MED SURG EXAM 4 -With 100% verified solutions 2024-2025-tutor verified, Exams of Nursing

Download MED SURG EXAM 4 -With 100% verified solutions 2024-2025-tutor verified and more Exams Nursing in PDF only on Docsity! MED SURG EXAM 4 -With 100% verified solutions 2024-2025-tutor verified A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease A An 86-year-old man with a history of asthma B A 32-year-old Asian-American man with colorectal cancer C A 45-year-old American Indian woman with diabetes mellitus D A 53-year-old postmenopausal woman who is on hormone therapy C A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect A Excruciating pain on inspiration B Left lateral chest wall pain C Disorientation and confusion D Numbness and tingling of the arm C A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure A Client's level of anxiety B Ability to turn self in bed C Cardiac rhythm and heart rate D Allergies to iodine-based agents D A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery A Administration of IV furosemide (Lasix) B Initiation of an external pacemaker C Assistance with endotracheal intubation D Placement of central venous access C A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this client's teaching A "The best way to lose weight is a high-protein, low-carbohydrate diet." B "You should balance weight loss with consuming necessary nutrients." C "A nutritionist will provide you with information about your new diet." D "If you exercise more frequently, you won't need to change your diet." B A nurse cares for a client who has advanced cardiac disease and states, "I am having trouble sleeping at night." How should the nurse respond A "I will consult the provider to prescribe a sleep study to determine the problem." B "You become hypoxic while sleeping; oxygen therapy via nasal cannula will help." C "A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night." D "Use pillows to elevate your head and chest while you are sleeping." D A C E A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure (Select all that apply.) A Assist the provider to place a central venous access device. B Prepare for continuous blood pressure and pulse monitoring. C Administer the client's prescribed beta blocker. D Give the client nothing by mouth 3 to 6 hours before the procedure. E Explain to the client that dobutamine will simulate exercise for this examination. B D E A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess (Select all that apply.) A Thrombophlebitis B Stroke C Pulmonary embolism D Myocardial infarction E Cardiac tamponade A C E The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning A Cholesterol: 126 mg/dL B High-density lipoprotein cholesterol (HDL-C): 48 mg/dL C Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL D Triglycerides: 198 mg/dL D A nurse is working with a client who takes atorvastatin (Lipitor). The client's recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best A Ask if the client eats grapefruit. B Assess the client for dehydration. C Facilitate admission to the hospital. D Obtain a random urinalysis. A A student nurse asks what "essential hypertension" is. What response by the registered nurse is best A "It means it is caused by another disease." B "It means it is 'essential' that it be treated." C "It is hypertension with no specific cause." D "It refers to severe and life-threatening hypertension." C A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best A Assess the client's support system. B Assist in finding one change the client can control. C Determine what stressors the client faces in daily life. D Inquire about delegating some of the client's obligations. B The nurse is caring for four hypertensive clients. Which drug-laboratory value combination should the nurse report immediately to the health care provider A Furosemide (Lasix)/potassium: 2.1 mEq/L B Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L C Spironolactone (Aldactone)/potassium: 5.1 mEq/L D Torsemide (Demadex)/sodium: 142 mEq/L A A nurse is teaching a larger female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best A "No, women should only have one beer a day as a general rule." B "No, you should not drink any alcohol with hypertension." C "Yes, since you are larger, you can have more alcohol." D "Yes, two beers per day is an acceptable amount of alcohol." A C Provide pamphlets on heart disease at the grocery store. D Set up an "Ask the nurse" booth at the pet store. B A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities A "I can use a heating pad on my legs if it's set on low." B "I should not cross my legs when sitting or lying down." C "I will go out and buy some warm, heavy socks to wear." D "It's going to be really hard but I will stop smoking." A What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins (Select all that apply.) A Administering mild analgesics for pain B Applying elastic compression stockings C Elevating the legs when sitting or lying D Reminding the client to do leg exercises E Teaching the client about surgical options B C D A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP) (Select all that apply.) A Administering preoperative medication B Ensuring the consent is signed C Marking pulses with a pen D Raising the siderails on the bed E Recording baseline vital signs D E A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep vein thrombosis (DVT) prevention (Select all that apply.) A Apply compression stockings. B Assist with ambulation. C Encourage coughing and deep breathing. D Offer fluids frequently. E Teach leg exercises. A B D A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the client's plan of care (Select all that apply.) A Assess the client for bleeding. B Monitor the daily activated partial thromboplastin time (aPTT) results. C Stop the IV for aPTT above baseline. D Use an IV pump for the infusion. E Weigh the client daily on the same scale. A B D A client is being discharged on warfarin (Coumadin) therapy. What discharge instructions is the nurse required to provide (Select all that apply.) A Dietary restrictions B Driving restrictions C Follow-up laboratory monitoring D Possible drug-drug interactions E Reason to take medication A C D E Which statements by the client indicate good understanding of foot care in peripheral vascular disease (Select all that apply.) A "A good abrasive pumice stone will keep my feet soft." B "I'll always wear shoes if I can buy cheap flip-flops." C "I will keep my feet dry, especially between the toes." D "Lotion is important to keep my feet smooth and soft." E "Washing my feet in room-temperature water is best." C D E A nurse is caring for a client with a nonhealing arterial ulcer. The physician has informed the client about possibly needing to amputate the client's leg. The client is crying and upset. What actions by the nurse are best (Select all that apply.) D Positive pronator drift A A nurse asks a client to take deep breaths during an electroencephalography. The client asks, "Why are you asking me to do this" How should the nurse respond A "Hyperventilation causes vascular dilation of cerebral arteries, which decreases electoral activity in the brain." B "Deep breathing helps you to relax and allows the electroencephalograph to obtain a