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Timby's Med-Surg Finals Study
A complete Blood count indicates that a client is anemic. What disorder in the client's health history is most likely contribuƟng to the reducƟon in red blood cells? - Renal failure When the nurse reviews the client's complete blood cell count, what finding is most suggesƟve that a client is at risk for acquiring an infecƟon? - Loan number of agranulocytes A physician tells a client that her body is not making enough blood cells. AŌer the physician leaves, the client appears very upset and states, "I do not even know how my body is supposed to make blood cells." What is the simplest, yet correct, instrucƟon for the nurse to give the client at this Ɵme? - The bone marrow produces blood cells. What blood type could be transfused into anyone if there is no Ɵme to perform a type and crossmatch of the recipient's blood? - O, Rh negaƟve AŌer compleƟon of a bone marrow aspiraƟon, what is most important for the nurse to monitor? - Bleeding from the puncture site. A client arrives at the emergency department aŌer a motorcycle accident. Vital signs are T, 97.7F; P, 122; R, 28; and BP, 96/54. The client has suffered profuse blood loss. From the clinical picture, what posiƟon is best for the nurse to place the client? - Reverse Trendelenburg The nurse is assessing a client with anemia possibly resulƟng from malaria. What informaƟon would be most important to ascertain to assist a physician in making a correct diagnosis? - Foreign travel A client has been diagnosed with pernicious anemia. She says, "I'm worried because my grandmother died of the disease years ago." What nursing explanaƟon is most accurate? - "We now give vitamin B to control the disease." A college student diagnosed with infecƟous mononucleosis asks the school health nurse how old the condiƟon was acquired. The best answer by the nurse is that the virus is transmiƩed by what methods? - Contact with the saliva of an infected person
A hospitalized client with Hodgkin's disease is at risk for ineffecƟve airway clearance and impaired gas exchange related to compression of the trachea by enlarged lymph nodes. What measures should the nurse take first to help ensure that breathing and blood oxygen saturaƟon remain adequate? - Place the client in semi- to high-Fowler's posiƟon. When performing a physical assessment of the client in the early stages of Hodgkin's disease, what is the most likely finding when the nurse palpates the client's lymph nodes? - The lymph nodes are enlarged and painless A nurse is asked to assist the physician with a diagnosƟc Romberg test, what nursing intervenƟon is most appropriate to ensure client safety? - Stand close to the client in case the client should begin to sway What level of consciousness (LOC) is correct for a nurse to document when calling a client's name causes the client to awaken temporarily, followed by driŌing back to sleep? - Somnolent When a nurse uses the Glasgow coma scale to assess a client, what method should the nurse use to determine the "best verbal response" from the client? - Note the client's responses to general orientaƟon quesƟons Immediately following a lumbar puncture, a client asks to ambulate to the restroom. What nursing acƟon is most correct? - Explained that the client must temporarily lie flat and use a urinal Because older adults oŌen do not exhibit the typical signs and symptoms of meningiƟs, what assessment findings should the nurse be especially vigilant for an older clients with suspected meningiƟs? - -Low- grade fever -Nuchal rigidity -Altered mental status When the nurse select the equipment to place in the room of a client who has been diagnosed with Guillain-Barre syndrome, what item is essenƟal to managing the client's care? - Supplemental oxygen
A new nurse is receiving instrucƟon on the best method for screening a client's hearing. Which statement by the new nurse indicates that more teaching is required? - "I will say something in a normal voice with my back to the client and ask the client to repeat the statement" A nurse is tesƟng a client's hearing with a Weber test. Which statement by the client confirms the nurse's assessment that the client's hearing is normal? - "I am able to hear the same sound in both ears" I'm caring for a client who is visually impaired, what are the best techniques for communicaƟon? - -Avoid using words such as "see" or "look" -Explain where items are on the diet tray
