Medical Surgical Assessment A Assessment A
Medical Surgical
Study online at https://quizlet.com/_8awv9t
1. A nurse is reviewing the laboratory results of a C) Creatinine 1.9 mg/dL
client who is scheduled for a CT scan with an IV
contrast agent. Which of the following laboratory Creatinine 1.9 mg/dL is not with-
findings should the nurse report to the provider in the expected reference range.
prior to the procedure? Therefore, the nurse should report
the finding to the provider before
A) Sodium 136 mEq/L the client has a CT scan with an IV
B) Potassium 4.8 mEq/L contrast agent. This finding places
C) Creatinine 1.9 mg/dL the client at risk for developing
D) Calcium 10 mg/dL contrast-induced nephropathy.
2. A nurse is monitoring a client who is taking acar- B) Abdominal cramps
bose. Which of the following findings should the
nurse identify as an adverse effect of the medica- Acarbose affects the gastrointesti-
tion? nal system. Therefore, the nurse
should monitor the client for
A) Polyuria abdominal cramping, rumbling
B) Abdominal cramps bowel sounds, and diarrhea as ad-
C) Renal insufficiency verse effects of this medication.
D) Insomnia
3. A nurse is assisting with the care of a client who A) Monitor the insertion site for
had a cardiac catheterization via the right femoral bleeding
artery. Which of the following actions should the
nurse take to prevent postprocedure complica- The nurse should monitor the
tions? (Select all) client's insertion site for manifes-
tations of hemorrhaging.
A) Monitor the insertion site for bleeding
B) Position the affected extremity at a 45 degree D) Maintain the pressure dress-
angle ing.
C) Restrict the client's fluid intake
The nurse should maintain the
client's pressure dressing to pre-
, Medical Surgical Assessment A Assessment A
Medical Surgical
Study online at https://quizlet.com/_8awv9t
D) Maintain the pressure dressing vent hemorrhaging and allow for
E) Check the client's peripheral pulses 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.
4. A nurse is contributing to the plan of care for A) Encourage abdominal breath-
a client who has chronic obstructive pulmonary ing
disease (COPD) and is dyspneic. Which of the fol-
lowing interventions should the nurse include in The nurse should encourage ab-
the plan? dominal breathing, which reduces
the workload on the accessory
A) Encourage abdominal breathing muscles of respiration during dys-
B) Direct the client to inhale with pursed lips pneic episodes.
C) Set the oxygen therapy at 5L/min
D) Instruct the client to lean back while coughing
5. A nurse is preparing to administer phytonadione 7mg/10 mg *1mL= 0.7 mL
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.
6. A nurse is examining a client's IV site and notes A) Thrombophlebitis
a red line up his arm. The client reports a throb-
bing, burning pain at the IV site. The nurse should The nurse should identify pain,
identify that the client's manifestations indicate warmth, and a red streak up
which of the following complications of IV thera-
, Medical Surgical Assessment A Assessment A
Medical Surgical
Study online at https://quizlet.com/_8awv9t
py? the arm as indications of throm-
bophlebitis.
A) Thrombophlebitis
B) Infiltration
C) Hematoma
D) Venous spasms
7. A nurse is reinforcing teaching about manage- A) Increase intake of fiber-rich
ment of constipation with a client who has hy- foods
pothyroidism. Which of the following should the
nurse include in the teaching? The nurse should instruct the
client to increase the amount of
A) Increase intake of fiber-rich foods fiber-rich foods in his diet. Dried
B) Take a laxative every morning beans and brown rice are exam-
C) Maintain a fluid intake of 1200 mL per day ples of fiber-rich foods.
D) Limit activity to preserve energy
8. A nurse is caring for a client who has a compound A) Perform pin site care daily
fracture of the femur and was placed in balanced
suspension skeletal traction 4 days ago. Which of The nurse should perform pin site
the following actions should the nurse take? care daily with chlorhexidine solu-
tion or use a solution according to
A) Perform pin site care daily facility protocol. The nurse should
B) Remove the overbed trapeze also monitor the pin sites for man-
C) Remove the boot every 2 hr ifestations of infection.
