Exam 2 V1: NUR170 / NUR 170 (Latest 2026/2027 Update) Concepts of Medical Surgical Nursing | Questions & Answers | 100% Correct | Galen

Exam 2 V1: NUR170 / NUR 170 (Latest 2026/2027 Update) Concepts of Medical Surgical Nursing | Questions & Answers | 100% Correct | Galen Q: The home health nurse is assigned to visit these clients when a change in agency staffing requires that one of the clients be rescheduled for a visit on the following day. Which client will be best to reschedule? Answer Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93% Q: A client is admitted to the medical floor with a new diagnosis of lung cancer. How will the nurse initially assist the client in managing the anxiety associated with the new diagnosis? Answer Encourage the client to ask questions and verbalize concerns. Encourage the client to ask questions and verbalize concerns. Q: When caring for a client who has just undergone thoracentesis, which of these interventions does the nurse perform first? Answer Schedule an immediate chest x-ray. Q: A client has returned to the medical surgical unit after a bronchoscopy. Which nursing task is best for the charge nurse to delegate to the experienced unlicensed assistive personnel (UAP)? Answer Monitor blood pressure and pulse. Q: The nurse is preparing the client for a diagnostic bronchoscopy. Which nursing intervention is essential for the nurse to perform prior to the procedure? Answer Ensure the client has had nothing by mouth. Q: The RN has received report about four clients. Which client needs the most immediate assessment? Answer Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry Q: Which assessment finding in the client with exacerbation of emphysema requires intervention by the nurse? Answer Bronchial breath sounds heard at the bases Q: A client with asthma reports shortness of breath. Which of these findings does the nurse anticipate when assessing this client's chest? Answer Expiratory wheezing not cleared by coughing Q: The RN and the LPN/LVN are working together to provide care for a group of clients on a medical surgical unit. Which of these actions is most appropriate for the RN to perform? Answer Plan client and family teaching regarding upcoming pulmonary function testing. Q: The nurse is assessing a client with chronic bronchitis who smoked 3 packs of cigarettes daily for 32 years. How does the nurse document pack-year history of smoking in the medical record? Answer Client has a 96 pack-year history Q: The nurse is caring for a client with heart failure and acute kidney injury. For which of these breath sounds will the nurse assess? Answer Crackles Q: The nurse in the outpatient clinic is scheduling a client for pulmonary function tests. When teaching the client about pulmonary function testing (PFT), which point is essential for the nurse to emphasize? Answer Ensure the client does not smoke for 6 hours before the test. Q: The nurse in a life care community for geriatric clients is providing education to a group of residents on expected changes during aging. Which of these activities does the nurse encourage the older adult to perform to maintain respiratory function? Answer Walk as tolerated each day. Q: A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What primary assessment will the nurse make while preparing the client for a computed tomography (CT) scan? Answer "Are you allergic to iodine or shellfish?" Q: The nurse is caring for four clients who came to the emergency department with a productive cough. Which of these clients requires immediate intervention by the nurse? Answer The client with pink, frothy sputum Q: Which client does the charge nurse on the medical-surgical unit assign to an RN who has floated from the postanesthesia care unit (PACU)? Answer Client who had 1200 mL of pleural fluid removed by thoracentesis Q: The nurse is providing education on preventing pulmonary disorders at a community health fair. Which of these groups does the nurse target? Answer Bakers Coal miners Furniture refinishers Potters Q: The emergency department nurse is assessing a client who believes he has sustained a pneumothorax after an outpatient thoracentesis earlier today. For which of these symptoms will the nurse assess? Answer Sensation of air hunger Tracheal deviation Blue discoloration of the lips Q: The nurse is preparing a client with possible pulmonary embolism for a CT scan with contrast. Prior to the scan, which of these assessment questions is essential for the nurse to ask? Answer Answer "Did you take metformin today?" Q: The nurse is caring for a client who just returned from an open lung biopsy and has a prescription for morphine by client controlled analgesia (PCA). Which of these actions to detect early opioid induced respiratory depression does the nurse recommend? Answer Continuous capnography Q: The nurse is working in an urgent care clinic where four clients are waiting to be seen. Which client needs to be evaluated first by the nurse? Answer Client who is speaking in three-word sentences and has an SpO2 of 90% Q: The nurse in the medical clinic is performing an assessment on an older adult client. Which finding requires further assessment by the nurse? Answer Inability to state name and date of birth Q: The nurse is planning to provide tracheostomy care for a client with a soiled tracheostomy dressing. Which of these actions would be included in the plan of care? Answer Suction the client if needed. Cleanse the inner cannula with a mixture of peroxide and saline. Replace the dressing with a sterile, folded 4 × 4 gauze. Q: A client has just been admitted to the emergency department and requires high-flow oxygen therapy after suffering facial burns and smoke inhalation. Which oxygen delivery device will the nurse select? Answer Face tent Q: The respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tubing is clear. What is the best immediate action by the nurse? Answer Suction the tracheostomy tube Q: A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the inner cannula and the tracheostomy tube. Which action should the nurse take first? Answer Direct someone to call the Rapid Response Team (RRT) while using a resuscitation bag and facemask. Q: A client with respiratory failure has been intubated and placed on a ventilator with 100% oxygen delivery to maintain adequate saturation. Twenty-four hours later, the nurse notes new onset crackles and decreased breath sounds. The most recent arterial blood gases (ABGs) show a PaO2 level of 95 mm Hg. What action will the nurse take next? Answer Collaborate with the provider to lower the FiO2 level. Q: The nurse is caring for a group of clients on a medical surgical unit. Which client will the nurse assess first? Answer A client admitted 2 hours ago who has a 90 pack-year smoking history and is receiving 50% oxygen by Venturi mask A client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck." What is the nurse's best response? Answer "Do you have a light scarf that you could place over it?" A client has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy procedure. Which nursing action must be taken first? Answer Auscultate lung sounds. A client with pneumonia is receiving 100% oxygen via a non-rebreather mask. Which of these situations requires immediate intervention by the nurse? Answer The oxygen reservoir deflates during inspiration. A client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about correct tracheostomy care? Answer "I can only take baths, but no showers." "I can put normal saline in my tracheostomy to keep the secretions from getting thick." "I should put cotton or foam over the tracheostomy hole." "I will be unable to wear a necklace." The nurse is caring for a client who has had a tracheostomy placed yesterday. Which of these assessments is essential for the nurse to make? Answer Assess for tachypnea. The nurse is caring for a client with COPD who has a prescription for supplemental oxygen. Which situation will cause the nurse to further assess the need to increase the fraction of inspired oxygen (FiO2)? Answer Client has developed restlessness over the last hour The nurse on a pulmonary unit is caring for a client who has had a tracheostomy placed earlier today. Which of these techniques representing best practice will use the nurse use when suctioning the client's tracheostomy tube? Answer Hyperoxygenate before and after suctioning. A client with chronic obstructive pulmonary disease (COPD) has a prescription to adjust oxygen to maintain SpO2 between 90% and 92%. Which action can be delegated to an unlicensed assistive personnel (UAP) under the supervision of an RN? Answer Adjust the position of the oxygen tubing. An older adult client is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN? Answer Suction the tracheostomy using sterile technique. A client who smokes is being discharged home on oxygen. The client states, "My lungs are already damaged, so I'm not going to quit smoking." What is the discharge nurse's best response? Answer "Let's discuss why smoking around oxygen is dangerous." A client who has a "do not resuscitate" (DNR) prescription has a non-rebreather oxygen mask, and breathing appears to be labored. What does the nurse do first? Answer Ensure that the tubing is patent and that oxygen flow is high. The interprofessional team is collaborating about using noninvasive positive-pressure ventilation (NPPV) for a confused client with pneumonia. What information is essential for the nurse to share with the team while making this decision? Answer The client is unable to cough and protect the airway. The adult client with degenerative arthritis is admitted for surgery to create a tracheostomy. What is the best communication method for this client during the postoperative period? Answer Picture board The nurse is developing the plan of care to reduce risk for aspiration for a client with a tracheostomy. Which nursing interventions would be included in the plan of care? Maintain the client upright for 30 minutes after eating. Provide small, frequent meals. Teach the client to "tuck" the chin down in the forward position to swallow. A registered nurse (RN) from the orthopedic unit has been assigned to the medical unit for the day. Which client assignment for the reassigned RN is the best? The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply The client is aphasic. The client has weakness on the right side of the body The client has weakness on the right side of the face and tongue. The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? "We need to remind him to turn his head to scan the lost visual field." The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? Consistently uses adaptive equipment in dressing self The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? "I don't need to use my walker to get to the bathroom." The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. Padding the side rails of the bed. Placing an airway at the bedside. Placing oxygen and suction equipment at the bedside. Flushing the intravenous catheter to ensure that the site is patent. Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect? Impaired voluntary movements The home health nurse visits a client who is taking phenytoin for control of seizures. During the assessment, the nurse notes that the client is taking birth control pills. Which information should the nurse include in the teaching plan? There is the potential of decreased effectiveness of birth control pills while taking phenytoin. A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL (140 mcmol/L). Which finding would be expected as a result of this laboratory result? Slurred speech The nurse has given medication instructions to a client receiving phenytoin. Which statement indicates that the client has an adequate understanding of the instructions? "Good oral hygiene is needed, including brushing and flossing." The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. Loosening restrictive clothing Removing the pillow and raising padded side rails Positioning the client to the side, if possible, with the head flexed forward A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item? A hearing aid The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function will yield the best information about these cranial nerves? Eye movements The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record? The client experienced paresthesias a few days before admission to the hospital. The nurse in the health care clinic is providing medication instructions to a client with a seizure disorder who will be taking divalproex sodium. The nurse should instruct the client about the importance of returning to the clinic for monitoring of which laboratory study? Liver function studies The nurse assesses a client who is diagnosed with a stroke (brain attack). On assessment, the client is unable to understand the nurse's commands. Which condition should the nurse document? Damage to the auditory association areas The nurse is providing instructions to a client who will be taking phenytoin. Which statement, if made by the client, would indicate an understanding of the information about this medication? "I need to perform good oral hygiene, including flossing and brushing my teeth." The nurse is performing an assessment on a client with a diagnosis of thrombotic stroke (brain attack). Which assessment question would elicit data specific to this type of stroke? "Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?" The nurse is creating a plan of care for a client with dysphagia following a stroke (brain attack). Which should the nurse include in the plan? Select all that apply. Thicken liquids. Assist the client with eating. Assess for the presence of a swallow reflex. Provide ample time for the client to chew and swallow. The nurse is creating a plan of care for a client with a stroke (brain attack) who has right homonymous hemianopsia. Which should the nurse include in the plan of care for the client? Instruct the client to turn the head to scan the right visual field. The nurse is preparing