med surg homework

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No Timer Mar. 13 Night Med-Surg 11 hwk - 06

1. A client is scheduled to receive morphine sulfate. Which of the following is an appropriate nursing action?

Monitor the pulse rate and withhold administration if

5. An 80-year-old man states that he experiences dribbling of clear yellow urine, hesitancy in starting urination, and a sensation of incomplete emptying of the bladder. The nurse identifies which of the following as the most likely cause of the symptoms?

The aging process

An enlarged prostate gland

A UTI

Chronic constipation

6. An 18-year-old client is experiencing a sickle cell crisis. Which of the following interventions is indicated for this client?

ROM exercises every 2 hours

Fluid restriction of

0.40 ml

10. The nurse is reaching a class on wound healing. Which of the following is an accurate statement concerning wound healing?

Accumulation of blood in a wound becomes a growth medium for infection.

A tight dressing increases the blood supply carrying nutrients to the area.

Clients taking steroids have a heightened inflammatory response.

Activity promotes wound healing.

11. The client was experiencing severe pain secondary to a migraine headache. The physician s orders read: Give morphine sulfate 12 mg IM stat for pain. On hand was morphine 15 mg/ml. How many milliliters did the nurse draw up?

0.2 ml

0.4 ml

0.6 ml

0.8 ml

12. After a thyroidectomy, a client develops spasms of the hands and feet accompanied by muscle twitching. The nurse identifies these symptoms as signs of:

Hypocalcemia

Hypercalcemia

Hypokalemia

Hyperkalemia

13. Four units of regular insulin are given subcutaneously to a client at 4 PM for an elevated glucose level. The client is at greatest risk for rebound hypo glycemia at:

4:01 PM

8 PM

Midnight

6 AM the following morning

14. A client has been given a diagnosis of esophageal stricture. It is important for the nurse to teach him to:

Eat hot, spicy foods to relax the stricture.

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Lie supine after eating.

Eat just before bedtime.

Ear small amounts frequently

15. The client was diagnosed with strep throat. The physician ordered benzathine penicillin G (Bicillin) 2,400,000 unit s implementation stat. The pharmacy sent a 10-ml vial of Bicillin containing 600,000 units/ml. How many milliliters will the nurse give?

1 ml

2 ml

3 ml

4 ml

16. When planning for care of the client with a percutaneous endoscopic gastrostomy (PEG) tube, it would be important for the nurse to include which of the following:

Nasal assessment for skin irritation from the tube

Securing the tube to the client s cheek

Assessing for tube displacement after coughing or suctioning

Assessing bowel elimination patterns

17. A child sustains a burn injury when a boiling pot of water is knocked off a stove. The skin on the child s chest appears sunburned and is dry. The nurse describes the burn injury as a:

Smoke inhalation injury

Superficial (first-degree) injury

Partial-thickness (second-degree) injury

Full-thickness (third-degree) injury

18. The physician ordered amikacin (Amikin) 40 mg every 8 hours for a 2 year-old child. On hand is a 100 mg/2-ml vial. How many milliliters will the nurse administer?

0.4 ml

0.6 ml

0.8 ml

1.0ml

19.



An adult client with angina has a radial pulse of 58 bpm. This slow rate is considered below normal and is called:

Tachycardia

Arrhythmia

Sinus rhythm

Bradycardia

20. When discharging a client with a prescription for warfarin (Coumadin) , the nurse instructs the client not to take aspirin because aspirin:

Can cause irritation to the lining of the stomach

Frequently has delayed effects and is not readily absorbed in the body

Interferes with clot formation and could precipitate bleeding

Is not very effective and causes more side effects than most medications

21. The physician has ordered a urinalysis for a client. The nurse gives which of the following instructions?

Women should cleanse the perineum from hack to front.

Hands should he washed before collecting the specimen.

The container should be pressed gently against the genitalia.

The first portion of the voiding should not be collected.

22. A client with AIDS is unable to cough because of weakness and fatigue. The client is at risk for:

Impaired gas exchange

Pain

Altered thought processes

Ineffective airway clearance

23. The nurse is assessing the client for hypovolemic shock. Which of the following symptoms would the nurse expect to find?

A slow, thready pulse

Deep, slow respirations

Cold, moist skin

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24. A neighbor, who is working in the yard burning leaves, suddenly begins screaming for help. His clothing is on fire and he is screaming uncontrollably. The nurses first action is to:

25. A client states that his eyes and skin itch 10 minutes after a penicillin derivative is administered. Hives are noted on the dents arms, trunk, and legs. The nurse can anticipate that which of the following may occur?

26. Erik Erikson defines the developmental stage of late adulthood (age60 years or older) as:

27. The nurse is to make an entry on a clients chart at 4 PM using military time. The time the nurse enters is:_____(Hint: type numbers only e.g. 200)

1400

28. A 57-year-old client recovering from a peptic ulcer and asks about foods. The nurses directions include:

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29. A 77-year-old client seeks the nurses advice on constipation. Which of the following is not good advice?

30. A male client has a diagnosis of herpes genitalis infection. The nurse should instruct him to:

31. A client has been placed on oral anticoagulants after an Ml. Which of the following instructions should the nurse give to the client?

32. A client is evaluated in the clinic 2 years after having a kidney transplant. The nurse expects this client to be most concerned about:

33. During the physical assessment of a woman with an exacerbation of systemic lupus erythematosus (SLE), the nurse is likely to note which of the following?