D) Keep the weights on a stable, flat surface
9. A nurse observes a client who is lying in bed D) Loosen clothing around the
experiencing a tonic-clonic seizure. Which of the client's neck
following actions should the nurse take?
The nurse should loosen clothing
A) Lower the side rails of the client's bed around the client's neck to main-
B) Apply wrist restraints to the client
, Medical Surgical Assessment A Assessment A
Medical Surgical
Study online at https://quizlet.com/_8awv9t
C) Position the client in the semi-Fowler's posi- tain an open airway and prevent
tion aspiration.
D) Loosen clothing around the client's neck
10. A nurse is contributing to the plan of care for C) Encourage the client to com-
a client who has multiple sclerosis and is taking plete ADLs
dantrolene to manage muscle spasms. Which of
the following interventions should the nurse in- The nurse should encourage the
clude? client to complete ADLs and pro-
vide assistance as needed. Per-
A) Apply hot packs to the client's muscles forming self-care increases the
B) Schedule physical therapy in the afternoon client's independence, strength,
C) Encourage the client to complete ADLs and level of functioning.
D) Administer valerian to promote sleep
11. A nurse is reinforcing discharge teaching to pre- A) Avoid liquids at mealtimes
vent dumping syndrome for a client following a
partial gastrectomy for ulcers. Which of the fol- The nurse should remind the client
lowing information should the nurse include in to avoid drinking liquids at meal-
the teaching? times to prevent the food from
emptying into the small bowel too
A) Avoid liquids at mealtimes quickly.
B) Exclude eating starchy vegetables
C) Avoid eating high-protein meals
D) Plan to increase intake of sweetened fruits
12. A nurse is collecting data from a client who has D) Decreased shortness of breath
heart failure and is taking digoxin. Which of the
following outcomes from the medication should The nurse should expect the client
the nurse expect? to have decreased shortness of
breath. Digoxin increases the con-
A) Increased weight tractility of the heart, which de-
B) Increased heart rate creases pulmonary congestion.
Medical Surgical
Study online at https://quizlet.com/_8awv9t
1. A nurse is reviewing the laboratory results of a C) Creatinine 1.9 mg/dL
client who is scheduled for a CT scan with an IV
contrast agent. Which of the following laboratory Creatinine 1.9 mg/dL is not with-
findings should the nurse report to the provider in the expected reference range.
prior to the procedure? Therefore, the nurse should report
the finding to the provider before
A) Sodium 136 mEq/L the client has a CT scan with an IV
B) Potassium 4.8 mEq/L contrast agent. This finding places
C) Creatinine 1.9 mg/dL the client at risk for developing
D) Calcium 10 mg/dL contrast-induced nephropathy.
2. A nurse is monitoring a client who is taking acar- B) Abdominal cramps
bose. Which of the following findings should the
nurse identify as an adverse effect of the medica- Acarbose affects the gastrointesti-
tion? nal system. Therefore, the nurse
should monitor the client for
A) Polyuria abdominal cramping, rumbling
B) Abdominal cramps bowel sounds, and diarrhea as ad-
C) Renal insufficiency verse effects of this medication.
D) Insomnia
3. A nurse is assisting with the care of a client who A) Monitor the insertion site for
had a cardiac catheterization via the right femoral bleeding
artery. Which of the following actions should the
nurse take to prevent postprocedure complica- The nurse should monitor the
tions? (Select all) client's insertion site for manifes-
tations of hemorrhaging.
A) Monitor the insertion site for bleeding
B) Position the affected extremity at a 45 degree D) Maintain the pressure dress-
angle ing.
C) Restrict the client's fluid intake
The nurse should maintain the
client's pressure dressing to pre-
, Medical Surgical Assessment A Assessment A
Medical Surgical
Study online at https://quizlet.com/_8awv9t
D) Maintain the pressure dressing vent hemorrhaging and allow for
E) Check the client's peripheral pulses 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.
