Medsurg 2: Exam 1 Questions 2023

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. (Correct answer) The progressive nature of multiple sclerosis, particularly difficulty in ambulation, can lead to role changes as the client may require increasing assistance with daily tasks.

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 (Correct answer) An elevated sedimentation rate is an indicator of inflammation or infection, such as osteomyelitis, and should be reported.

A nurse is caring for a client who is postoperative. Complete the diagram by specifying what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Hypovolemia

Initiate fluid challenge and insert a large-gauge IV.

Monitor blood pressure and urine output. (Correct answer) The nurse should initiate a fluid challenge and insert a large-gauge IV because the client is likely experiencing hypovolemia as evidenced by restlessness, tachycardia, and hypotension. Monitoring blood pressure and urine output will help assess the effectiveness of treatment.

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 bed during each treatment session.” (Correct answer) The client must remain still during brachytherapy sessions to prevent dislodging the radioactive source.

A nurse is caring for a client who is receiving dialysis treatment. For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.

Indicated:

Place the client in Trendelenburg position.

Notify the provider immediately.

Administer a 0.9% sodium chloride 200 mL IV bolus.

Apply oxygen at 2 L/min via nasal cannula.

Not Indicated:

Obtain the client’s blood glucose level.

Perform a 12-lead ECG. (Correct answer) The indicated interventions are necessary to manage dialysis complications such as hypotension or hypoxemia. Blood glucose measurement and ECG are not directly related to the dialysis process in this scenario.

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 (Correct answer) Dysphagia increases the risk for aspiration, which requires immediate attention in a stroke patient.

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

Place a pillow between the client’s legs. (Correct answer) A pillow between the legs helps prevent hip dislocation by maintaining proper alignment.

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.” (Correct answer) Ginkgo biloba can increase the risk of bleeding, particularly 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. (Correct answer) Deep breathing and coughing are important postoperative techniques to prevent pulmonary complications after surgery.

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 (Correct answer) Thoracentesis removes excess fluid from the pleural space, relieving dyspnea caused by lung compression.

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

The client’s heart rate increases. (Correct answer) An increased heart rate is a sign of hypoxia, which can occur during suctioning due to insufficient oxygenation.

A nurse in the emergency department is caring for a client. Drag one condition and one client finding to fill in each blank in the following sentence.

The client is experiencing manifestations of PANCREATITIS as evidenced by the AMYLASE AND LIPASE. (Correct answer) Elevated amylase and lipase levels are indicative of 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) (Correct answer) A high fever following a thyroidectomy may indicate a thyroid storm, a potentially life-threatening complication.

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. (Correct answer) These are classic symptoms of tuberculosis, which requires immediate airborne precautions to prevent transmission.

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. (Correct answer) These actions support the prevention of complications such as pain, deep vein thrombosis, and impaired wound healing.

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. (Correct answer) A patent IV allows for rapid administration of medications if a seizure occurs.

A nurse is caring for a client. Drag one condition and one client finding to fill in each blank in the following sentence.

The client is experiencing manifestations of PERITONITIS due to X-RAY RESULTS. (Correct answer) X-ray results indicating free air in the abdomen are consistent with 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.” (Correct answer) Epoetin alfa can cause hypertension, so monitoring blood pressure is essential.

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

Obtain vital signs. (Correct answer) The priority is to assess for hemodynamic stability by checking vital signs, especially blood pressure and heart rate.

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. (Correct answer) Hypokalemia can cause decreased gastrointestinal motility, resulting in hypoactive bowel sounds.

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

“I will refer you to community resources that can provide support.” (Correct answer) Emotional and social support is crucial for clients undergoing significant surgical procedures like a mastectomy.

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

Constipation. (Correct answer) 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. (Correct answer) Numbness and tingling are common due to nerve damage during surgery.

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. (Correct answer) A pressure bag ensures continuous flow through the arterial line to prevent clot formation.

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. (Correct answer) ALS affects respiratory muscles, so managing secretions and ensuring effective breathing are top priorities.

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. (Correct answer) Low back pain and apprehension are classic symptoms of a hemolytic reaction.

