Nursing Concepts and Interventions, Exams of Medicine

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MED SURG 1 Final Exam updated 2024

A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected.The nurse should anticipate using which of the following types of insulin to treat this client? - verified answer Regular insulin A nurse is discussing the difference between skeletal and skin traction with a newly licensed nurse. Which of the statements by the newly licensed nurse indicates understanding? - verified answer Skeletal traction is more appropriate than skin traction for reducing a fracture. A nurse is proving discharge teaching to a client who has a fracture of the right tibia and a fiberglass cast. Which of the following instructions should the nurse include in the teaching? - verified answer Report any worsening or unrelieved pain A nurse is caring for a client who has gastrointestinal bleeding. Which of the following actions should the nurse take? - verified answer Assess orthostatic blood pressure A nurse is caring for a client with type 1 diabetes mellitus who reports felling shaky and having palpitations. When the nurse finds the client's blood glucose to be 48 mg/dL on glucometer, he should give the client which of the following - verified answer Graham crackers A nurse is teaching a client who has diabetes about which dietary source should provide the greatest percentage of calories. Which of the following statements indicates the client understands the teaching? - verified answer I should eat more calories from complex carbohydrates than anything else A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alteration in function should the nurse expect? - verified answer Inability to recognize his family members A nurse is providing teaching for a client who is newly diagnosed with type 2 diabetes Mellitus and has a prescription for glipizide. Which of the following statements by the nurse best describes action action of glipizide - verified answer Glipizide stimulates your pancreas to release insulin A nurse in a community clinic is assessing an older adult client for manifestation of dehydration. Which of the following findings should the nurse expect - verified answer Furrows in the tongue

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take? - verified answer Position the child laterally A nurse is caring for a client who has active pulmonary tuberculosis (TB) and a new prescription for IV rifampin. The nurse should instruct the client that they should expect to experience which of the following manifestations while taking this medication? - verified answer Red colored urine A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the nurse plan to take? - verified answer Check the clients vital signs every hour during the transfusion A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrient should the nurse include in the teaching - verified answer Protein A nurse is caring for an older adult client who has a urinary track infection. Which of the following manifestation should the nurse identify as a findings specially associated with this client? - verified answer Confusion A nurse is providing teaching to a client who is taking warfarin about monitoring it's therapeutic effects. Which of the following explanation should the nurse provide about the international normalized ratio (INR) test? - verified answer The INR is a standardized test that eliminates the variations between laboratories reports in Prothrombin times. A nurse is teaching group of nursing students about Pyelonephritis. Which of the following statements should the nurse include in the teaching - verified answer Pyelonephritis increases a pregnant woman's risk for preterm labor A nurse is teaching about diseases management for a client who has type 1 diabetes Mellitus.Which statement made by the clinic indicates an understanding of the teaching? - verified answer I give the insulin injection in the abdominal area A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor? - verified answer Family history A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft surgery and is receiving opioid medication to manage discomfort. Aside from managing pain, which of the following desires effects of medications should the nurse identify as most important for the clients recovery? - verified answer It facilitates the clients deep breathing

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? Select all that apply - verified answer Increased heart rate, blood pressure, respiratory rate A nurse is providing teaching about dietary recommendations to a client who has iron deficiency anemia. Which of the following dietary recommendation should the nurse include as a food that enhances iron absorption one consumed with nonheme iron? - verified answer Tomato juice A nurse is assessing a client who has chronic venous is efficiency. Which of the following findings should the nurse expect - verified answer Edema A nurse is caring for an older client who has had surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following intervention should the nurse include in the client,s postoperative plan of care? Select all that apply - verified answer -Discontinue suction when assessing for peristalsis -irrigate the NG tube with 0.9% sodium chloride arrogation solution -place sequential compression devices on the bilateral lower extremity's -reposition the client from side to side every 2 hr is correct A nurse is teaching a client who has a new prescription for ranitidine to treat peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply - verified answer -I can take this medication with or without food