4. A nurse is contributing to the plan of care for A) Encourage abdominal breath-
a client who has chronic obstructive pulmonary ing
disease (COPD) and is dyspneic. Which of the fol-
lowing interventions should the nurse include in The nurse should encourage ab-
the plan? dominal breathing, which reduces
the workload on the accessory
A) Encourage abdominal breathing muscles of respiration during dys-
B) Direct the client to inhale with pursed lips pneic episodes.
C) Set the oxygen therapy at 5L/min
D) Instruct the client to lean back while coughing
5. A nurse is preparing to administer phytonadione 7mg/10 mg *1mL= 0.7 mL
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.
6. A nurse is examining a client's IV site and notes A) Thrombophlebitis
a red line up his arm. The client reports a throb-
bing, burning pain at the IV site. The nurse should The nurse should identify pain,
identify that the client's manifestations indicate warmth, and a red streak up
which of the following complications of IV thera-
, Medical Surgical Assessment A Assessment A
Medical Surgical
Study online at https://quizlet.com/_8awv9t
py? the arm as indications of throm-
bophlebitis.
A) Thrombophlebitis
B) Infiltration
C) Hematoma
D) Venous spasms
7. A nurse is reinforcing teaching about manage- A) Increase intake of fiber-rich
ment of constipation with a client who has hy- foods
pothyroidism. Which of the following should the
nurse include in the teaching? The nurse should instruct the
client to increase the amount of
A) Increase intake of fiber-rich foods fiber-rich foods in his diet. Dried
B) Take a laxative every morning beans and brown rice are exam-
C) Maintain a fluid intake of 1200 mL per day ples of fiber-rich foods.
D) Limit activity to preserve energy
8. A nurse is caring for a client who has a compound A) Perform pin site care daily
fracture of the femur and was placed in balanced
suspension skeletal traction 4 days ago. Which of The nurse should perform pin site
the following actions should the nurse take? care daily with chlorhexidine solu-
tion or use a solution according to
A) Perform pin site care daily facility protocol. The nurse should
B) Remove the overbed trapeze also monitor the pin sites for man-
C) Remove the boot every 2 hr ifestations of infection.
D) Keep the weights on a stable, flat surface
9. A nurse observes a client who is lying in bed D) Loosen clothing around the
experiencing a tonic-clonic seizure. Which of the client's neck
following actions should the nurse take?
The nurse should loosen clothing
A) Lower the side rails of the client's bed around the client's neck to main-
B) Apply wrist restraints to the client
, Medical Surgical Assessment A Assessment A
Medical Surgical
Study online at https://quizlet.com/_8awv9t
C) Position the client in the semi-Fowler's posi- tain an open airway and prevent
tion aspiration.
D) Loosen clothing around the client's neck
10. A nurse is contributing to the plan of care for C) Encourage the client to com-
a client who has multiple sclerosis and is taking plete ADLs
dantrolene to manage muscle spasms. Which of
the following interventions should the nurse in- The nurse should encourage the
clude? client to complete ADLs and pro-
vide assistance as needed. Per-
A) Apply hot packs to the client's muscles forming self-care increases the
B) Schedule physical therapy in the afternoon client's independence, strength,
C) Encourage the client to complete ADLs and level of functioning.
D) Administer valerian to promote sleep
11. A nurse is reinforcing discharge teaching to pre- A) Avoid liquids at mealtimes
vent dumping syndrome for a client following a
partial gastrectomy for ulcers. Which of the fol- The nurse should remind the client
lowing information should the nurse include in to avoid drinking liquids at meal-
the teaching? times to prevent the food from
emptying into the small bowel too
A) Avoid liquids at mealtimes quickly.
B) Exclude eating starchy vegetables
C) Avoid eating high-protein meals
D) Plan to increase intake of sweetened fruits
12. A nurse is collecting data from a client who has D) Decreased shortness of breath
heart failure and is taking digoxin. Which of the
following outcomes from the medication should The nurse should expect the client
the nurse expect? to have decreased shortness of
breath. Digoxin increases the con-
A) Increased weight tractility of the heart, which de-
B) Increased heart rate creases pulmonary congestion.
