Med Surg Proctored 2023 version exam 3

A nurse is assessing a group of clients for indications of role changes. The nurse should identify that which of the following clients is at risk for experiencing a role change?

A client who has multiple sclerosis and is experiencing progressive difficulty ambulating.

Explanation: The progressive nature of multiple sclerosis can lead to significant changes in the client’s ability to perform daily tasks, affecting their role at home or work.

A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider?

Sedimentation rate

Explanation: An elevated sedimentation rate (ESR) is a common indicator of inflammation and can suggest an infection such as osteomyelitis in a client with a recent fracture.

A nurse is caring for a client who is postoperative. What condition is the client most likely experiencing, and what actions should the nurse take?

Hypovolemia

Initiate fluid challenge and insert a large-gauge IV.

Monitor blood pressure and urine output.

Explanation: The client’s symptoms indicate hypovolemia, and the nurse should administer fluids and monitor vital signs to assess the response.

A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for brachytherapy. Which of the following instructions should the nurse include?

“You will need to stay still in the bed during each treatment session.”

Explanation: During brachytherapy, it is important to minimize movement to prevent dislodging the radioactive source.

A nurse is caring for a client who is receiving dialysis treatment. Which of the following interventions are indicated or not indicated?

Indicated: Place the client in Trendelenburg position, notify the provider immediately, administer a 0.9% sodium chloride IV bolus, apply oxygen at 2 L/min.

Not Indicated: Obtain blood glucose level, perform a 12-lead ECG.

Explanation: These interventions are prioritized for managing dialysis-related complications such as hypotension.

A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings?

Dysphagia

Explanation: Dysphagia (difficulty swallowing) is a critical concern in stroke patients as it can lead to aspiration and respiratory complications.

A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

Place a pillow between the client’s legs.

Explanation: A pillow helps prevent hip dislocation by maintaining proper alignment of the hip joint.

A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make?

“Ginkgo biloba can cause an increased risk for bleeding.”

Explanation: Ginkgo biloba can increase the risk of bleeding, especially in clients taking anticoagulants or undergoing surgery.

A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take?

Demonstrate ways to deep breathe and cough.

Explanation: Teaching proper breathing techniques helps prevent postoperative respiratory complications.

A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer?

Dyspnea

Explanation: Thoracentesis removes excess fluid from the pleural space, relieving pressure and improving breathing.

A nurse is assessing a client while suctioning the client’s tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia?

The client’s heart rate increases.

Explanation: Tachycardia is a sign of hypoxia and indicates that the client may not be receiving adequate oxygen.

A nurse in the emergency department is caring for a client. The client is experiencing manifestations of which condition?

Pancreatitis as evidenced by elevated amylase and lipase levels.

Explanation: Elevated levels of these enzymes are diagnostic markers for pancreatitis.

A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse’s priority?

Temperature 38.9° C (102° F)

Explanation: A high temperature post-thyroidectomy can indicate infection or a thyroid storm, a life-threatening condition.

A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first?

Initiate airborne precautions.

Explanation: These symptoms are indicative of tuberculosis, requiring immediate airborne isolation to prevent the spread of infection.

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take? (Select all that apply.)

Instruct the client to splint the abdomen with a pillow for coughing.

Report urinary output to the provider.

Plan to ambulate the client as soon as possible.

Ask the client to rate their pain on a 0 to 10 pain scale.

Explanation: These actions help promote recovery and prevent complications post-surgery.

A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement?

Ensure that the client has a patent IV.

Explanation: Having a patent IV allows for the quick administration of emergency medications in the event of a seizure.

A nurse is caring for a client experiencing manifestations of peritonitis. What diagnostic test should the nurse expect to confirm this condition?

X-ray results

Explanation: An abdominal X-ray can reveal air or fluid in the abdomen, which are indicators of peritonitis.

A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching?

“I will monitor my blood pressure while taking this medication.”

Explanation: Epoetin alfa can increase blood pressure, so clients must regularly monitor it.

A nurse is caring for a client who has portal hypertension and is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first?

Obtain vital signs.

Explanation: Vital signs will help assess the severity of the bleeding and the client’s overall condition.

A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect?

Hypoactive bowel sounds

Explanation: Hypokalemia can cause decreased gastrointestinal motility, leading to hypoactive bowel sounds.

A nurse is providing preoperative teaching for a client scheduled for a mastectomy. Which of the following statements should the nurse make?

“I will refer you to community resources that can provide support.”

Explanation: Support groups and community resources can help the client cope with the physical and emotional impacts of mastectomy.

A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect?

Constipation

Explanation: Hypothyroidism slows metabolism, which can lead to constipation.

A nurse is providing discharge teaching to a client who is postoperative following a modified radical mastectomy. Which of the following instructions should the nurse include?

Numbness can occur along the inside of the affected arm.

Explanation: Numbness may result from nerve damage during the mastectomy and can be a common postoperative effect.

A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take?

Place a pressure bag around the flush solution.

Explanation: A pressure bag is necessary to maintain pressure within the arterial line and prevent blood from backing up into the system.

A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse’s priority?

Increased respiratory secretions

Explanation: ALS affects the muscles required for breathing, and increased respiratory secretions can further impair the client’s ability to breathe effectively.

A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction?