• I will eat five small meals every day A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? - verified answer Encourage the client to increase fluid intake A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes Mellitus.The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? - verified answer -Blurred vision -tachycardia -moist, clammy skin

A nurse is caring for an antipartum client who has iron deficiency anemia. When teaching the client about nutrition, the nurse should emphasize the need for an increased intake of which of the following fools? - verified answer Red meat and organ me A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for a culture. - verified answer Cleans the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen A nurse is completing a medication history for a client who reports using over-the-counter calcium carbonate antacid. Which of the following recommendation should the nurse make about taking this medication. - verified answer Drink a glass of water after taking the medication A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurses priority? - verified answer CD4-T-cell count 180 cells/mm A nurse is teaching a client who has urolithiasis (renal calculi).The nurse explained that which of the following conditions can increase the risk for renal calculi. - verified answer Dehydration A nurse is caring for a client who the provider suspects might have Pernicious anemia. The nurse should expect the provider to prescribe which of the following diagnostic tests? - verified answer Schilling test A nurse is caring for a client who has peripheral arterial disease, which of the following systems should the nurse expect to find in the early stage of the disease? - verified answer Intermittent claudication A nurse is caring for a client who is well hydrated and who demonstrates no evidence of anemia. Which of the following laboratory values gives the nurse an assessment of the adequacy of the clients Protien uptake and synthesis - verified answer Albumin A nurse this is caring for a client who has a stage 3 pressure ulcer. The nurse should recognize that which of the following laboratory findings will affect bone healing? - verified answer Serum albumin 3.2 g/dl A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the clients EKG should the nurse interpret as a sign of hypokalemia? - verified answer Abnormally prominent U wave

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? - verified answer Apply a moisture barrier ointment to the clients skin A nurse is teaching a client who has diabetes Mellitus and receives 25 units of NPH insulin every morning if her blood glucose level is above 200 mg/dL. Which of the following information should the nurse include - verified answer Expect the NPH Insulin to peek in 6 to 14 hr A nurse is preparing to administer 10 units of regular insulin and 20 units of MPH Insulin to a client. What is a sequence of events that nurse should follow? - verified answer -Inspect files for contaminants -roll mph vile between palms of hands -inject air into MPH Insulin vile -inject air into regular insulin vile -withdraw short acting insulin into syringe -add intermediate insulin to syringe. A nurse working for a home health agency is teaching a client who has diabetes Mellitus about diseases management. Which of the following glycosylated hemoglobin values should the nurse include in the teaching as an indicator that the client is appropriately controlling his glucose levels? - verified answer 6.3% A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understand the purpose of the test is to check the store for which of the following substances - verified answer Blood A nurse is caring for a client who is pre-operative. The nurse signs as a witness on the clients consent form. The nurses signature on the consent form indicates which of the following? - verified answer Confirms the client appears competent to provide consent A nurse is caring for a client who reports recurrent flake pain, nausea, and vomiting for 24 hours. Which of the following actions is the nurses priority - verified answer Administer pain medication A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestation should the nurse expect? - verified answer Agitation

A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as a priority? - verified answer Hematemesis A nurse is caring for a child who is having a tonic clonic seizure and vomiting. Which of the following actions is the nurses priority? - verified answer Position the child side lying A nurse is reviewing the medical record of a client who has a urinary track infection. Which of the following findings should the nurse recognized as a risk factor - verified answer Diabetes Mellitus A nurse is providing dietary teaching to a client who has frequent kidney stones. Which of the following instruction should the nurse include in the teaching - verified answer Avoid eating three nuts, such as almonds A nurse is reviewing the arterial blood gas results of a client who the person provider suspects has a metabolic acidosis. Which of the following results should the nurse expect to see - verified answer PH below 7. A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss.The client reports chills and back pain, and the clients blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first - verified answer Stop the infusion of blood A nurse is teaching a client who has a new prescription for docusate. Which of the following information should the nurse include in the teaching? - verified answer Take the medication with a full glass of water A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nurse action should the nurse take to promote the clients comfort. - verified answer Obtain a pair of slippers socks for the client A nurse is providing dietary teaching for a client who has just learned that she has type 2 diabetes Mellitus.The nurse should explain that which of the following sweeteners will add calories to the clients carbohydrate count? - verified answer Sorbitol A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm - verified answer The P wave falls before the QRS complex

