Capstone Med Surg Assessment NR601

**A nurse is teaching a client about using a continuous positive airway pressure (CPAP) device to treat obstructive sleep apnea. Which of the following information should the nurse include in the teaching?**It delivers a preset amount of airway pressure throughout the breathing cycle
**A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching? **Shortness of breath might be an indication of transplant rejection
**A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and is receiving 3% sodium chloride via continuous IV. Which of the following laboratory findings should the nurse identify as an indication that the SIADH is resolving?**Urine specific gravity 1.020
**A nurse is teaching a client about fecal occult blood testing (FOBT) for the screening of colorectal cancer. Which of the following statements should the nurse include in the teaching?**You should avoid taking corticosteroids prior to testing
**A nurse is preparing a client for a colonoscopy. Which of the following medications should the nurse anticipate the provider to prescribe as an anesthetic for the procedure?**Propofol
A nurse is planning care for a client who has acute pancreatitis. Which of the following interventions should the nurse include in the client’s plan? (Select all that apply.) Monitor blood glucose levels; Maintain NPO status until pain-free; Manage acute pain
**A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as the client to include in their diet?**3 oz of chicken breast
**A nurse is reviewing the medical record of a client who has unstable angina. Which of the findings should the nurse report to the provider?**Breath sounds
**A nurse is providing discharge instructions to a client who has GERD. Which of the following statements by the client demonstrates an understanding of the teaching?**I will limit activities that require bending at the waist
**A nurse at a provider’s office is interviewing a client who has multiple sclerosis and has been taking dantrolene for several months. Which of the following client statements should the nurse identify as an indication that the medication is effective?**I don’t have muscle spasms as frequently
**A nurse is assessing a client who reports a possible exposure to HIV. Which of the following findings should the nurse identify as an early manifestation of HIV infection?**Fatigue
**A nurse is teaching a client who has type 1 diabetes mellitus about hypoglycemia. Which of the following statements by the client indicates an understanding of the teaching?**I can drink 4 ounces of soda if my blood sugar is low
**A nurse is providing discharge teaching to a client who has heart failure and a prescription for furosemide 20 mg PO two times daily. Which of the following instructions should the nurse include in the teaching?**Increase intake of high-potassium foods
**A nurse is caring for a client who has burn injuries covering their upper body and is concerned about their altered appearance. Which of the following statements should the nurse make?**It could be helpful for you to attend a support group for people who have burn injuries
**A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?**Monitor the client’s skin under the halo vest
**A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention?**Respiratory rate 30/min
**A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig’s sign?**After hip flexion, the client is unable to extend their leg completely without pain
**A nurse is teaching a group of assistive personnel (AP) about caring for clients who have Alzheimer’s disease. Which of the following information should the nurse include in the teaching?**Provide supervision to prevent a client from becoming injured or lost
**A home health nurse is providing teaching to the family of a client who has a seizure disorder. Which of the following interventions should the nurse include in the teaching?**Position the client on their side during a seizure
**A nurse is contributing to the plan of care for a client who has pyelonephritis. Which of the following interventions should the nurse include?**Begin antibiotic therapy after culture and sensitivity results are obtained
**A nurse is assessing a client who has a herniated lumbar disc. Which of the following findings should the nurse expect?**The client reports tingling and a burning sensation in one foot
**A nurse is caring for a client who has acute gastritis and is NPO. The client has a new prescription to resume oral intake. Which of the following items should the nurse offer the client?**Gelatin
**A triage nurse finds a school-age child lying in the road following a school bus crash with multiple casualties. The child has a respiratory rate of 8/min, is unresponsive to verbal commands, and groans to painful stimuli. The nurse should assign the client which of the following triage tags?**Red
**A nurse is teaching a client who has a new diagnosis of polycystic kidney disease. Which of the following statements should the nurse include in the teaching?**Apply dry heat to your abdomen when needed
**A nurse is assessing a client who has right lower lobe pneumonia. Which of the following findings should the nurse expect?**Dull percussion sounds
A nurse is providing teaching to the caregivers of a client who has Alzheimer’s disease. Which of the following instructions should the nurse give? (Select all that apply.)