Low back pain and apprehension

Explanation: Hemolytic reactions often present with symptoms such as low back pain and feelings of unease due to the rapid breakdown of red blood cells.

A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include?

Flex the foot every hour when awake.

Explanation: Regular foot flexion helps improve circulation and prevent blood clots after knee surgery.

A nurse is providing teaching to a female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching?

“A risk factor for my condition is obesity.”

Explanation: Obesity increases pressure on the bladder, which can worsen stress incontinence.

A nurse is assessing a client who has Graves' disease. Which of the following images should indicate to the nurse that the client has exophthalmos?

Select the picture with the eyes that appear to be bulging.

Explanation: Exophthalmos, or bulging eyes, is a common symptom of Graves' disease.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take?

Contact the provider to clarify the prescription.

Explanation: Clients receiving TPN are at risk for hyperglycemia, so blood glucose should be monitored more frequently than just before meals and at bedtime.

A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, “Last week I crashed my car because my vision suddenly became blurry.” Which of the following actions is the nurse’s priority?

Check the client’s neurologic status.

Explanation: Sudden blurry vision and a recent car accident could indicate neurological issues, such as a stroke or transient ischemic attack.

A nurse is performing a dressing change for a client recovering from a hemicolectomy. When removing the dressing, the nurse notes a large part of the bowel protruding through the abdomen. Which of the following actions should the nurse take first?

Call for help.

Explanation: This is a medical emergency (evisceration), and immediate assistance is required.

A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hours ago. Which of the following findings should the nurse expect?

Stone fragments in the urine

Explanation: After lithotripsy, clients often pass fragments of kidney stones in the urine as a normal part of the procedure.

A nurse is reviewing the laboratory results of a client who has a history of aplastic anemia. Which of the following findings indicates that the client is experiencing pancytopenia?

WBC count 2,000/mm³ (Normal range: 5,000-10,000/mm³)

Explanation: Pancytopenia involves a decrease in all blood cell types, including white blood cells.

A nurse in a provider’s office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication?

Report of a night cough

Explanation: A night cough can be a sign of heart failure, a potential side effect of beta-blockers like propranolol.

A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first?

Check for the type and number of units of blood to administer.

Explanation: Ensuring that the correct type and amount of blood is being administered is crucial to preventing transfusion reactions.

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan?

Encourage the client to take deep breaths after the procedure.

Explanation: Deep breathing helps re-expand the lung and prevent complications like atelectasis after a thoracentesis.

A nurse is caring for a client in the emergency department (ED). Select the 4 findings that require follow-up by the nurse.

Visual disturbances

Tingling of the lips

Hand grasps

Expressive aphasia

Explanation: These symptoms may indicate neurological issues, such as a stroke, which require immediate attention.

A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication?

Crackles heard on auscultation

Explanation: Crackles in the lungs could indicate fluid overload, a potential side effect of mannitol.

A nurse is caring for a client in the emergency department (ED). For each finding below, click to specify if the finding is consistent with migraine, stroke, or meningitis. Each finding can support more than one disease process.

Migraine: hand grasps, numbness, aphasia, visual changes, family history

Stroke: hand grasps, numbness, aphasia, visual changes, family history

Meningitis: hand grasps, visual changes

Explanation: These symptoms overlap among different conditions like migraines, strokes, and meningitis.

A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect?

PaCO₂ 56 mm Hg (Normal range: 35-45 mm Hg)

Explanation: Clients with COPD often have elevated CO₂ levels due to impaired gas exchange.

A nurse is caring for a client in the emergency department (ED). The nurse should identify that the client is most likely experiencing a migraine and should address the client’s pain.

Explanation: Pain is the priority for clients with migraines.

A nurse is caring for a client who had a nephrostomy tube inserted 12 hours ago. Which of the following findings indicates a potential complication?

The client reports back pain.

Explanation: Back pain after nephrostomy tube placement could indicate a blockage or infection.

A nurse is caring for a client who has a migraine. Which of the following interventions should the nurse anticipate? (Select all that apply.)

Administer sumatriptan

Dim the lights in the client’s room

Explanation: Sumatriptan is a common medication for migraines, and a dark room helps reduce light sensitivity, which is common during migraines.

Following the administration of sumatriptan, the nurse should monitor for chest pain due to the risk of myocardial ischemia.

Explanation: Sumatriptan can cause coronary vasospasm, leading to chest pain.

A nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following information should the nurse include in the teaching?

Void before and after intercourse.

Explanation: Voiding before and after intercourse helps flush bacteria from the urinary tract, reducing the risk of infections.

The nurse is caring for a client who has a migraine. The nurse is evaluating the client’s understanding of discharge instructions. Which of the following client statements indicates an understanding of the teaching?

“Foods that contain tyramine might trigger my headaches.”

“I will keep a food and headache diary.”

“I will place a cool cloth on my forehead when I experience a migraine.”

Explanation: Avoiding triggers like tyramine, keeping a diary to identify triggers, and applying a cool cloth are all effective strategies for managing migraines.

A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?

Heart rate 110/min

Explanation: Tachycardia is a common sign of fluid volume deficit as the body tries to compensate for low blood volume.

A nurse is caring for a client 1 hour 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?

Apply firm pressure to the insertion site.

Explanation: Firm pressure can stop the bleeding and reduce the size of the hematoma, which is the priority action.