for the admission to the unit of a client with a diagnosis of seizures and asks the nursing student to institute full seizure precautions. Which item if noted in the client's room would need to be removed and warrants the need to review seizure precautions with the student? Padded tongue blade The home health nurse is visiting a client with a diagnosis of multiple sclerosis. The client has been taking oxybutynin. The nurse evaluates the effectiveness of the medication by asking the client which assessment question? "Are you getting up at night to urinate?" The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric stroke. The nurse notes that the client is alert and oriented to time and place. On the basis of these assessment findings, the nurse should make which interpretation? Is likely to have perceptual and spatial disabilities The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack). On reviewing the client's record, the nurse notes an assessment finding of anosognosia. The nursing care plan should address which manifestation related to this finding? The client will exhibit neglect of the affected side. The nurse is creating a plan of care for a client with a stroke (brain attack) who has global aphasia. The nurse should incorporate communication strategies into the plan of care because of which expected characteristic of the client's speech? Associated with poor comprehension The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack) with anosognosia. To meet the needs of the client with this deficit, the nurse should include activities that will achieve which outcome? Increase the client's awareness of the affected side. The home care nurse is visiting a client with a diagnosis of Parkinson's disease. The client is taking benztropine mesylate orally daily. The nurse provides information to the spouse regarding the side effects of this medication and should tell the spouse to report which side effect if it occurs? Inability to urinate The nurse is documenting nursing observations in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure? Spasms of the entire body At 8:00 a.m., a client who has had a stroke (brain attack) was awake and alert with vital signs of temperature 98º F (37.2º C) orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99º F (36.7º C) orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse should take which action? Call the primary health care provider (PHCP). The nurse is teaching a client hospitalized with a seizure disorder and the client's spouse about safety precautions after discharge. The nurse determines that the client needs further teaching if the client states an intention to take which action? Drink alcohol in small amounts and only on weekends. At the end of the work shift, the nurse is reviewing the respiratory status of a client admitted with a stroke (brain attack) earlier in the day. The nurse determines that the client's airway is patent if which data are identified? Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear A client who had a stroke (brain attack) has right-sided hemianopsia. What should the nurse plan to do to help the client adapt to this problem? Teach the client to scan the environment. The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is necessary to determine information about which items as part of routine assessment of seizures? Select all that apply. Postictal status Duration of the seizure Changes in pupil size or eye deviation Seizure progression and type of movements A client is admitted with an exacerbation of multiple sclerosis. The nurse is assessing the client for possible precipitating risk factors. Which factor, if reported by the client, should the nurse identify as being unrelated to the exacerbation? Ingestion of increased fruits and vegetables A client with multiple sclerosis is experiencing muscle weakness, spasticity, and an ataxic gait. On the basis of this information, the nurse should include which client problem in the plan of care? Interruption in physical mobility The nurse is planning care for the client with a neurogenic bladder caused by multiple sclerosis. The nurse plans for fluid administration of at least 2000 mL/day. Which plan would be most helpful to this client? 400 to 500 mL with each meal and 200 to 250 mL at midmorning, midafternoon, and late afternoon Which assessment finding should the nurse expect to note in the client hospitalized with a diagnosis of stroke who has difficulty chewing food? Dysfunction of trigeminal nerve (cranial nerve V) A client with multiple sclerosis tells a home health care nurse that she is having increasing difficulty in transferring from the bed to a chair. What is the initial nursing action? Observe the client demonstrating the transfer technique. A client has sustained damage to Wernicke's area from a stroke (brain attack). On assessment of the client, which sign or symptom would be noted? Problem with understanding language A client brought to the emergency department had a seizure 1 hour ago. Family members were present during the episode and reported that the client's jaw was moving as though grinding food. In helping to determine the origin of this seizure, what should the nurse include in the client's assessment? History of prior trauma A client who suffered a stroke is prepared for discharge from the hospital. The primary health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. What action should the nurse include in the client's plan of care? Consider the use of active, passive, or active-assisted exercises in the home. The nurse is assessing the function of cranial nerve XII in a client who sustained a stroke. To assess function of this nerve, which action should the nurse ask the client to perform? Extend the tongue. The nurse is caring for a client who has just been admitted to the hospital with a diagnosis of a hemorrhagic stroke. The nurse should place the client in which position? Head of the bed elevated 30 degrees with the head in midline position The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply. Hyperoxygenating before suctioning Maintaining the head and neck in midline position Maintaining the head of the bed (HOB) at 30 degrees elevation The nurse is trying to communicate with a client who had a stroke and has aphasia. Which actions by the nurse would be most helpful to the client? Select all that apply. Speaking to the client at a slower rate Allowing plenty of time for the client to respond Looking directly at the client during attempts at speech The client has an impairment of cranial nerve II. Specific to this impairment, what should the nurse plan to do to ensure client safety? Provide a clear path for ambulation without obstacles. The client with a head injury opens eyes to sound, has no verbal response, and localizes to painful stimuli when applied to each extremity. How should the nurse document the Glasgow Coma Scale (GCS) score? GCS = 9 The nurse is caring for a client who is in the chronic phase of stroke (brain attack) and has a right-sided hemiparesis. The