Install safety locks and alarm systems
Place nightlights throughout the home
Establish a predictable daily routine for the client

**A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50, PaCO2 29 mm Hg, and HCO3 25 mEq/L. The nurse should recognize that the client has which of the following acid-base imbalances?**Respiratory alkalosis
**A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include?**Consume high-calorie foods
**A nurse is caring for a client who has a right-sided pneumothorax. Following chest tube insertion, which of the following findings indicates that the chest drainage system is functioning correctly?**Gentle bubbling in the suction chamber
**A nurse is caring for a client who has a new diagnosis of tuberculosis. Which of the following precautions should the nurse initiate to prevent transmission of the disease?**Airborne precautions
**A nurse is planning care for a client who has Ménière’s disease and is experiencing episodes of vertigo. Which of the following interventions should the nurse include in the plan?**Provide a low-sodium diet
**A nurse reviewing laboratory reports for a client who is taking NSAIDs for rheumatoid arthritis. Which of the following results should the nurse recognize as a possible adverse effect of NSAID therapy?**Positive fecal occult blood test
**A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates the client might be experiencing a hemolytic transfusion reaction?**Report of chest pain
**A nurse is caring for a client who had surgery 2 days ago and reports incisional pain. Which of the following actions should the nurse take first?**Ask the client to describe the pain and rate it on a scale of 0 to 10
A nurse is teaching strategies to prevent carpal tunnel syndrome to a group of office workers. Which of the following instructions should the nurse include? (Select all that apply.)

Take breaks from repetitive activity
Use a wrist rest when working at a computer station
Stretch your fingers and wrists periodically while working

**A nurse is assessing a client who has a tension pneumothorax following blunt chest trauma. Which of the following findings should the nurse expect?**Tracheal deviation to the unaffected side
**A nurse is caring for an adult client who asks about vaccinations against communicable diseases. The nurse should inform the client that which of the following vaccines are available? **(Select all that apply.)

Hepatitis A vaccine
Hepatitis B vaccine
Pneumococcal vaccine

**A nurse is teaching a client who has angina pectoris about nitroglycerin sublingual tablets. Which of the following statements should indicate to the nurse that the client understands the teaching?**I will keep the tablets in the original container
**A nurse is preparing to administer epoetin to a client who has anemia due to chemotherapy. Which of the following actions should the nurse plan to take?**Review the client’s Hgb level prior to administration
**A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse report to the provider immediately?**Decreasing voice volume
**A nurse is assessing a client who has Addison’s disease. Which of the following manifestations should indicate to the nurse that the client is experiencing an Addisonian crisis?**Hypotension
**A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is the nurse’s priority?**Provide assistance with ambulation
**A nurse is providing teaching to a newly licensed nurse about caring for a client who is receiving a sealed radioactive implant. Which of the following information should the nurse include in the teaching?**Wear a lead apron during care
**A nurse is assessing a client who is postoperative following a kidney transplant. Which of the following findings indicates the client is experiencing transplant rejection?**Hypertension
**A nurse is providing teaching to a client who is scheduled for a bone marrow biopsy taken from the iliac crest. Which of the following information should the nurse include?**Take acetaminophen as prescribed for pain relief after the procedure
**A nurse is providing discharge instructions to a client who has a peptic ulcer. Which of the following dietary modifications should the nurse include?**Restrict intake of fried foods
**A nurse is assessing a client following a hypophysectomy. Which of the following findings indicates the client might be developing diabetes insipidus?**Low urine specific gravity
**A nurse is assessing a client who has a history of migraine headaches with aura and reports feeling “a migraine coming on.” The nurse should expect the client to report which of the following manifestations?**Visual disturbances
**A nurse is reviewing laboratory values for a client who has Cushing’s disease. Which of the following values should the nurse expect?**Sodium 150 mEq/L
**A nurse is assessing a client who has had a left-hemisphere stroke. Which of the following findings should the nurse expect?**Expressive aphasia
A nurse is assessing a client who has a mild traumatic brain injury. The nurse should report which of the following findings as a complication of this injury? (Select all that apply.)

