NUR 425 Med Surg Exam 1
A nurse is caring for a pt who has visual impairment/loss. What do you think the nurse
should implement? - answer Count steps to the bathroom with the pt
A nurse is teaching a pt who asks about taking a glucosamine supplement for
osteoarthritis. What information should the nurse include in the teaching? - answer
Avoid taking glucosamine if you have a shellfish allergy
A nurse is discussing activity modification with a pt who had a right total hip
arthroplasty. What statement should the nurse include in the information? -
answerPlace a pillow between your legs when lying in bed
A nurse is teaching a newly licensed nurse about preventing a catheter-associated
urinary tract infection for a pt who has an indwelling urinary catheter. What instruction
should the nurse include? - answer Ensure the urinary catheter tubing is not kinked
A nurse is planning wound management for a pt who has a stage 3 pressure injury.
What intervention should the nurse include in the plan? - answer Measure the depth of
the wound with a cotton-tipped applicator
A nurse is planning care for four clients following a change-of-shift report. Which of the
following clients is the nurse's priority? - answerA pt who has peptic ulcer disease and a
rigid abdomen
A nurse is planning care for four pts following the change-of-shift report. Which of the
following clients should the nurse see first? - answerA client who has a pacemaker and
has persistent hiccuping
A nurse is caring for a pt who is postoperative and has a history of heart failure. The pt
reports slight dyspnea when ambulating. What finding should the nurse expect when
performing a skin assessment? - answerShiny areas on the client's ankles and feet
A hospice nurse is planning end-of-life comfort care for a pt. What intervention should
the nurse include in the plan? - answerPosition the client on their side to improve
breathing
A nurse is teaching a pt who has a prescription for continuous ambulatory peritoneal
dialysis. What instruction should the nurse include? - answerAllow the dialysate to dwell
for 4 hr during each exchange
, A nurse is providing hydrotherapy for a pt who has full-thickness turns on the lower leg.
What action should the nurse take? - answerWash the pt's burns with mild soap and
water
A nurse is assessing a pt who is receiving head and neck radiation therapy to treat
esophageal cancer. The nurse should identify what finding as an adverse effect of this
treatment? - answerThe client reports a dry mouth, tooth decay and dysphagia (difficulty
swallowing)
A nurse is assessing a pt who has an endotracheal tube and is receiving mechanical
ventilation. The pt is agitated and appears to be in respiratory distress. What action
should the nurse take first? - answerManually ventilate the client using a bag-valve
device
A nurse is assisting with a paracentesis for a client who has ascites. What action should
the nurse take? - answerWeigh the client before the procedure
A nurse is reviewing the WBC differential count of a pt who is postoperative. The nurse
should identify that which of the following findings is a manifestation of a bacterial
wound infection? - answerNeutrophil count 9,000/mm3
A nurse is teaching a pt who is to have a transurethral resection of the prostate (TURP)
with continuous bladder irritation postoperatively. Which of the following statements by
the pt should the nurse identify as an indication the pt understands the teaching? -
answerAfter the catheter is removed, I can expect to experience some burning when I
urinate
A nurse is planning care for a pt who was admitted with a right hip fracture and is
scheduled for surgery the following day. Which of the following actions should the nurse
plan to take? - answerBathe the client with an antiseptic solution the night before and
the day of the surgery
A nurse is assessing a pt who has dry age-related macular degeneration (AMD) of the
left eye. What finding should the nurse expect? - answerGradual decrease of central
vision
A nurse in the emergency department is assessing a pt who was admitted following a
traumatic brain injury (TBI). What finding should the nurse identify as an indication of
increased ICP? - answerEcchymosis around both eyes
A nurse is caring for a pt who has DM and has a blood glucose level of 298mg/dL. What
finding should the nurse expect? - answerAbdominal cramping
A nurse is testing the cranial nerves (CN) of a pt who has a possible brain tumor. What
action should the nurse take when testing CN VII? - answerObserve for symmetry when
the client smiles
A nurse is caring for a pt who has visual impairment/loss. What do you think the nurse
should implement? - answer Count steps to the bathroom with the pt
A nurse is teaching a pt who asks about taking a glucosamine supplement for
osteoarthritis. What information should the nurse include in the teaching? - answer
Avoid taking glucosamine if you have a shellfish allergy
A nurse is discussing activity modification with a pt who had a right total hip
arthroplasty. What statement should the nurse include in the information? -
answerPlace a pillow between your legs when lying in bed
A nurse is teaching a newly licensed nurse about preventing a catheter-associated
urinary tract infection for a pt who has an indwelling urinary catheter. What instruction
should the nurse include? - answer Ensure the urinary catheter tubing is not kinked
A nurse is planning wound management for a pt who has a stage 3 pressure injury.