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. (Correct answer) Flexing the foot helps promote circulation and prevent blood clots after 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.” (Correct answer) Obesity is a risk factor for stress incontinence because it increases pressure on the bladder.

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. (Correct answer) Exophthalmos is characterized by bulging eyes, 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. (Correct answer) The nurse should clarify the frequency of glucose monitoring since TPN can cause fluctuations in blood glucose.

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. (Correct answer) Sudden vision changes and a recent fall could indicate a neurological condition that requires immediate evaluation.

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

Call for help. (Correct answer) Evisceration is a surgical emergency, and the nurse must call for help immediately while preparing to cover the bowel with sterile saline-soaked gauze.

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. (Correct answer) After ESWL, clients often pass fragments of kidney stones in their urine.

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 (5000 to 10,000/mm³) (Correct answer) Pancytopenia is characterized by low levels of all blood cell types, including white blood cells (WBCs).

A nurse in a provider’s office is assessing aclient 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. (Correct answer) A persistent cough may indicate heart failure, a potential adverse effect of 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. (Correct answer) Verifying the correct blood type and number of units is the first step to ensure the safe administration of a blood transfusion.

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. (Correct answer) Deep breathing after a thoracentesis helps re-expand the lungs and prevent complications like atelectasis.

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 (Correct answer) These findings could indicate neurological impairment, possibly from a stroke or another serious condition.

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. (Correct answer) Crackles may indicate fluid overload, a potential adverse 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. (Correct answer) These findings overlap in various conditions, but the distinctions help guide the diagnosis and treatment plan.

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 (35 to 45 mm Hg) (Correct answer) Clients with advanced COPD typically have elevated PaCO₂ levels due to chronic respiratory acidosis.

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 the nurse should address the client’s PAIN. (Correct answer) Addressing pain management is critical in clients experiencing 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. (Correct answer) Back pain may indicate an obstruction or infection, which requires immediate attention.

A nurse is caring for a client in the emergency department (ED) 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. (Correct answer) Sumatriptan is commonly used to treat migraines, and dimming the lights helps alleviate symptoms.

A nurse is caring for a client in the emergency department (ED). Following the administration of sumatriptan, the nurse should monitor for CHEST PAIN due to the risk of MYOCARDIAL ISCHEMIA. (Correct answer) Sumatriptan can cause coronary vasospasm, leading to chest pain and potentially myocardial ischemia.

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. (Correct answer) Voiding before and after intercourse helps to flush out bacteria that could lead to a UTI.

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? Select all that apply.

“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.” (Correct answer) These actions are appropriate for managing and preventing 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. (Correct answer) Tachycardia is a common sign of fluid volume deficit.

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. (Correct answer) Firm pressure will help control the bleeding and prevent further complications from the hematoma.

A nurse in an emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report?

“It’s like a curtain closed over my eye.” (Correct answer) A detached retina can cause the sensation of a curtain or veil over part of the visual field.

A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following nursing interventions is the priority?

Administering epinephrine. (Correct answer) Epinephrine is the first-line treatment for anaphylaxis to reduce airway swelling and improve breathing.

A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

“Ibuprofen can cause gastrointestinal bleeding in older adult clients.” (Correct answer) NSAIDs like ibuprofen increase the risk of gastrointestinal bleeding, especially in older adults.

A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse’s priority to report to the provider?

Restlessness. (Correct answer) Restlessness could indicate disequilibrium syndrome, a potential complication of hemodialysis, and requires immediate attention.

A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain?

Alternate application of heat and cold to the affected joints. (Correct answer) Alternating heat and cold can help reduce inflammation and relieve pain in clients with rheumatoid arthritis.

A nurse is caring for a client who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of hyperkalemia?

A client who has chronic glomerulonephritis with oliguria. (Correct answer) Hyperkalemia is common in clients with kidney failure due to the inability to excrete potassium.

A nurse is planning care to decrease psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. Which of the following interventions should the nurse include in the plan?

Tell the client that it is possible to return to similar previous levels of activity. (Correct answer) Offering hope and discussing the possibility of returning to regular activities can help alleviate psychosocial stress in clients starting dialysis.

A nurse is caring for a client who is 4 hours postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider?