Unequal pupils
Drainage from the ear

**A nurse is providing discharge teaching to a client who has multiple sclerosis. Which of the following instructions should the nurse include in the teaching?**It is important to develop a daily schedule that reduces fatigue and conserves energy
**A nurse is caring for a client who is postoperative immediately following a pheochromocytoma removal. Which of the following actions is the nurse’s priority?**Monitor blood pressure
**A nurse is teaching a client who has glaucoma and is to start taking timolol. Which of the following information should the nurse include?**Watch for a decreased heart rate while using this medication
**A nurse is providing teaching to a client who has a new onset of genital herpes. Which of the following statements should the nurse include in the teaching?**Stress can activate an outbreak
**A nurse is instructing a client’s caregiver on how to position the client before administering tube feedings in the home. Which of the following statements by the caregiver demonstrates an understanding of the teaching?**I will sit him up in bed
**A nurse is teaching a client who has asthma about using a peak flow meter. When a yellow zone meter reading appears, the nurse should instruct the client to take which of the following actions?**Take prescribed relief medication
**A nurse is caring for a client who is postoperative and reports frequent leakage of small amounts of urine. The nurse notes that the client’s bladder is palpable upon examination. The nurse should identify these findings as which of the following forms of incontinence?**Overflow
**A nurse is assessing a client who has tuberculosis and is taking rifampin. Which of the following findings should the nurse report as an adverse effect of the medication?**Yellowing of the sclera
**A nurse is caring for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse include in the plan of care to prevent autonomic dysreflexia?**Monitor bowel movement regularity
**A nurse is caring for a client who is using a ventilator when the low-pressure ventilator alarm sounds. Which of the following actions should the nurse take?**Check the ventilator tubing connections
**A nurse is caring for a client who has renal calculi. Which of the following prescriptions by the provider is the priority action for the nurse to take?**Strain all urine
**A nurse is providing discharge teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements by the client indicates an understanding of the teaching?**I’ll use my reaching device to help me pick up objects I drop on the floor
**A nurse is providing teaching for a client who has Parkinson’s disease and a new prescription for selegiline. Which of the following statements should the nurse include?**Avoid eating aged cheeses or smoked meats while taking this medication
**A nurse is caring for a client who has renal failure. Which of the following arterial blood gas (ABG) results should the nurse expect?**pH 7.25, HCO3 20 mEq/L, PaCO2 35 mm Hg
**A nurse is reviewing a client’s medical record prior to administering furosemide via IV bolus to a client who has heart failure. For which of the following findings should the nurse withhold the medication and notify the provider?**Hypokalemia
**A nurse is initiating a plan of care for a client who has COPD. Which of the following interventions should the nurse include?**Educate the client on pursed-lip breathing
**A nurse is receiving report on a group of clients. Which of the following clients should the nurse assess first?**A client who received parenteral cephalosporin and reports urticaria and edema
**A nurse is discussing risk factors for hepatitis A with a newly licensed nurse. Which of the following clients should the nurse identify as being at an increased risk for hepatitis A?**A client who has recently done volunteer work in a developing country
**A nurse is providing education regarding the prevention of urinary tract infections (UTIs) to a client who has a history of cystitis. Which of the following statements by the client indicates that the teaching has been effective?**I will empty my bladder every 2 to 3 hours throughout the day
**A nurse is providing instructions to a newly licensed nurse about NG intubation for a client who is postoperative following a colectomy. Which of the following statements should the nurse include?**The tube decreases pressure within the stomach
A nurse is caring for a client who has a history of tonic-clonic seizures. Which of the following precautions should the nurse take? (Select all that apply.)

Keep a suction apparatus at the bedside
Keep the bed in the lowest position
Keep oxygen equipment at the bedside