nurse identifies that the client is unable to feed self. Which is the appropriate nursing intervention? Assist the client to eat with the left hand to build strength A client is newly admitted to the hospital with a diagnosis of stroke (brain attack) manifested by complete hemiplegia. Which item in the medical history of the client should the nurse be most concerned about? Emphysema The nurse is caring for a client with Parkinson's disease. Which finding about gait should the nurse expect to note in the client? Shuffling and propulsive A client who has had a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the nurse should take which actions? Select all that apply. Thickening liquids to the consistency of oatmeal Placing food on the unaffected side of the mouth Allowing plenty of time for chewing and swallowing The nurse is caring for a client who was admitted for a stroke (brain attack) of the temporal lobe. Which clinical manifestations should the nurse expect to note in the client? The client will have difficulty understanding language. The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data? Ask the client to follow the flashlight through the 6 cardinal positions of gaze. The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique? Holding the sides of the client's great toe and, while moving it, asking what position it is in The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve? Separate the client's jaw by pushing down on the chin. The nurse is performing a physical examination on an assigned client. Which item should the nurse select to test the function of cranial nerve II? Snellen chart The nurse is preparing to test the sensory function of cranial nerve V in a client. The nurse should obtain which item to test the sensory function of this nerve? A wisp of cotton The nurse is planning to test the sensory function of the olfactory nerve (cranial nerve 1). The nurse would gather which items to perform the test? Cloves, peppermint, and soap Which action would the nurse take to test cranial nerve XI, the spinal accessory nerve? Ask the client to shrug the shoulders against the nurse's resistance. The nurse should ask a client to take which action when testing the function of the spinal accessory nerve (CN XI)? Elevate the shoulders. A client is receiving phenobarbital sodium. Which finding on the nursing assessment would indicate that the client is experiencing a common side or adverse effect of this medication? drowsiness The nurse is observing a new nursing graduate who is preparing an intermittent intravenous (IV) infusion of phenytoin for a client with a diagnosis of seizures. Which solution used by the nursing graduate should indicate to the nurse an understanding of proper preparation of this medication? 0.9% sodium chloride After review of the client's laboratory values, the nurse notes that a phenytoin level for a client receiving phenytoin is 7 mcg/mL (27.78 mmol/L). The nurse makes which interpretation regarding this laboratory result? The level is lower than the expected therapeutic range. A client with status epilepticus has been prescribed phenytoin to be given by the intravenous (IV) route. The nurse administering the medication is careful not to exceed which recommended infusion rate? 50 mg/min A client is scheduled to begin medication therapy with valproic acid. The nurse looks for the results of which laboratory test(s) before administering the first dose? liver function test A client is scheduled to begin therapy with carbamazepine. The nurse should assess the results of which test(s) before administering the first dose of this medication to the client? complete blood cell count A client who has been taking phenytoin for seizure control has a serum phenytoin level of 8 mcg/mL (35.71 mmol/L). On the basis of this finding, which note should the nurse enter in the client's health record? Client has an inadequate medication level. A client has a medication prescription for phenytoin to be administered by the intravenous route. After drawing up the medication, the nurse notes the presence of precipitate in the syringe. Which action should the nurse take? discard the syringe and begin again A client began taking amantadine approximately 2 weeks ago. The client reports to the clinic for a follow-up evaluation. The nurse determines that the client is experiencing a side or adverse effect related to the use of this medication if which is noted? Client complaints of urinary retention Phenytoin 100 mg to be given orally 3 times daily has been prescribed to a client. The home health nurse visits the client and provides instructions regarding the medication. Which statement, if made by the client, would indicate an understanding of the instructions? "I will use a soft toothbrush to brush my teeth." A client has been prescribed benztropine. The nurse should assess for which gastrointestinal (GI) problems as a side or adverse effect of this medication? dry mouth The nurse has a prescription to administer diazepam 5 mg by the intravenous (IV) route to a client. The nurse should administer the medication over a period of at least how long? 1 minute A client is receiving phenytoin. To monitor for side and adverse effects of this medication, the nurse assesses the results of which laboratory test? Complete blood count (CBC) The nurse has a prescription to administer phenytoin 100 mg mixed in 5% dextrose in water by the intravenous (IV) route to a client. After reading this prescription, which action should the nurse take? Contact the primary health care provider (PHCP) to question the prescription. The nurse in the primary health care provider's office is reviewing the results of a client's phenytoin level determination performed that morning. The nurse identifies that a therapeutic medication level has been achieved if which result is noted? 15 mcg/mL (59.52 mmol/L) A client has a prescription for valproic acid. To maximize the client's safety, the nurse should plan to monitor for which potential complications of this medication? Select all that apply. Pancreatitis Hepatotoxicity A client taking carbamazepine asks the nurse what to do if a dose is inadvertently missed. The nurse responds that which action should be taken? Take the dose as long as it is not close to the time for the next dose. The nurse has given medication instructions to a client beginning carbamazepine. The nurse determines that the client understands the use of the medication if he makes which statement? "I will use sunscreen when outdoors." A client receiving therapy with carbidopa/levodopa is upset and tells the home health nurse that his urine has turned a darker color since he started taking this medication. The client wants to discontinue its use. In formulating a response to the client's concerns, the nurse interprets that this change is indicative of which condition? A harmless side effect of the medication The nurse is collecting data from a client and notes that the client is taking carbamazepine. The nurse determines that this medication has