A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the clients? - verified answer Chvostek,s sign Teaching a client who has tuberculosis and is to start combination drug therapy. Which of the following medication should the nurse plan to administer? Select all that apply - verified answer Rifampin, isoniazid, pyrazinamide Nurse observes mild hand tremors in a client who has diabetes Mellitus. Which of the following actions should the nurse take after obtaining a glucose meter reading of 60 mg/dL - verified answer Administer 15 g of carbohydrates A client who has a history of myocardio infraction is prescribed aspirin 325 mg.The nurse recognizes that the aspirin is given due to which of the following actions of the medication? - verified answer Antiplatelet aggregate A client is prescribe Lansoprazole 15mg PO once a day. At which of the following time should the nurse administer the medication? - verified answer 30 minutes before breakfast The nurse is implementing a plan of care for a client who has aids were three occurring pneumonia. Which of the following actions should the nurse take? - verified answer Obtain a sputum culture A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis about the use of antitubercular medications. Which of the following information should the nurse include in the teaching? - verified answer A typical course of treatment involves 6 to 9 months of consistent medication use A nurse is caring for a client who has heart failure and is receiving IV furosemide. The nurse should monitor the client for which of the following electrolyte imbalances? - verified answer Hyperuricemia A nurse is auscultating clients lung sounds and identifies crackles in the left lower lobe.which of the following intervention should the nurse take? - verified answer Repeat auscultation after asking the client to breathe deeply and cough.

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? Select all that apply - verified answer Excessive laxative ignoring the urge to defecate inadequate fluid intake A nurse is caring for a client who has HIV-1 infection and is prescribed zidovudine as part of antiretroviral therapy. The nurse should monitor the client for which of the following adverse affects of this medication - verified answer Aplastic anemia A nurse is teaching a client who has a new prescription for sucralfate to treat a gastric ulcer. Which of the following statements by the client indicates an understanding of the teaching? - verified answer I will take this medication 1 hour before meals and at bedtime A nurse is teaching a client who has a new diagnosis of arterial fibrillation. The nurse should instruct the client to monitor for which of the following complications - verified answer Pulmonary embolism A nurse is teaching a client who has a new prescription for regular insulin and NPH Insulin. Which of the following instruction should the nurse include in the teaching? - verified answer Keep the open vial of insulin at room temperature A nurse is teaching a school age child who has type 1 diabetes mellitus and his parents about illness management. Which of the following instruction should the nurse include - verified answer Test the urine for ketones A nurse is assessing a client who is in Skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? - verified answer Fever A nurse is teaching a client who has a history of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse in identify as a contributing factor to the development of the anemia? - verified answer Chronic blood loss A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should document this as which of the following types of wounds? - verified answer Laceration

While auscultating a clients heart sounds the nurse hears turbulence between the S1 and S2 heart cells. The nurse should document this findings as which of the following? - verified answer A systolic murmur A nurse is providing teaching for a client who has experience in acute episode of gastritis. Which of the following instructions to the nurse include in the teaching? - verified answer Avoid drinking alcohol A nurse working on a medical unit is caring for a client who is prescribed seizure precautions.What should the nurse include in the clients plan of care? - verified answer Obtain IV access A nurse is teaching a client who has a new prescription for Ciprofloxin to treat an uncomplicated UTI which of the following instruction should the nurse include - verified answer Monitor for tendon pain A nurse is caring for a client who is post operative and in skeletal traction. When assessing the client, the nurse should expect which of the following findings? select all that apply - verified answer - Slight pain at the insertion site, -serious drainage on the dressing, -minimal Adema around the pin A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing action should the nurse complete first? - verified answer Auscultate lung fields A nurse is caring for a client who has a severe gangrenous infection on the right lower extremity. The nurse should plan pre-operative teaching based on the possibility of which of the following amputation procedures? - verified answer Your pain will gradually become less severe A nurse is providing discharge teaching to a client who has a plaster of Paris walking cast on his left lower leg. Which of the following instructions to the nurse include? - verified answer Report any numbness or pain in your toes A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching? - verified answer Aplastic anemia results from decreased bone marrow productions of RBCs

