |nurse |is |preparing |to |administer |phytonadione |7 |mg |subcutaneously |to |a |client |who |has |an |INR |of |
4. |Available |is |phytonadione |10 |mg/mL. |How |many |mL |should |the |nurse |administer? |(Round |the |
answer |to |the |nearest |tenth. |Use |a |leading |zero |is |it |applies. |Do |not |use |a |trailing |zero. |- |correct |
answer |7mg/10 |mg |*1mL= |0.7 |mL
A |nurse |is |examining |a |client's |IV |site |and |notes |a |red |line |up |his |arm. |The |client |reports |a |throbbing, |
burning |pain |at |the |IV |site. |The |nurse |should |identify |that |the |client's |manifestations |indicate |which |
of |the |following |complications |of |IV |therapy?
A) |Thrombophlebitis
B) |Infiltration
C) |Hematoma
D) |Venous |spasms |- |correct |answer |A) |Thrombophlebitis
The |nurse |should |identify |pain, |warmth, |and |a |red |streak |up |the |arm |as |indications |of |
thrombophlebitis.
A |nurse |is |reinforcing |teaching |about |management |of |constipation |with |a |client |who |has |
hypothyroidism. |Which |of |the |following |should |the |nurse |include |in |the |teaching?
A) |Increase |intake |of |fiber-rich |foods
B) |Take |a |laxative |every |morning
C) |Maintain |a |fluid |intake |of |1200 |mL |per |day
D) |Limit |activity |to |preserve |energy |- |correct |answer |A) |Increase |intake |of |fiber-rich |foods
The |nurse |should |instruct |the |client |to |increase |the |amount |of |fiber-rich |foods |in |his |diet. |Dried |
beans |and |brown |rice |are |examples |of |fiber-rich |foods.
A |nurse |is |caring |for |a |client |who |has |a |compound |fracture |of |the |femur |and |was |placed |in |balanced |
suspension |skeletal |traction |4 |days |ago. |Which |of |the |following |actions |should |the |nurse |take?
A) |Perform |pin |site |care |daily
, B) |Remove |the |overbed |trapeze
C) |Remove |the |boot |every |2 |hr
D) |Keep |the |weights |on |a |stable, |flat |surface |- |correct |answer |A) |Perform |pin |site |care |daily
The |nurse |should |perform |pin |site |care |daily |with |chlorhexidine |solution |or |use |a |solution |according |
to |facility |protocol. |The |nurse |should |also |monitor |the |pin |sites |for |manifestations |of |infection.
A |nurse |observes |a |client |who |is |lying |in |bed |experiencing |a |tonic-clonic |seizure. |Which |of |the |
following |actions |should |the |nurse |take?
A) |Lower |the |side |rails |of |the |client's |bed
B) |Apply |wrist |restraints |to |the |client
C) |Position |the |client |in |the |semi-Fowler's |position
D) |Loosen |clothing |around |the |client's |neck |- |correct |answer |D) |Loosen |clothing |around |the |client's |
neck
The |nurse |should |loosen |clothing |around |the |client's |neck |to |maintain |an |open |airway |and |prevent |
aspiration.
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?
A) |Apply |hot |packs |to |the |client's |muscles
B) |Schedule |physical |therapy |in |the |afternoon
C) |Encourage |the |client |to |complete |ADLs
D) |Administer |valerian |to |promote |sleep |- |correct |answer |C) |Encourage |the |client |to |complete |ADLs
The |nurse |should |encourage |the |client |to |complete |ADLs |and |provide |assistance |as |needed. |
Performing |self-care |increases |the |client's |independence, |strength, |and |level |of |functioning.
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precise detailed answers
| |
A |nurse |is |reviewing |the |laboratory |results |of |a |client |who |is |scheduled |for |a |CT |scan |with |an |IV |
contrast |agent. |Which |of |the |following |laboratory |findings |should |the |nurse |report |to |the |provider |
prior |to |the |procedure?
A) |Sodium |136 |mEq/L
B) |Potassium |4.8 |mEq/L
C) |Creatinine |1.9 |mg/dL
D) |Calcium |10 |mg/dL |- |correct |answer |C) |Creatinine |1.9 |mg/dL
Creatinine |1.9 |mg/dL |is |not |within |the |expected |reference |range. |Therefore, |the |nurse |should |report |
the |finding |to |the |provider |before |the |client |has |a |CT |scan |with |an |IV |contrast |agent. |This |finding |
places |the |client |at |risk |for |developing |contrast-induced |nephropathy.
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?
A) |Polyuria
B) |Abdominal |cramps
C) |Renal |insufficiency
D) |Insomnia |- |correct |answer |B) |Abdominal |cramps
Acarbose |affects |the |gastrointestinal |system. |Therefore, |the |nurse |should |monitor |the |client |for |
abdominal |cramping, |rumbling |bowel |sounds, |and |diarrhea |as |adverse |effects |of |this |medication.