been prescribed to treat which condition? Trigeminal neuralgia The nurse has completed discharge teaching for a client prescribed carbamazepine. Which statement by the client indicates that education about the main effect of the medication was effective? "This medication has an anticonvulsant effect." The primary health care provider (PHCP) writes a prescription for carbamazepine for a client who was admitted to the hospital. The nurse contacts the PHCP to verify the prescription if which condition is noted in the assessment data? Bone marrow depression A client has a prescription to receive valproic acid daily. To ensure the client's safety, when is the best time for the nurse to schedule the administration of this medication? at bedtime The nurse is preparing to ambulate a client with Parkinson's disease who has recently been started on levodopa/carbidopa. Before performing this activity with the client, the nurse should include which most important assessment in the client's plan of care? Postural (orthostatic) vital signs A client with a diagnosis of trigeminal neuralgia is started on a regimen of carbamazepine. The nurse provides instructions to the client about the side and adverse effects of the medication. Which client statement indicates an understanding of the side and adverse effects of the medication? "I will report a fever or sore throat to my primary health care provider." A client who is taking phenytoin for a seizure disorder is being admitted to the hospital because of an increase in seizure activity. The client reports severe vomiting for the last 24 hours and an inability to take phenytoin during that time. The nurse anticipates that the primary health care provider will most likely prescribe which medication? Fosphenytoin sodium The nurse teaches the wife of a client who is receiving levodopa/carbidopa to avoid pyridoxine medications. Which statement by the wife indicates an understanding of the instructions? "Vitamin B6 reverses the effectiveness of the medication, meaning a higher dose is needed." The nurse is giving medication instructions to a client who is receiving phenytoin for epilepsy. Which instruction should the nurse include to promote adherence to the medication? Monitor plasma medication levels to provide information about compliance. The nurse is preparing an intravenous (IV) infusion of phenytoin as prescribed by the primary health care provider for the client with seizures. Which solution should the nurse plan to use to dilute this medication? Normal saline solution The nurse is reviewing the results of a test on a sample drawn from a child who is receiving carbamazepine for the control of seizures. The results indicate a serum carbamazepine level of 10 mcg/mL (42.33 mmol/L). The nurse analyzes the results and anticipates that the primary health care provider (PHCP) will note which prescription? Continuation of the presently prescribed dosage The nurse is told that the result of a serum carbamazepine level for a client who is receiving the medication for the control of seizures is 13 mcg/mL (55.03 mmol/L). Based on this laboratory result, the nurse anticipates that the primary health care provider (PHCP) will document which prescription? A decrease of the dosage of the medication The nurse is providing instructions to a client beginning medication therapy with divalproex sodium for treatment of absence seizures. The nurse instructs the client that which represents the most frequent side or adverse effect of this medication? Nausea and vomiting The nurse is speaking with a client taking phenytoin for seizure control. The client states that she has started using birth control pills to prevent pregnancy. Which would be an important point for the nurse to emphasize to the client? Phenytoin may decrease the effectiveness of birth control pills, and additional measures should be taken to avoid pregnancy. The nurse is reading the laboratory results for a client being treated with carbamazepine for prophylaxis of complex partial seizures. When evaluating the client's laboratory data, the nurse determines that which value is consistent with a side or adverse effect of this medication? White blood cell count, 3200 mm3 (3.2 × 109/L) The nurse is assisting in the care of a client being discharged on phenytoin 100 mg three times daily. When providing client teaching about this medication, the nurse should be sure to include which points? Select all that apply. Use a soft toothbrush while taking this medication. The medication may turn the urine pink, red, or brown. Alcohol should be avoided while taking this medication. The nurse is providing instructions to an adolescent prescribed phenytoin for the control of seizures. Which statement by the adolescent indicates a need for further teaching regarding the medication? "If my gums become sore and swollen, I need to stop the medication." The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement? "I'll try to eat my food either very warm or very cold." A client with trigeminal neuralgia tells the nurse that acetaminophen is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication? Direct bilirubin level of 2 mg/dL (34 mcmol/L) A client who has experienced a stroke has partial hemiplegia of the left leg. The nurse interprets that the client could benefit from the support and stability provided by which item? Quad cane The home health nurse has been discussing interventions to prevent constipation in a client with multiple sclerosis. The nurse determines that the client is using the information most effectively if the client reports which action? Initiating a bowel movement every other day, 45 minutes after the largest meal of the day The nurse is administering an intravenous dose of methocarbamol to a client with multiple sclerosis. For which adverse effect should the nurse monitor? bradycardia A client with vascular headaches is taking ergotamine. The home health nurse should periodically assess him or her for which finding? Cool, numb fingers and toes The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply. A hyperinflated chest noted on the chest x-ray Decreased oxygen saturation with mild exercise The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. Activities should be resumed gradually. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. Respiratory isolation is not necessary, because family members already have been exposed. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statement? "I should not be contagious after 2 to 3 weeks of medication therapy." The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply. Dyspnea Night sweats A bloody, productive cough A cough with the expectoration of mucoid sputum The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis? Sputum culture The nurse is teaching a client about changes in body image related to chronic obstructive pulmonary disease (COPD). Which statement by the client would indicate that teaching was successful? "My nails may become clubbed." The nurse instructs a client with chronic obstructive pulmonary disease (COPD) to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome? Promote carbon dioxide elimination. The nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse should incorporate which intervention as the best strategy to assist the client in coping with the illness? Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease. A client diagnosed with tuberculosis (TB) is distressed over fatigue and the loss of physical stamina. What should the nurse tell the client? This is expected, and the client should gradually increase activity as tolerated. The nurse is assessing a client with the typical clinical manifestations of tuberculosis (TB). During history-taking the nurse anticipates that the client will report presence of cough and fatigue for what period of time? Several weeks to months The clinic nurse administers a tuberculin skin test to a client. The nurse tells the client to return to the clinic for the results in how long? 48 to 72 hours A client with a history of recent upper respiratory infection comes to the urgent care center complaining of chest pain. The nurse determines that the pain is most likely of a respiratory origin if the client makes which statement about the pain? "It hurts more when I breathe in." A client who experiences frequent upper respiratory infections (URIs) asks the nurse why food does not seem to have any taste during illness. Which response by the nurse is most appropriate? "Blocked nasal passages impair the sense of smell." The nurse reads in the progress notes for a client with pneumonia that areas of the client's lungs are being perfused but are not being ventilated. How does the nurse correctly interpret this documentation? A shunt unit exists. Which are possible causes of upper airway obstruction? Select all that apply. Laryngeal edema Head and neck cancer Foreign body aspiration Lymph node enlargement The nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment finding would indicate deterioration in ventilation? Rapid, shallow respirations The nurse is planning care for an 81-year-old unresponsive client admitted to the hospital with a medical diagnosis of pneumonia. The nurse has identified the problem of inability to clear the airway related to retained secretions. Which intervention is most appropriate? Provide nasotracheal suctioning as needed to remove secretions. A client with chronic obstructive pulmonary disease (COPD) has a respiratory rate of 24 breaths per minute, bilateral crackles, and cyanosis and is coughing but unable to expectorate sputum. Which problem is the priority? Inability to clear the airway related to inability to expectorate sputum The nurse is caring for a client diagnosed with tuberculosis (TB). Which assessments, if made by the nurse, are consistent with the usual clinical presentation of TB? Select all that apply. Cough Dyspnea chills and night sweats A client with chronic obstructive pulmonary disease (COPD) is being evaluated for lung transplantation. The nurse performs the initial physical assessment. Which findings should the nurse anticipate in this client? Select all that apply. Dyspnea at rest Clubbed fingers Muscle retractions Prolonged expiratory breathing phase Which position would best help the breathing of a client with chronic obstructive pulmonary disease (COPD)? Tripod position The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings? pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L A client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse should determine that which finding documented in the client's record is an expected finding with this client? Hyperinflation of lungs documented by chest x-ray Which are risk factors for chronic obstructive pulmonary disease (COPD)? Select all that apply. Cigarette smoking Genetic risk factor Environmental factors Alpha-1 antitrypsin (AAT) deficiency The nurse is discharging a client with chronic obstructive pulmonary disease (COPD) and reviewing specific instructional points about COPD. What comment by the client indicates that further teaching is needed? "I have to keep my nasal cannula oxygen levels between 4 and 6 L/min." The nurse is about to administer a contrast medium to the client undergoing diagnostic testing. Which question does the nurse first ask the client? Are you taking ibuprofen daily The nurse is caring for a client who is scheduled to have a transcranial Doppler (TCD). What does this diagnostic test evaluate? Cerebral vasospasm Which task does the nurse plan to delegate to the unlicensed assistive personnel (UAP) caring for a group of clients in the neurosurgical unit? Attend to the care needs of a client who has had a transcranial Doppler study Which information is most important for the nurse to communicate to the primary care provider (PCP) about a client who is scheduled for CT angiography? Poor skin turgor and dry mucous membranes The nurse has just received report on a group of clients on the neurosurgical unit. Which client is the nurse's first priority? Client whose Glasgow Coma Scale (GCS) has changed from 15 to 13 The nurse is performing a neurologic assessment on an 81-year-old client. Which physiologic change does the nurse expect to find because of the client's age? Decreased coordination Which cranial nerve allows a person to feel a light breeze on the face? V (trigeminal) The nurse has just received report on a group of clients. Which client does the nurse assess first? Client who had a cerebral arteriogram and has a cool, pale leg The nurse has just received change-of-shift report about a group of clients on the neurosurgical unit. Which client does the nurse attend to first? Middle-aged adult client who had a cerebral aneurysm clipping and is becoming increasingly confused An older client presents to the clinic after a ground level fall at home. What statement by the client indicates the need for more injury prevention education? "I only eat little snacks so I don't gain weight." A client is scheduled for an electroencephalogram (EEG) in the morning. Which instruction does the nurse give the client? "Do not take any sedatives 12-24 hours before the test." The nurse prepares to assess a client with diabetes mellitus for sensory loss. Which equipment is the best choice for the nurse use to perform this assessment? Cotton-tipped applicator The nurse is assessing a client with a neurologic condition who is reporting difficulty chewing when eating. The nurse suspects that which cranial nerve has been affected? Trigeminal (CN V) Which client diagnosed with neurologic injury is typically at highest risk for depression? Young man with a spinal cord injury A client has just returned from cerebral angiography. Which symptom does the client display that causes the nurse to act immediately? Bleeding Which client will the neurologic unit charge nurse assign to a registered nurse who has floated from the labor/delivery unit for the shift? Adult client who has just returned from having a cerebral arteriogram and needs vital sign checks every 15 minutes. The nurse