**A nurse is creating a plan of care for a client who has meningitis. Which of the following interventions should the nurse include?**Keep the client’s environment dark and quiet
**A nurse is caring for a client who is postoperative following a below-the-knee amputation. Which of the following actions should the nurse take?**Place the client prone for 20 min every 3 hr
**A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig’s sign?**After hip flexion, the client is unable to extend their leg completely without pain
**A nurse is caring for a client who has rheumatoid arthritis and has been taking prednisone. Which of the following findings should the nurse identify as an adverse effect of this medication?**Hypertension
**A nurse is caring for a client who has increased intracranial pressure (ICP). Which of the following interventions should the nurse implement?**Keep the client’s neck in a midline position
**A nurse in a rural community center is providing education to a group of clients about first aid interventions for snake bites to prevent further injury. Which of the following instructions should the nurse include in the teaching?**Immobilize the affected extremity with a splint
**A nurse is providing discharge teaching to a client who is starting to take carbidopa/levodopa to treat Parkinson’s disease. Which of the following instructions should the nurse include in the teaching?**This medication can cause your urine to turn a dark color
**A nurse is providing dietary teaching for a client who has chronic cholecystitis. Which of the following diets should the nurse recommend?**Low-fat diet
**A nurse is providing teaching to a client who is scheduled for an electroencephalogram (EEG). Which of the following statements by the client indicates an understanding of the teaching?**I will be exposed to flashes of light during the procedure
**A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching?**Shortness of breath might be an indication of transplant rejection
**A nurse is caring for a client who has been experiencing repeated tonic-clonic seizures over the course of 30 min. After maintaining the client’s airway and turning the client on their side, which of the following medications should the nurse administer?**Diazepam IV
**A nurse is providing discharge instructions to a client who has GERD. Which of the following statements by the client demonstrates an understanding of the teaching?**I will limit activities that require bending at the waist
**A nurse is caring for a client who is at high risk for iron deficiency anemia. Which of the following foods should the nurse instruct the client to increase in their diet?**Raisins
**A nurse is caring for a client who has a right-sided pneumothorax. Following chest tube insertion, which of the following findings indicates that the chest drainage system is functioning correctly?**Gentle bubbling in the suction chamber
**A nurse is planning care for a client who has acute post-streptococcal glomerulonephritis. Which of the following interventions should the nurse include in the client’s plan?**Administer diuretics to the client
**A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?**Monitor the client’s skin under the halo vest
**Nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse identify as a possible complication of TPN administration?**Pitting edema of bilateral lower extremities
**A nurse is assessing a client who has a heart rate of 40/min. The client is diaphoretic and has chest pain. Which of the following medications should the nurse plan to administer?**Atropine
**A nurse is preparing to discharge a client who has a new diagnosis of chronic kidney disease (CKD). Which of the following referrals should the nurse plan to initiate?**Dietary services
**A nurse is caring for a client who has burn injuries covering their upper body and is concerned about their altered appearance. Which of the following statements should the nurse make?**It could be helpful for you to attend a support group for people who have burn injuries
**A nurse is caring for a client who has dehydration. The client has a peripheral IV and has a prescription for an infusion of 0.9% sodium chloride 1,000 mL with 40 mEq potassium chloride to infuse over 1 hr. Which of the following actions should the nurse take first?**Evaluate the patency of the IV
**A nurse is admitting a client who has suspected appendicitis. Which of the following findings should the nurse report to the provider immediately?**Distended, board-like abdomen
**A nurse in an emergency department is caring for a client who has sustained multiple injuries. The nurse observes the client’s thorax moving inward during inspiration and outward during expiration. The nurse should suspect which of the following injuries?**Flail chest
**A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the following findings should the nurse expect?**Decreased deep-tendon reflexes
**A nurse is providing teaching to a client who is scheduled for electromyography (EMG). The nurse should include which of the following information in the teaching?**You should expect insertion of small needle electrodes into the muscles
**A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include?**Consume high-calorie foods
A nurse is providing discharge teaching to a client who has acute leukemia and received chemotherapy 12 hr ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Use an electric shaver
Avoid crowds
Consume a low-residue diet
Monitor for bruising

**A nurse is planning care for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority?**Administer oxygen to a client who has an oxygen saturation of 91%
**A nurse is caring for a client who is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?**Lie on your right side
**A nurse is assessing a client who has a permanent spinal cord injury and is scheduled for discharge. Which of the following client statements indicates that the client is coping effectively?**I would like to play wheelchair basketball. When I get stronger, I think I’ll look for a league
**A nurse is caring for a client who has chronic kidney disease. Which of the following diets should the nurse anticipate the provider to prescribe?**Potassium-restricted diet

Capstone Med Surg Assessment NR601

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