34. On arrival at the hospital, the primary focus for a client with a thermal injury is:

35. A client has received steroid therapy for 1 year. Which of the following is caused by long-term steroid therapy?

36. The apgar scale is an assessment tool that rates the physiological characteristics of the newborn infant. The maximum total score is ____

10

37. Which of the following statements made by a client indicates that a complication of peritoneal dialysis is occurring?

38. A client with a DVT suddenly cries out with sharp, stabbing pains in the chest and becomes dyspneic, anxious, and cyanotic. The nurse correctly identifies this as which of the following?



39. A client has a diagnosis of epiglottitis. It would be most important for the nurse to keep which of the following at the bedside?

40. A 44-year-old male client recently had a lumbosacral laminectomy to repair a herniated nucleus pulposus. The nurse would:

41. A client is placed on hemodialysis best assess the clients progress by: The nurse would

42. A 66-year-old client is seen at the clinic. She has had nausea and vomiting for 2 days and is complaining of dizziness. She thinks she has food poisoning. Evaluating her vital signs, the nurse would also include:

43. A female client has an indwelling urinary catheter. The nurse notices that the urine has a strong odor and I cloudy. The nurse s next action is to:



44. A 32-year-old client had a cholecystectomy 2 hours ago. The client weighs 250 lb and had general anesthesia. The client is complaining of pain. Priority nursing diagnosis at this time is:

45. Classic subjective complaints of a UTI are:

46. The most appropriate position for giving a client a back rub at the hour of sleep is:

47. A nurse is conducting a physical assessment on a client. Which of the following characteristics of a mole on the skin warrants further evaluation by a physician?

48. A client has been diagnosed with epilepsy. Which of the following is an appropriate action for the nurse to take when a client is having a seizure?



49. The nurse is developing a plan of care for a client who has a diagnosis of actite pancreatitis. The rationale for maintaining the client on bed rest is to:

50. A second-day postoperative client is having incisional pain. The client was medicated an hour ago. Which of the following noninvasive nursing interventions will best aid in decreasing pain at this time?

51. A client has light-colored stools and dark urine. The nurse correctly identifies these symptoms as being associated with:

52. A 74-year-old woman is admitted with symptoms of vaginal bleeding. The nurse identifies this bleeding as most likely a result of:



5. A 24-year-old woman is pregnant for the first time. The term for a first pregnancy is:

54. A client in a nursing home is at high risk to develop pressure ulcers because of immobility incontinence and low serum albumin. Which of the following would the nurse assess for as a first sign of a pressure ulcer?

55. A client is admitted with a diagnosis of peptic ulcer disease . Which of the following symptoms would alert the nurse that the ulcer has perforated?The client complains of chronic continuous pain persisting for a week.

5. Which of the following is an applicable nursing diagnosis for a client admitted with renal stones?

57. A client with a history of recurrent Ts is being evaluated in the clinic. Which of the following actions indicates that the client is adhering to instructions?



5. A 4-year-old recently married man is admitted for an ileal conduit urinary diversion.The nurse should:

59. Which of the following statements made by a client indicates a need for additional diabetic teaching?

0. n giving dietary discharge instructions to a client with a recent myocardial infarction the nurse instructs him to avoid foods that:

1. An 1-year-old client sustained a compound fracture of the left tibia while skiing and is admitted to the emergency room . The rationales for cleaning the wound from the area of least contamination to the area of greatest contamination are to:

2. An 0-year-old client who had a left cerebrovascular accident A is eperiencing continuous ooing of small amounts of liuid stool and has not had a bowel movement in 4 days. e eats only 20 of meals served to him. The ooing of stool is most likely a result of:



. A client has a bowel movement that consists of dark tarry stools. The nurse would epect that the client is eperiencing bleeding from:

4. The nurse is assessing a client who has recently been found to be hyperthyroid. The nurse would epect to find which of the following symptoms?

5. The nurse is doing discharge planning with a uadriplegic client. Which of the following instructions should be given to the client with an indwelling urinary catheter connected to gravity drainage?

. A 4-year-old child is admitted with a fever of 105. 40.5 and a potential diagnosis of infectious meningitis. The physician has ordered a lumbar puncture. The purpose of this test is:



7. After a liver biopsy the nurse should place the client in which of the following positions?

. The nurse identifies which of the following as care of the client during the rehabilitation phase of burn care?

9. A nurse is working in the and receives a frantic phone call from a mother whose 2-year-old child has swallowed a bottle of aspirin about 20 tables. The nurse instructs her to:

70. A freuent site and cause of nosocomial infection is the:

71. When positioning a postoperative client who has had a total hip replacement the nurse is careful to keep the operative leg:



72. A 53-year-old client with a recent stroke is very frustrated because he will not be able to return to his occupation as an airline pilot. He is very angry today and refuses his medication. What should the nurse understand?

73. A 19-year-old primigravida is admitted with preeclampsia. The nurse will monitor her very closely for:

74. An infant whose respirations are slow and irregular at 1 and 5 minutes after birth will receive an Apgar respiratory score of:

75. A 50-year-old man complains of chills, low back pain, and nausea 10 minutes after a blood transfusion has begun. An hour later, his temperature increases to 102F (38.8C), he is hypotensive, and he voids urine red in color. Which type of blood transfusion reaction is occurring?

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