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?
|(Select |all)
,A) |Monitor |the |insertion |site |for |bleeding
B) |Position |the |affected |extremity |at |a |45 |degree |angle
C) |Restrict |the |client's |fluid |intake
D) |Maintain |the |pressure |dressing
E) |Check |the |client's |peripheral |pulses |- |correct |answer |A) |Monitor |the |insertion |site |for |bleeding
The |nurse |should |monitor |the |client's |insertion |site |for |manifestations |of |hemorrhaging.
D) |Maintain |the |pressure |dressing.
The |nurse |should |maintain |the |client's |pressure |dressing |to |prevent |hemorrhaging |and |allow |for |the |
cannulation |site |to |heal.
E) |Check |the |client's |peripheral |pulses.
The |nurse |should |assess |the |client's |peripheral |pulses |to |help |identify |signs |of |arterial |occlusion.
A |nurse |is |contributing |to |the |plan |of |care |for |a |client |who |has |chronic |obstructive |pulmonary |disease
|(COPD) |and |is |dyspneic. |Which |of |the |following |interventions |should |the |nurse |include |in |the |plan?
A) |Encourage |abdominal |breathing
B) |Direct |the |client |to |inhale |with |pursed |lips
C) |Set |the |oxygen |therapy |at |5L/min
D) |Instruct |the |client |to |lean |back |while |coughing |- |correct |answer |A) |Encourage |abdominal |breathing
The |nurse |should |encourage |abdominal |breathing, |which |reduces |the |workload |on |the |accessory |
muscles |of |respiration |during |dyspneic |episodes.
,A |nurse |is |preparing |to |administer |phytonadione |7 |mg |subcutaneously |to |a |client |who |has |an |INR |of |
4. |Available |is |phytonadione |10 |mg/mL. |How |many |mL |should |the |nurse |administer? |(Round |the |
answer |to |the |nearest |tenth. |Use |a |leading |zero |is |it |applies. |Do |not |use |a |trailing |zero. |- |correct |
answer |7mg/10 |mg |*1mL= |0.7 |mL
A |nurse |is |examining |a |client's |IV |site |and |notes |a |red |line |up |his |arm. |The |client |reports |a |throbbing, |
burning |pain |at |the |IV |site. |The |nurse |should |identify |that |the |client's |manifestations |indicate |which |
of |the |following |complications |of |IV |therapy?
A) |Thrombophlebitis
B) |Infiltration
C) |Hematoma
D) |Venous |spasms |- |correct |answer |A) |Thrombophlebitis
The |nurse |should |identify |pain, |warmth, |and |a |red |streak |up |the |arm |as |indications |of |
thrombophlebitis.
A |nurse |is |reinforcing |teaching |about |management |of |constipation |with |a |client |who |has |
hypothyroidism. |Which |of |the |following |should |the |nurse |include |in |the |teaching?
A) |Increase |intake |of |fiber-rich |foods
B) |Take |a |laxative |every |morning
C) |Maintain |a |fluid |intake |of |1200 |mL |per |day
D) |Limit |activity |to |preserve |energy |- |correct |answer |A) |Increase |intake |of |fiber-rich |foods
The |nurse |should |instruct |the |client |to |increase |the |amount |of |fiber-rich |foods |in |his |diet. |Dried |
beans |and |brown |rice |are |examples |of |fiber-rich |foods.
A |nurse |is |caring |for |a |client |who |has |a |compound |fracture |of |the |femur |and |was |placed |in |balanced |
suspension |skeletal |traction |4 |days |ago. |Which |of |the |following |actions |should |the |nurse |take?
A) |Perform |pin |site |care |daily
, B) |Remove |the |overbed |trapeze
C) |Remove |the |boot |every |2 |hr
D) |Keep |the |weights |on |a |stable, |flat |surface |- |correct |answer |A) |Perform |pin |site |care |daily
The |nurse |should |perform |pin |site |care |daily |with |chlorhexidine |solution |or |use |a |solution |according |
to |facility |protocol. |The |nurse |should |also |monitor |the |pin |sites |for |manifestations |of |infection.
A |nurse |observes |a |client |who |is |lying |in |bed |experiencing |a |tonic-clonic |seizure. |Which |of |the |
following |actions |should |the |nurse |take?
A) |Lower |the |side |rails |of |the |client's |bed
B) |Apply |wrist |restraints |to |the |client
C) |Position |the |client |in |the |semi-Fowler's |position
D) |Loosen |clothing |around |the |client's |neck |- |correct |answer |D) |Loosen |clothing |around |the |client's |
neck
The |nurse |should |loosen |clothing |around |the |client's |neck |to |maintain |an |open |airway |and |prevent |
aspiration.
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?
A) |Apply |hot |packs |to |the |client's |muscles
B) |Schedule |physical |therapy |in |the |afternoon
C) |Encourage |the |client |to |complete |ADLs
D) |Administer |valerian |to |promote |sleep |- |correct |answer |C) |Encourage |the |client |to |complete |ADLs
The |nurse |should |encourage |the |client |to |complete |ADLs |and |provide |assistance |as |needed. |
Performing |self-care |increases |the |client's |independence, |strength, |and |level |of |functioning.