A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm diagnosis of active pulmonary TB? - verified answer Sputum culture for acid fast bacillus A nurse is providing discharge teaching to a client who has peripheral arterial disease. Which of the following instruction should the nurse include in the teaching? - verified answer Adjust the thermostat so that the environment is warm A nurse is planning care for a client who has diverticulitis. Which of the following menu selection should the nurse include in the plan? - verified answer Grilled chicken breast with white rice A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings? - verified answer The weights rest against the foot of the bed A nurse is assessing a client who is receiving a unit of packed red blood cells. Which of the following findings is a manifestation of a cute hemolytic reaction? - verified answer Client reports a low back pain A nurse is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider? - verified answer Yellow green drainage on the surgical incision A nurse is caring for a 2-year-old child who has seizures and is receiving phenytoin in suspension form. Which of the following actions should the nurse take before administering each dose? - verified answer Shake the container vigorously A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantarflexion contractures? - verified answer Footboard A nurse in an emergency department is caring for a client who has diabetic ketoacidosis and a blood glucose level of 925 MG/DL. The nurse should anticipate which of the following prescriptions from the provider? - verified answer 0.9% sodium chloride IV bolus A nurse is planning care for a client who has Cystitis. Which of the following intervention should the nurse include in the plan? - verified answer Instruct the client to avoid drinking carbonate beverages

A nurse is caring for a client who has peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of Gastrointentional perforation - verified answer Set an abdominal pain A nurse is reviewing the laboratory results of a client who is at risk for developing diabetes Mellitus. The nurse should recognize that which of the following results indicates the client meets the criteria for a diagnosis of diabetes mellitus - verified answer Fasting blood glucose 155 MG/DL A nurse is teaching a client how to draw up regular insulin And NPH Insulin into the same syringe. Which of the following instruction should the nurse include? - verified answer Discard regular insulin that appears cloudy A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first? - verified answer Review the clients electrolyte values A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident 3 weeks ago. Which of the following goals should the nurse include in the clients rehabilitation program? - verified answer Establish the ability to communicate effectively Nurses planning care for a client who is confined to bed. which of the following actions should the nurse include in the plan? - verified answer Reposition the client every 2 hrs A nurse is in a clients room when the client begins having a tonic clonic seizure. Which of the following actions should the nurse take first? - verified answer Turn the clients head to the side A nurse is putting care for an older adult client who is at risk for developing pressure ulcers. Which of the following intervention should the nurse use to help maintain the integrity of the clients skin? - verified answer Use a transfer device to lift the client up in bed He knows is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication the client might be experiencing a hemolytic reaction? - verified answer Hypotension A nurse is caring for a client who has Crohn's disease. Which of the following food choices would follow the recommended diet for clients who have Crohn's disease? - verified answer Toast with jelly

A nurse is preparing a client for outpatient surgery. After the nurse in search the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take? - verified answer Remove the catheter and insert another into a different site A nurse in the post anesthesia care unit is caring for a client who has postoperative following a thoracotomy And lobectomy. Which of the following post operative assessments should the nurse give highest priority to? - verified answer Arterial blood gases A nurse is caring for a client who is postoperative and is at risk for developing Venus thromboembolism. The nurse should instruct the client to avoid which of the following unsafe actions - verified answer Massaging her legs This this is chain for a child who is having a seizure. Which of the following actions should the nurse take? Select all that apply - verified answer -Assess the clients airway patency -remove objects from the clients bed -place the client and east side lying position A nurse enters a clients room and finds him on the floor in the clonic phase of a tonic clonic seizure. Which of the following actions should the nurse take? - verified answer Place a pillow under the clients head A community health nurse is conducting an educational program on various environmental pollutants. The nurse should emphasize the clients who have which of the following disorders are especially vulnerable to Ozone effects? - verified answer Asthma A nurse is providing dietary teaching for a client who takes furosemide. The nurse should recommend which of the following foods as a best source of potassium? - verified answer Bananas A nurse is instructing the mother of a toddler who has iron deficiency anemia to increase iron in the child's diet in addition to the prescribed iron supplement. Which of the following foods should a nurse recommend? - verified answer Tuna fish A nurse is assessing a clients wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? - verified answer Serosanguineous