What intervention should the nurse include in the plan? - answer Measure the depth of
the wound with a cotton-tipped applicator
A nurse is planning care for four clients following a change-of-shift report. Which of the
following clients is the nurse's priority? - answerA pt who has peptic ulcer disease and a
rigid abdomen
A nurse is planning care for four pts following the change-of-shift report. Which of the
following clients should the nurse see first? - answerA client who has a pacemaker and
has persistent hiccuping
A nurse is caring for a pt who is postoperative and has a history of heart failure. The pt
reports slight dyspnea when ambulating. What finding should the nurse expect when
performing a skin assessment? - answerShiny areas on the client's ankles and feet
A hospice nurse is planning end-of-life comfort care for a pt. What intervention should
the nurse include in the plan? - answerPosition the client on their side to improve
breathing
A nurse is teaching a pt who has a prescription for continuous ambulatory peritoneal
dialysis. What instruction should the nurse include? - answerAllow the dialysate to dwell
for 4 hr during each exchange
, A nurse is providing hydrotherapy for a pt who has full-thickness turns on the lower leg.
What action should the nurse take? - answerWash the pt's burns with mild soap and
water
A nurse is assessing a pt who is receiving head and neck radiation therapy to treat
esophageal cancer. The nurse should identify what finding as an adverse effect of this
treatment? - answerThe client reports a dry mouth, tooth decay and dysphagia (difficulty
swallowing)
A nurse is assessing a pt who has an endotracheal tube and is receiving mechanical
ventilation. The pt is agitated and appears to be in respiratory distress. What action
should the nurse take first? - answerManually ventilate the client using a bag-valve
device
A nurse is assisting with a paracentesis for a client who has ascites. What action should
the nurse take? - answerWeigh the client before the procedure
A nurse is reviewing the WBC differential count of a pt who is postoperative. The nurse
should identify that which of the following findings is a manifestation of a bacterial
wound infection? - answerNeutrophil count 9,000/mm3
A nurse is teaching a pt who is to have a transurethral resection of the prostate (TURP)
with continuous bladder irritation postoperatively. Which of the following statements by
the pt should the nurse identify as an indication the pt understands the teaching? -
answerAfter the catheter is removed, I can expect to experience some burning when I
urinate
A nurse is planning care for a pt who was admitted with a right hip fracture and is
scheduled for surgery the following day. Which of the following actions should the nurse
plan to take? - answerBathe the client with an antiseptic solution the night before and
the day of the surgery
A nurse is assessing a pt who has dry age-related macular degeneration (AMD) of the
left eye. What finding should the nurse expect? - answerGradual decrease of central
vision
A nurse in the emergency department is assessing a pt who was admitted following a
traumatic brain injury (TBI). What finding should the nurse identify as an indication of
increased ICP? - answerEcchymosis around both eyes
A nurse is caring for a pt who has DM and has a blood glucose level of 298mg/dL. What
finding should the nurse expect? - answerAbdominal cramping
A nurse is testing the cranial nerves (CN) of a pt who has a possible brain tumor. What
action should the nurse take when testing CN VII? - answerObserve for symmetry when
the client smiles