is performing a rapid neurologic assessment on a trauma client. Which assessment findings are normal? Glasgow Coma Score (GCS) 15 Minimal response to stimulation A client receiving propranolol (Inderal) as a preventative for migraine headaches is experiencing side effects after taking the drug. Which side effect is of greatest concern to the nurse? Slow heart rate The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects? Headaches Dizziness Diplopia A female client with newly diagnosed migraines is being discharged with a prescription for sumatriptan (Imitrex). Which comment by the client indicates an understanding of the nurse's discharge instructions? "I must report any chest pain right away." A client newly diagnosed with Parkinson disease (PD) is being discharged. Which instruction is best for the nurse to provide to the client's spouse? Administer medications promptly on schedule to maintain therapeutic drug levels. The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? Forces a tongue blade in the mouth. A client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? Intravenous access (IV) Suction equipment at the bedside Siderails raised The nurse is teaching a client, newly diagnosed with migraines, about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan? "I must not miss meals." A client with Parkinson disease (PD) is being discharged home with his wife. To ensure success with the management plan, which discharge action is most effective? Involving the client and his wife in developing a plan of care A client presents to the clinic with a migraine and is lying in a darkened room with a wet cloth on the head after receiving treatment. In preparation for dismissal home, what does the nurse do next? Allow the client to remain undisturbed. The nurse has received report on a group of clients. Which client requires the nurse's attention first? Young adult who has experienced four tonic-clonic seizures within the past 30 minutes The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been ordered for treatment of epilepsy. The nurse instructs the client to avoid which beverage? Grapefruit juice A client is admitted into the emergency department (ED) with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring? Classic migraine The nurse's friend fears that something is wrong with his grandmother, saying that she is becoming extremely forgetful and disoriented and is beginning to wander. What is the nurse's best response? "Have you taken her for a check-up?" A client has Parkinson's disease (PD). Which nursing intervention best protects the client from injury? Monitoring the client's sleep patterns A client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What does the nurse do first? Establish an airway. The nurse is reviewing the history of a client who has been prescribed topiramate (Topamax) for prevention of migraines. The nurse plans to contact the primary care provider (PCP) if the client has which condition? Bipolar disorder A client has been diagnosed with Primary Progressive MS (PPMS) and the nurse is providing education at the clinic. What statement by the client indicates the need for more teaching? "It's important I work out in the afternoon so my muscles are warmed up." A client with severe muscle spasticity has been prescribed tizanidine (Zanaflex, Sirdalud). The nurse instructs the client about which adverse effect of tizanidine? Drowsiness The nurse is teaching a client newly diagnosed with multiple sclerosis (MS). Which statement by the client indicates a correct understanding of the pathophysiology of the disease? "Parts of my nervous system have plaques." A client has been admitted with a diagnosis of stroke (brain attack). The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms? Impulsiveness and smiling The nurse is teaching a client and family about home care after a stroke. Which statement made by the client's spouse indicates a need for further teaching? "I should spend all my time with my husband in case I'm needed." A client has had a traumatic brain injury and is mechanically ventilated. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)? Maintaining neutral head position A client is eating a soft diet while recovering from a stroke. The client reports food accumulating in the cheek of the affected side. What is the nurse's best response? "Let's see if the speech-language pathologist can help." The daughter of a client who has had a stroke asks the nurse for additional resources. What is the nurse's best response? "The National Stroke Association has resources available." A client is admitted with a stroke (brain attack). Which tool does the nurse use to facilitate a focused neurologic assessment of the client? National Institutes of Health Stroke Scale (NIHSS) Which are risk factors for stroke? High blood pressure Previous stroke or transient ischemic attack (TIA) Smoking Use of oral contraceptives A client recovering from a stroke reports double vision that is preventing the client from effectively completing activities of daily living. How does the nurse help the client compensate? Covers the affected eye A client in the emergency department (ED) has slurred speech, confusion, and visual problems and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The client also has a history of hypertension and atherosclerosis. What does the nurse suspect that the client is probably experiencing? Thrombotic stroke A client presents to the Emergency Department from an assisted living facility after a ground level fall with a head strike. The client has a Glasgow Coma Score (GCS) of 12, which is decreased for this client, and has projectile vomiting. What is the priority intervention for this client? Positioning the client to prevent aspiration A client hospitalized for hypertension presses the call light and reports "feeling funny." When the nurse gets to the room, the client is slurring words and has right-sided weakness. What does the nurse do first? Assesses airway, breathing, and circulation Which eye procedure requires informed consent from the client? Fluorescein angiography A client says, "I have problems reading signs when I am driving." Which test does the nurse use to best assess this client's problem? Snellen chart The nurse is teaching a client who is scheduled for an ultrasonography of the eye. Which statement by the client indicates a need for further instruction? "I'll have to wear a bandage over my eye after the test." A client who is using eye drops in both eyes develops a viral infection in one eye and asks the nurse what to do. What is the nurse's best response? "You will need to use a separate bottle of drops for each eye." The nurse providing education on eye protection suggests the special need for protective eyewear for which clients? Lifeguard Racquetball player While reading a client's optical chart, the nurse notices that the client has emmetropia. Which corrective equipment does the nurse expect to see this client wearing? Nothing; this is normal Clients with a family history