Either is caring for a client who has a large lower leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing? - verified answer Grilled salmon A nurse is caring for a client who is diabetic and reports a headache, restlessness, fatigue, and hunger. The nurse should identify that the client is likely experiencing which of the following conditions? - verified answer Hypoglycemia A nurse is caring for a client who has a gastric ulcer. Which of the following herbal supplements should the nurse recommend? - verified answer licorice A nurse is caring for a client who has ulcerative colitis and is teaching the client about the common link with Crohn's disease. Which of the following information should the nurse include? - verified answer Both are inflammatory Hey nurse is providing teaching to a client about measures to prevent urinary track infections. Which of the following client statements indicates they need for further teaching? - verified answer I will need to wipe my perineal area from back to front after urination A nurse is admitting in order of dark client who has diabetic neuropathy with a painful, burning feet. Which of the following intervention should the nurse anticipate the healthcare provider to prescribe? - verified answer Place a bed cradle on the clients bed A nurse is reviewing the arterial blood gas value of a client who has conic kidney disease. Which of the following set of values should the nurse expect - verified answer pH 7. HCO3-19 mEq/L PaCO2 30 mm Hg A nurse is caring for a client who has returned to the unit following a surgical procedure. The clients oxygen saturation is 85%. Which of the following actions should the nurse take first - verified answer Raise the head of the bed A nurse is providing discharge teaching to the parents of a child who has a new diagnosis of diabetes Mellitus. Which of the following statements by the parents indicates an understanding of the teaching? - verified answer My son might complain of feeling shaky when he has a low blood glucose level

Nurse is going for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse A need for further teaching - verified answer I only need to catheterize myself twice every day A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client became apprehensive and tachycardic, report being headache and lower back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions - verified answer Hemolytic A nurse is teaching a client who has a urinary track infection and is taking Ciprofloxacin.Which of the following instruction should the nurse give the client? - verified answer You should report any tendon discomfort you experience while taking this medication A nurse is caring for a client who has an NG tube. The nurse test the pH of the secretion to determine if the tube is correctly placed. Which of the following reading should the nurse expect? - verified answer 4. A nurse is planning care for a client who is receiving enteral feeding through an NG tube. which of the following actions should the nurse plan to take first? - verified answer Aspirate the clients stomach contents A nurse is teaching a client who has iron deficiency anemia about ferrous Sulfate. Which of the following instruction should the nurse include in the teaching - verified answer Take the ferrous sulfate between meals A nurse in a providers office is assessing a client who reports occasional atypical chest pain, palpitations , and exercise intolerance. On auscultation, the nurse notes a systolic click. The nurse should recognize this finding as a manifestation of which of the following conditions. - verified answer Mitral valve prolapse A nurse is caring for a client who has HIV. Which of the following laboratory test should the nurse monitor to assess the effectiveness of the therapy? - verified answer Quantitative RNA assay A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both buy nebulizer. Which of the following statements by the client indicates an understanding of the teaching? - verified answer I will be sure to take the albuterol before taking the cromolyn

A nurse is auscultating a clients heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds - verified answer The Fourth heart sound S A nurse in a clinic is collecting a history from a client who reports that a member of his family just received a diagnosis of pulmonary tuberculosis. The nurse should expect that the provider will prescribe which of the following diagnostic tests first? - verified answer Nucleic acid amplification test (NAAT)