- Provide a visual descripƟon of the room A nurse is instrucƟng a client about the eyedrops prescribed for the new diagnosis of open-angle glaucoma. Which of the following statements indicates a need for further teaching? - "It is all right if I skip a dose every now and then" A nurse notes on the client's record that there is a history of moderate sensorineural hearing loss related to presbycusis. Which of the following strategies will best enhance the nurse's ability to interact with this client? - -Face the client when communicaƟng with him or her -Reduce background noise when conversing with the client -Rephrase whatever the client does not understand What acƟons would the nurse perform while administering ear drops to remove excess cerumen? - - When inserƟng the irrigaƟng syringe to deeply -Direct the flow of the eardrops toward the roof of the canal -Warm the eardrops by holding the container in the hand for a few minutes Which is the best advice that the anƟbioƟc the nurse is administering for the treatment of acute oƟƟs media is having a therapeuƟc effect? - Ear discomfort is relieved The nurse is assured that a client with chronic verƟgo understands the safety measures needed to prevent injury by which of the following statements? - "I am must learn to move my hand slowly to prevent sudden dizziness"
A client tells the nurse of experiencing fluctuaƟng issues with verƟgo. What quesƟons are important for the nurse to ask if Ménière's disease is suspected? - -"Are you experiencing ringing in your ears?" -"Do you have problems with your hearing?" -"Have you experienced a sense of fullness in your ears?" The nurse, assessing a client's abdomen, does not hear any bowel sounds in the right lower quadrant (RLQ) for 5 minutes. Which acƟon is best for the nurse to do next? - Auscultate in another quadrant for a minimum of 3 minutes The nurse need to assess a client's abdomen. To best accomplish this, the nurse directs the client to lie in which of the following posiƟons? - Supine with knees flexed A nurse is providing pre-procedure instrucƟons to a client scheduled for a barium enema. Which of the following statements indicates that the client understands the instrucƟons? - "I can only have clear liquids the day before the test" Before administering the contrast substance (oral tablets taken the evening before the procedure) to a client scheduled for an oral cholecystography, which quesƟon is essenƟal for the nurse to ask? - "Is the client allergic to iodine?" A client has a colonoscopy. While recovering, the nurse assesses the client's abdomen. Which sign indicates a potenƟal complicaƟon of the colonoscopy? - Rebound tenderness The nurse is assisƟng a client following an episode of severe vomiƟng and dehydraƟon. The client is now toleraƟng fluids. What food choice suggesƟon by the nurse is most appropriate as the client progresses with the diet? - Tomato soup Which of the following acƟons by the nurse promotes safety for a client receiving bolus tube feedings via a nasogastric tube? - -Assess to placement according to agency policy -Check the residual volume prior to the bolus feeding -Irrigate the nasogastric tube with 30 mL water following the bolus
What is the best acƟon a nurse can take when a client says she douched just prior to coming for a gynecological examinaƟon that will include a Pap test? - Reschedule the Pap test aŌer no prior douching Discharge instrucƟons from the nurse following a D & C should include noƟfying the physician if what sign or symptom develops? - Elevated temperature What instrucƟons are essenƟal by the nurse when preparing a client for a mammogram? - -Omit applying deodorant -Perform a breast self-examinaƟon prior to the test -Avoid body powder containing talc During physical examinaƟon of the male reproducƟve system, what method is best for providing the nurse with informaƟon about the density of the client's scrotal Ɵssue? - Using transilluminaƟon Following a prostaƟc biopsy, what suggesƟon can the nurse provide to help relieve the client's discomfort? - Take a sitz bath A client believes that she experiences PMS. When the nurse interviews the client, which statement is most suggesƟve of this condiƟon? - The client's symptoms begin two weeks before menstruaƟon A client who experiences infecƟous vaginiƟs on a frequent basis consults the nurse in the local health clinic about how to reduce or eliminate these infecƟons. When the nurse gathers informaƟon from the client, what is a possible eƟologic cars? - The client says she dishes aŌer each period What nursing informaƟon is a correct explanaƟon about when fibrocysƟc lesions usually become larger and more tender? - Just before menstruaƟon What groups of clients are at higher risk for developing breast cancer? - -Women with a family history of breast cancer -Women who are obese -Women having had no pregnancies -Women who are beyond menopause
A client with a malignant breast tumor undergoes a leŌ modified radical mastectomy. What nursing order is most appropriate to add to the client's immediate postoperaƟve plan for care? - Use the right arm when assessing blood pressures What are the current opƟons for women at high risk for breast cancer? - -Long-term follow-up
- Bilateral prophylacƟc mastectomy