of which eye disorder may have problems with increased intraocular pressure (IOP), requiring additional assessment? Glaucoma A client reports "something scratching on the inside of my eyelid." Before examining the eyelid, what does the nurse do first? Wash the hands Which proper technique does the nurse use for eye drop instillation? Placing the eye drop in the lower lid pocket Which assessment finding warrants further investigation by the nurse in the ophthalmology clinic? When assessing the cornea, the nurse notes cloudiness and the client reports pain when the ophthalmoscope light shines into the pupil. The nurse is teaching a client about visual changes that occur with age. Which statement does the nurse include? "It may take your eyes longer to adjust in a darkened room." Which systemic disorders may affect the eye and vision and require yearly eye examination by an ophthalmologist? Diabetes mellitus Hypertension Multiple sclerosis (MS) When performing an eye or vision assessment, which comment by the client alerts the nurse that immediate care by an ophthalmologist is needed? "Something hit my eye while I was cutting grass." A client is admitted to the emergency department with metal shards in the right eye. Which test is contraindicated for this client? Magnetic resonance imaging (MRI) The nurse is teaching a client about administering eye drops to treat open-angle glaucoma. Which statement by the client indicates a need for further instruction? I must press on the inside of my eye to prevent washout." The nurse is providing discharge instructions to a client with glaucoma. Which activities does the nurse instruct the client to avoid? Bending over to tie shoes Blowing the nose frequently Lifting objects weighing more than 10 pounds (4.5 kg) A client with new-onset diminished vision is being discharged and is concerned about living independently. Which nursing technique best facilitates independent self-care for the client? Building on the remaining vision Which client is most in need of immediate examination by an ophthalmologist? A 40-year-old with glasses and a reddened sclera who reports brow pain, headache, and seeing colored halos around lights A bedridden client with reduced vision has been admitted. Which nursing interventions will ease the client's hospital stay? Announce name and purpose when entering the client's room. Explain food positions on the tray using a clock face as the example. Orient the client to the location of the call light, and keep it in that place. Orient the client to the room surroundings and equipment. A client has sustained damage to the optic nerve (cranial nerve II) after a traumatic injury. Which intervention does the nurse anticipate to accommodate for this injury? Identifying food on the client's plate using the clock method A client is returning home after cataract surgery with a patch over the affected eye. Which statement by the client's spouse indicates a need for further instruction on providing a safe home environment? "I will rearrange the furniture for better flow before my spouse gets home." The nurse is providing postmortem care to a client who will donate a cornea. Which action is appropriate for the nurse to implement? Instill antibiotic drops into the eyes. A client with glaucoma is being assessed for new symptoms. Which symptom indicates a high priority need for reassessment of intraocular pressure? Gradual vision changes The nurse is performing preoperative teaching for an older adult client who will be having a cataract removed. Which instructions does the nurse include? "Several different types of eye drops are requested after surgery, and they have to be taken several times a day for up to 4 weeks." You will receive a medication to help you relax. Then you will receive eye drops to dilate your pupils and paralyze the lens." "Bring sunglasses with you on the day of your procedure." What is the action of miotic drugs that constrict the pupils in the client with glaucoma? Enhance aqueous circulation to site of absorption A client has recently had cataract surgery. The nurse will instruct the client to notify the health care provider immediately if which symptom occurs? Reduction in vision Which type of drug therapy does the nurse anticipate giving to a client with Ménière's disease to decrease endolymph volume? Diuretics Which test best determines hearing acuity? Audiometry The nurse is teaching a client with impaired hearing about audiometric testing. Which statement by the nurse effectively communicates information about the procedure to the client? "I will sit right in front of you in the soundproof booth and give you instructions on what types of sounds you will hear and how you'll need to respond." What is the proper technique for assessing an adult client's ear with an otoscope? Pull the pinna up and back with the nondominant hand. The nurse has just received change-of-shift report about these clients. Which client needs to be assessed first? Client with labyrinthitis who has a temperature of 102.4° F (39.1° C) and a headache When preparing to examine an ear with drainage, what does the nurse do first? Dons clean gloves An older adult client comes in for a routine visit. During the assessment he is irritable and says, "Speak up and quit mumbling!" How will the nurse respond? Apologizes and speaks louder and clearer Which clients are at high risk for developing hearing problems? Airline mechanic Client with Down syndrome Drummer in a rock band Teenager listening to music using ear buds The nurse is teaching a client about ear protection. Which statement by the client indicates that teaching was effective? "I wear foam ear inserts at works where it is noisy." Which technique is correct when instilling ear drops? Place the medication bottle in a bowl of warm water before instillation. A client recently diagnosed with Ménière's disease is struggling with tinnitus. How does the nurse provide support to this client? Refer the client to the American Tinnitus Association. Which type of hearing loss is most likely to be reversible when treated appropriately? Conductive hearing loss The nurse is assessing a client with recent changes in hearing. After taking a medication history, which drugs does the nurse identify as possible causes of the client's hearing change? Erythromycin Ibuprofen (Advil) Furosemide (Lasix) A client with asthma reports shortness of breath. Which of these findings does the nurse anticipate when assessing this client's chest? Expiratory wheezing not cleared by coughing A client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck." What is the nurse's best response? "Do you have a light scarf that you could place over it?" The nurse on a pulmonary unit is caring for a client who has had a tracheostomy placed earlier today. Which of these techniques representing best practice will use the nurse use when suctioning the client's tracheostomy tube? Hyperoxygenate before and after suctioning. A client who smokes is being discharged home on oxygen. The client states, "My lung