Extremity cool upon palpation. (Correct answer) A cool extremity may indicate impaired circulation and should be reported immediately.

A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which of the following actions should the nurse include in the client’s plan of care?

Wear a lead apron while providing care to the client. (Correct answer) A lead apron protects the nurse from radiation exposure during brachytherapy.

A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client’s condition is improving?

Glucose 272 mg/dL (74 to 106 mg/dL). (Correct answer) A decreasing glucose level indicates that treatment for diabetic ketoacidosis (DKA) is effective.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take?

Administer dextrose 10% in water until the new bag arrives. (Correct answer) Administering dextrose prevents hypoglycemia, which can occur if TPN is suddenly stopped.

A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide?

Increase fluid intake. (Correct answer) Increasing fluid intake helps flush out the barium and prevents constipation.

A nurse is teaching a class about client rights. Which of the following instructions should the nurse include?

A client should sign an informed consent before receiving a placebo during a research trial. (Correct answer) Informed consent is required for participation in research, including placebo-controlled trials.

A nurse on a medical-surgical unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires re-evaluation of the IV therapy prescription?

BUN (Correct answer) An elevated BUN may indicate dehydration or kidney dysfunction, requiring adjustment of IV fluids.

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Loosen restrictive clothing. (Correct answer) Loosening clothing helps prevent injury and ensures adequate ventilation during a seizure.

A nurse is providing education to a client who has tuberculosis (TB) and their family. Which of the following information should the nurse include in the teaching?

Family members in the household should undergo TB testing. (Correct answer) Close contacts of a client with active TB should be tested for the disease.

A nurse is planning care for a client who is postoperative following a laparotomy and has a closed-suction drain. Which of the following actions should the nurse take to manage the drain?

Compress the drain reservoir after emptying. (Correct answer) Compressing the reservoir creates the suction needed to remove fluid from the surgical site.

A nurse is providing teaching to a client who has cancer and a new prescription for an opioid analgesic for pain management. Which of the following information should the nurse include in the teaching?

“You should void every 4 hours to decrease the risk of urinary retention.” (Correct answer) Opioid use can cause urinary retention, so frequent voiding is recommended.

A nurse has received a report on a client who is being admitted to the emergency department. Select the 3 findings that require follow-up by the nurse.

Oxygen saturation.

Pain level.

Wound drainage. (Correct answer) These findings indicate potential respiratory compromise, uncontrolled pain, and infection, requiring immediate follow-up.

A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following findings indicates that the client is experiencing a complication?

The client’s surgical site dressing has required changing twice in 2 hours due to drainage. (Correct answer) Excessive drainage from the surgical site may indicate hemorrhage or infection and requires immediate attention.

The nurse is caring for a client. Complete the following sentence by using the lists of options. (Client has a penetrating wound to the anterior upper right chest.)

The client is most likely experiencing a HEMOTHORAX as evidenced by the client’s RESPIRATORY FINDINGS. (Correct answer) A penetrating chest wound can cause a hemothorax, which is indicated by respiratory distress.

A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure injury. Which of the following actions should the nurse take?

Use a 30-mL syringe. (Correct answer) A 30-mL syringe provides the appropriate pressure for irrigating a clean wound.

The nurse is caring for a client. Drag words from the choices below to fill in each blank in the following sentence. (Client has a penetrating wound to the anterior upper right chest.)

The nurse should first address the client’s OXYGENATION followed by the client’s BLOOD PRESSURE. (Correct answer) Oxygenation is the priority in clients with chest injuries, followed by stabilizing blood pressure.

A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking?

Slow the infusion rate. (Correct answer) These signs suggest fluid overload, and slowing the transfusion can help prevent worsening symptoms.

The nurse is caring for a client. For each potential provider’s prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. (Client has a penetrating wound to the anterior upper right chest.)

Anticipated:

Prepare the client for chest tube insertion.

Transfuse packed RBCs.

Initiate NPO status.

Contraindicated:

Place the client in Trendelenburg position.

Cover the client with a cooling blanket. (Correct answer) Chest tube insertion and transfusion are anticipated for hemothorax, while Trendelenburg and cooling blanket are inappropriate for this condition.

