MED SURG A
A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experiencing increased intracranial pressure (ICP)? (Select all that apply.)
A. Flat jugular veins
B. A Glasgow Coma...
MED SURG A
A nurse is caring for a client who has a closed head injury and has an intraventricular catheter
placed. Which of the following findings indicates that the client is experiencing increased
intracranial pressure (ICP)? (Select all that apply.)
A. Flat jugular veins
B. A Glasgow Coma Scale score of 15
C. Sleepiness exhibited by the client
D. Widening pulse pressure
E. Decerebrate posturing
ANS - C, D, E
A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion.
Which of the following prescribed medications should the nurse instruct the client to
withhold for 48 hr prior to cardioversion?
A. Enoxaparin
B. Metformin
C. Diazepam
D. Digoxin
ANS - D. Digoxin
A nurse is assessing a client who has acute cholecystitis. Which of the following findings is
the nurse's priority?
A. Anorexia
B. Abdominal pain radiating to the right shoulder
C. Tachycardia
D. Rebound abdominal tenderness
ANS - C. Tachycardia
A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place
which of the following items at the client's bedside?
A. Suction machine
B. Wire cutters
C. Padded clamp
D. Communication board
ANS - A. Suction machine
A nurse is caring for a client who is having a seizure. Which of the following interventions is
the nurse's priority?
A. Loosen the clothing around the client's neck
B. Check the client's pupillary response
,C. Turn the client to the side
D. Move furniture away from the client
ANS - C. Turn the client to the side
A nurse is providing teaching to a client who has hypothyroidism and is receiving
levothyroxine. The nurse should instruct the client that which of the following supplements
can interfere with the effectiveness of the medication?
A. Ginkgo biloba
B. Glucosamine
C. Calcium
D. Vitamin C
ANS - C. Calcium
A nurse is planning to irrigate and dress a clean, granulating would for a client who has a
pressure injury. Which of the following actions should the nurse take?
A. Apply a wet-to-dry gauze dressing
B. Irrigate with hydrogen peroxide solution
C. Use a 30-mL syringe
D. Attach a 24-gauge angiocatheter to the syringe
ANS - C. Use a 30-mL syringe
A nurse is providing teaching to a female client who has a history of urinary tract infections
(UTIs). Which of the following information should the nurse include in the teaching?
A. Avoid foods that are high in ascorbic acid
B. Add oatmeal to the water when taking a tub bath
C. Urinate every 6 hr
D. Take daily cranberry supplements
ANS - D. Take daily cranberry supplements
A nurse is providing teaching to a client who has esophageal cancer and is to undergo
radiation therapy. Which of the following statements should the nurse identify as an
indication that the client understands the teaching?
A. "I will was the ink markings off the radiation area after each treatment."
B. "I will use my hands rather than a washcloth to clean the radiation area."
C. "I will be able to be out of the sun 1 month after my radiation treatments are over."
D. "I will use a heating pad on my neck if it becomes sore during the radiation therapy."
ANS - B. "I will use my hands rather than a washcloth to clean the radiation area."
, A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the
formation of a hematoma at the insertion site and a decreased pulse rate in the affected
extremity. Which of the following interventions is the nurse's priority?
A. Initiate oxygen at 2 L/min via nasal cannula
B. Apply firm pressure to the insertion site
C. Take the client's vital signs
D. Obtain a stat order for an aPTT
ANS - B. Apply firm pressure to the insertion site
A nurse is caring for a client who has emphysema and is receiving mechanical ventilation.
The client appears anxious and restless, and the high-pressure alarm is sounding Which of the
following actions should the nurse take first?
A. Obtain ABGs
B. Administer propofol to the client
C. Instruct the client to allow the machine to breathe for them
D. Disconnect the machine and manually ventilate the client
ANS - C. Instruct the client to allow the machine to breathe for them
A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the
following laboratory values should the nurse expect?
A. Decreased prothrombin time
B. Elevated bilirubin level
C. Decreased ammonia level
D. Elevated albumin level
ANS - B. Elevated bilirubin level
A nurse is teaching a client who has venous insufficiency about self-care. Which of the
following statements should the nurse identify as an indication that the client understands the
teaching?
A. "I should avoid walking as much as possible."
B. "I should sit down and read for several hours a day."
C. "I will wear clean graduated compression stockings every day."
D. "I will keep my legs level with my body when I sleep at night."
ANS - C. "I will wear clean graduated compression stockings every day."
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of
the following laboratory values should the nurse report to the provider?
A. Potassium 4 mEq/L
B. WBC count 10,000/mm^3
C. Hct 45%
D. Hgb 8 g/dL
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