better waveform." C "Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity." D "Deep breathing will help you to blow off carbon dioxide and decreases intracranial pressures C A nurse is caring for a client with a history of renal insufficiency who is scheduled for a computed tomography scan of the head with contrast medium. Which priority intervention should the nurse implement A Educate the client about strict bedrest after the procedure. B Place an indwelling urinary catheter to closely monitor output. C Obtain a prescription for intravenous fluids. D Contact the provider to cancel the procedure C A nurse obtains a focused health history for a client who is scheduled for magnetic resonance imaging (MRI). Which condition should alert the nurse to contact the provider and cancel the procedure A Creatine phosphokinase (CPK) of 100 IU/L B Atrioventricular graft C Blood urea nitrogen (BUN) of 50 mg/dL D Internal insulin pump D A nurse delegates care to the unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating care for a client with cranial nerve II impairment A "Tell the client where food items are on the breakfast tray." B "Place the client in a high-Fowler's position for all meals." C "Make sure the client's food is visually appetizing." D"Assist the client by placing the fork in the left hand." A A nurse prepares a client for lumbar puncture (LP). Which assessment finding should alert the nurse to contact the health care provider A Shingles on the client's back B Client is claustrophobic C Absence of intravenous access D Paroxysmal nocturnal dyspnea A A nurse assesses a client who is recovering from a lumbar puncture (LP). Which complication of this procedure should alert the nurse to urgently contact the health care provider A Weak pedal pulses B Nausea and vomiting C Increased thirst D Hives on the chest C A nurse cares for a client who is recovering from a single-photon emission computed tomography (SPECT) with a radiopharmaceutical agent. Which statement should the nurse include when discussing the plan of care with this client A "You may return to your previous activity level immediately." B "You are radioactive and must use a private bathroom." C "Frequent assessments of the injection site will be completed." D "We will be monitoring your renal functions closely." A A nurse assesses a client with an injury to the medulla. Which clinical manifestations should the nurse expect to find (Select all that apply.) A Loss of smell B Impaired swallowing C Visual changes D Inability to shrug shoulders C Increased sensory perception D Decreased risk for infection E Change in sleep patterns B E A nurse delegates care for an older adult client to the unlicensed assistive personnel (UAP). Which statements should the nurse include when delegating this client's care (Select all that apply.) A "Plan to bathe the client in the evening when the client is most alert." B "Encourage the client to use a cane when ambulating." C "Assess the client for symptoms related to pain and discomfort." D "Remind the client to look at foot placement when walking." E "Schedule additional time for teaching about prescribed therapies." A B D A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the client's neurologic examination is normal. About what drug should the nurse plan to teach the client A Alteplase (Activase) B Clopidogrel (Plavix) C Heparin sodium D Mannitol (Osmitrol) B A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client A Assess for bladder retention and/or incontinence. B Listen to the client's lungs after eating or drinking. C Prop the client's right side up when sitting in a chair. D Rotate the client's meal tray when the client stops eating D A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain A Loss of bladder control B Other medical conditions C Progression of symptoms D Time of symptom onset D A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority A Administer pain medication. B Assess the client's vital signs. C Notify the Rapid Response Team. D Raise the head of the bed. C A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met A Chooses preferred items from the menu B Eats 75% to 100% of all meals and snacks C Has clear lung sounds on auscultation D Gains 2 pounds after 1 week C A client's mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the client's cerebral perfusion pressure, what should the nurse anticipate for this client A Impending brain herniation B Poor prognosis and cognitive function C Probable complete recovery D Unable to tell from this information B A client with a traumatic brain injury is agitated and fighting the ventilator. What drug should the nurse prepare to administer A Carbamazepine (Tegretol) B Dexmedetomidine (Precedex) C Diazepam (Valium) D Mannitol (Osmitrol B Nutritional deficit C Risk for acquiring an infection D Risk for skin breakdown C A nursing student studying the neurologic system learns which information (Select all that apply.) A An aneurysm is a ballooning in a weakened part of an arterial wall. B An arteriovenous malformation is the usual cause of strokes. C Intracerebral hemorrhage is bleeding directly into the brain. D Reduced perfusion from vasospasm often makes stroke worse. E Subarachnoid hemorrhage is caused by high blood pressure. A C D The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess (Select all that apply.) A Alcohol intake B Diabetes C High-fat diet D Obesity E Smoking A C D E A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP) (Select all that apply.) A Assess neurologic status with the Glasgow Coma Scale. B Check and document oxygen saturation every 1 to 2 hours. C Cluster client care to allow periods of uninterrupted rest. D Elevate the head of the bed to 45 degrees to prevent aspiration. E Position the client supine with the head in a neutral midline position B E A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include (Select all that apply.) A Discharging the client on a statin medication B Providing the client with comprehensive therapies C Meeting goals for nutrition within 1 week D Providing and charting stroke education E Preventing venous thromboembolism A D E A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders (Select all that apply.) A A client with a moderate trauma may need hospitalization. B A Glasgow Coma Scale score of 10 indicates a mild brain injury. C Only open head injuries can cause a severe TBI. D A client with a Glasgow Coma Scale score of 3 has severe TBI. E The terms "mild TBI" and "concussion" have similar meanings A D E A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population (Select all that apply.) A Admission can overwhelm the coping mechanisms for older clients. B Alcohol is typically involved in most traumatic brain injuries for this age group. C These clients are more susceptible to systemic and wound infections. D Other medical conditions can complicate treatment for these clients. E Very few traumatic brain injuries occur in this age group. A C D A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP) (Select all that apply.) A Applying a cool washcloth to the head B Assisting the client to a position of comfort C Keeping voices soft and soothing D Maintaining low lighting in the room E Providing antipyretics for fever A B C D