- ChemoprotecƟon with Tamoxifen What factor is most likely responsible for a young adult client's development of orchiƟs? - Client was never immunized for mumps What is the best reason for the nurse to advise a client who has been prescribed sildenafil (Viagra) for ED to avoid taking a nitrate such as sublingual nitroglycerin (Nitrostat)? - Client is likely to experience hypotension A client describes experiencing nocturia. To gather more informaƟon about symptoms associated with benign prostaƟc hypertrophy, what quesƟon is most important for the nurse to ask next? - "Do you have difficulty starƟng to void?" Following a vasectomy, a client quesƟons how soon he can be sure that his sexual partner will not become pregnant. What nursing response is most accurate? - AŌer 10 or more ejaculaƟons, most men are sterile A nurse collects a urine sample from a client and notes that the urine appears somewhat red. Which acƟon should the nurse take next? - Ask the client how long he or she has had reddish urine A nurse caring for a client who was in a motor vehicle accident notes that the client has a low red blood cell count but no obvious signs of bleeding. The nurse anƟcipates that which of the following tests will be done next? - Renal arteriogram A nurse, caring for a client scheduled for an IVP, explained that a laxaƟve is ordered prior to the IVP. What is the nurse's best explanaƟon for giving the client a laxaƟve? - "When the bowel is empty, the urologist can beƩer visualize the urinary structures"
A nurse is teaching a client with an ileal conduit about measures for the client to take to prevent a UTI. Which of the following statements by the client indicates an understanding of prevenƟng UTIs? - "I will use sterile technique to change the pouch" A client whose bladder cancer has been unresponsive to treatment will have his bladder surgically removed and an ileal conduit created to facilitate urinary eliminaƟon. When the client asks the nurse to clarify the surgeon's explanaƟon of the procedure, which statement is most correct? - "Urine will drain from an abdominal opening" The nurse examines a client who slipped and fell while climbing stairs and now has swelling of one ankle, pain on movement, and localized ecchymosis. What word correlates with the nurse's use of the term "ecchymosis" when documenƟng the assessment data? - Bruised What nursing assessment technique is best for determining the quality of the client's skin turgor? - Grasping a fold of skin over the sternum An older adult bedridden client frequently slides to the boƩom of the bed with the feet touching the footboard. The nurse analyzes the observaƟon, what is the most likely outcome of the client's downward movement in bed? - The client is at risk for bruising because of contact with the footboard When the nurse idenƟfies a client as being at risk for the development of a pressure sore, what nursing order is essenƟal to add to the plan of care at this Ɵme? - Change client's posiƟon every two hours During a rouƟne assessment, the nurse notes that a client's fingernails have a clubbed appearance. What is the nurse's most valid interpretaƟon regarding this finding? - The client may have chronic cardiopulmonary disease But health teaching is essenƟal when a female client is prescribed isotreƟnoin (Accutane) for treaƟng acne vulgaris? - Techniques for avoiding pregnancy What is the best nursing advice for people who have frequent outbreaks of Ɵnea pedis (athlete's foot)? - Never go barefoot when outdoors
When a client with shingles (herpes zoster) asks the nurse about what causes the disease, what is the most correct reply? - Is caused by the reacƟvaƟon of a dormant virus A biopsy of a scalp lesion of an Anglo-American client reveals the presence of a basal cell carcinoma. What characterisƟc most likely is a co-contributor to the development of this type of skin cancer? - Male paƩern baldness The nurse notes that the client's total bilirubin is 1.0 mg/dL. Which acƟon by the nurse is correct? - Record the results as normal AŌer a liver biopsy on the client with cirrhosis, which nursing intervenƟon is most appropriate to add to the plan of care? - PosiƟon the client on his or her right side Which acƟon by the nurse best reduces the risk of transmiƫng the virus for a client diagnosed with hepaƟƟs A (HAV)? - The nurse performs vigorous handwashing aŌer leaving the room A nurse inspects a breakfast tray for a client with pancreaƟƟs who has not had any food for several days, and had a nasogastric tube removed. The client is now on a bland, low-fat diet. Which food item, if found on the client's breakfast tray, should be removed? - Stewed prunes What nursing intervenƟons should the nurse consider for a client who had surgery for pancreaƟc carcinoma? - -Empty drainage collecƟon devices regularly
- Monitor blood glucose levels several Ɵmes each day A nurse stops to give first aid to a burn vicƟm running from a home that is on fire. The nurse rolls the vicƟm on the ground to smother the flames. The chest and neck of the vicƟm are burned. What is the next priority for the nurse? - Monitor the vicƟm for respiratory distress In the emergency department, it is determined that a burn vicƟm has deep parƟal- and full-thickness burns over 35% of the upper body. During the nursing assessment of the burn injury, what characterisƟcs will the nurse used to idenƟfy the iniƟal appearance of the full-thickness burn? - Pink and Blistered The blood pressure of a burn vicƟm has stabilized. What is the next best means of assessing the clients response to the iniƟal burn treatment? - Urinary output