The nurse is caring for a client following the placement of a chest tube for a hemothorax. Which of the following actions should the nurse take? Select all that apply.

Place the client in high-Fowler’s position.

Place two rubber-tipped hemostats in the client’s room.

Palpate the chest tube insertion site for subcutaneous emphysema.

Ensure that all chest tube connections are securely attached. (Correct answer) These actions help ensure proper functioning of the chest tube and prevent complications such as subcutaneous emphysema.

A nurse in an emergency department is caring for a client who has full-thickness burns over 20% of their total body surface area. After ensuring a patent airway and administering oxygen, which of the following items should the nurse prepare to administer first?

IV fluids. (Correct answer) IV fluids are the priority for burn clients to prevent hypovolemic shock.

The nurse is caring for a client 1 hour following chest tube insertion. Click to highlight the findings in the nurses' note that indicate the client’s condition is improving.

Client reports pain as 3 on a scale of 0 to 10.

Client reports shortness of breath has decreased.

Wound dressing is dry and intact.

Oxygen saturation 95% on 2 L/min via nasal cannula. (Correct answer) These findings suggest improvement in the client’s respiratory function and pain management.

A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse’s priority?

Turn the client to the side. (Correct answer) Turning the client to the side prevents aspiration and allows drainage of secretions during a seizure.

A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To reduce the risk of falls when ambulating, the nurse should provide which of the following instructions to the client?

“Scan the environment by turning your head from side to side.” (Correct answer) Scanning the environment compensates for the loss of visual fields in clients with homonymous hemianopsia.

A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend?

Add cabbage to the diet. (Correct answer) Adding cruciferous vegetables like cabbage can help reduce the risk of colorectal cancer.

A nurse is providing discharge instructions to a client who has laryngeal cancer and is receiving radiation therapy. Which of the following statements by the client indicates an understanding of the teaching?

“I will avoid direct exposure to the sun.” (Correct answer) Clients receiving radiation therapy should avoid direct sun exposure to prevent skin damage.

A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching?

“I should take this medication with a meal.” (Correct answer) Metformin should be taken with food to minimize gastrointestinal side effects.

A nurse is admitting a client who has active tuberculosis. Which of the following types of transmission precautions should the nurse initiate?

Airborne. (Correct answer) TB is transmitted through airborne droplets, requiring the use of airborne precautions.

A nurse is caring for a client who has a leg cast and is returning to demonstrate the proper use of crutches while climbing stairs. Identify the sequence the client should follow when demonstrating crutch use.

Places body weight on the crutches.

Advances the unaffected leg onto the stair.

Shifts weight from the crutches to the unaffected leg.

Brings the crutches and the affected leg up to the stair. (Correct answer) This sequence provides proper balance and stability while using crutches.

A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients?

A client who is postoperative following abdominal surgery and reports feeling that something “popped” when they coughed. (Correct answer) The sensation of something “popping” after surgery may indicate wound dehiscence, requiring immediate intervention.

A nurse is caring for a client who has terminal cancer. The client tells the nurse, “I wish I could stop these treatments. I am ready to die.” Which of the following statements should the nurse make?

“Discontinuing the treatments is your choice if it is your wish to do so.” (Correct answer) Respecting the client’s autonomy is essential in end-of-life care.

A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan?

Monitor the client’s temperature every 4 hours. (Correct answer) Frequent temperature monitoring is necessary to detect early signs of infection in neutropenic clients.

A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions?

Suppressing gastric acid production. (Correct answer) Omeprazole is a proton pump inhibitor that reduces stomach acid production.

A nurse is preparing to present a program about prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include? Select all that apply.

Follow a smoking cessation program.

Maintain an appropriate weight.

Eat a low-fat diet. (Correct answer) These lifestyle changes help reduce the risk of atherosclerosis.

A nurse is caring for a client who is brought to the emergency department following an oil fire. Drag words from the choices below to fill in each blank in the following sentence.

The nurse should first address the client’s AIRWAY followed by the client’s BURN INJURIES. (Correct answer) Airway management is the priority in clients with burn injuries, followed by treating the burns themselves.