NURSING 221 - Kaplan Med Surg 2 Latest Updated Rated 100%

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1. The nurse instructs a client who had a subtotal gastrectomy. Which statement should be included in the instructions? -Eat a low carbohydrate diet every day 2. The nurse is caring for a client... who had a tracheostomy performed the previous day. Which finding most concerns the nurse? -The client’s secretions are thick, yellow and dry 3. The nurse cares for a client with a diagnosis of acute adrenal insufficiency (adrenal crises). What will the nurse expect to observe? -Muscle cramps, fatigue and hypotension 4. A client reports that the migraine headaches have become more severe. Which clinical manifestations will the nurse expect the client to report? -Pain in one eye and one side of the face 5. The nurse instructs a client diagnosed with systemic lupus erythematosis (SLE). Which statement by the client indicates understanding of the instructions? -“Stress and fatigue may make my symptoms worse.” 6. The nurse cares for a client 24 hours after a cast application to the right leg from the groin to the foot. Which findings require an immediate intervention by the nurse? -The client reports the right toes are tingling 7. The nurse cares for a client recently diagnosed with a tumor in the frontal lobe of the brain. Which statement would the nurse expect the client to make? -“I feel like my concentration is not very good.” 8. The nurse cares for a client diagnosed with asthma. The client is taking 20mg of oral prednisone daily. Which statements should be included in the teaching? (select all that apply) -You may experience some stomach upset when taking prednisone -The medication will need to be slowly decreased before it is disconnected -You are at greater risk for infection while you are taking this medication 9. The nurse cares for a client in the emergency room diagnosed with a traumatic amputation of the leg and hypovolemic shock. What is the most appropriate action the nurse should take? -Administer Lactated Ringer’s solution intravenously 10. The nurse instructs a client who reports frequent history of urinary tract infections. Which statement should be included in the instructions? -You should drink at least 2000ml of fluid everyday 11. The nurse instructs a client diagnosed with gastro esophageal reflux disease (GERD). Which statement should be included in the instructions? -Sleep with head and should elevated on pillows 12. A nurse reviews laboratory reports for a client diagnosed with acute glomerulonephritis. What will the nurse expect to observe? -Increased urine protein 13. The nurse gives discharge instructions to a client who had a total knee replacement about prevention of thromboembolism. Which statement by the client indicates understanding of the instructions? -My toes should protrude through the toe hole of the anti-embolism stockings 14. The nurse cares for a client diagnosed with full-thickness burns of both legs. What will the nurse expect to observe? 3rd degree burn (observe what you see) 15. The nurse cares for a 78 year old client with the diagnosis of colostrum deficile infection. What action is most appropriate for the nurse to take while caring for this client? -Wear a gown and gloves while assisting the client with bathing 16. The nurse cares for a client diagnosed with benign prostatic hypertrophy (BPH). Which clinical manifestation would the nurse expect the client to have? -Difficulty initiating voiding 17. The nurse cares for a client diagnosed with severe Parkinson’s disease. What will the nurse expect to observe? -Increased salivation 18. The nurse notes a client’s cardiac rhythm suddenly shows ventricular tachycardia. It is most important for the nurse to administer which medication? -Lidocane 19. The nurse evaluates a client’s compliance with the diabetic diet, insulin and activity regimens over a 2 month period. What is the best way for the nurse to collect this date? -Obtain a glycosylated hemoglobin level (HbA1c) 20. The nurse instructs an adult newly diagnosed with cystic fibrosis. The nurse should include which statements? (select all that apply) -The cystic fibrosis may cause you to have fertility problems -An aerobic exercise program is an important part of your treatment 21. The nurse performs cardiopulmonary resuscitation (CPR) on a 62 year old man. What is the correct compression depth for this client? -2 inches or more 22. The nurse cares for a client diagnosed with metastic breast cancer. What is the most reliable indicator of pain during the care of this client? -Client’s rating of pain intensity 23. The nurse cares for a client diagnosed with a closed head injury after a car accident. The family reports that the client hit his head on the dash board. Which observation if made by the nurse 48 hours after the accident requires an immediate intervention? -Clear fluid is dripping from the ear 24. The nurse cares for a client who had a tonic-clonic lasting 90 seconds followed by a period of decreased consciousness lasting 2 minutes followed by another seizure. What is the priority action the nurse should take? -Administer Diazepam (Valium) as ordered 25. The nurse cares for a client 12 hours after the client had a fractured femur and pelvis. The client reports shortness and breath and is anxious. What is the first action the nurse should take? -Instruct the client to cough and deep breathe 26. The nurse cares for a client diagnosed acute renal failure and a serum of potassium of 6.2meq/dl. What is a priority assessment the nurse should make? -Heart, rate and rhythm 27. A nurse instructs the client about oral iron replacement. Which statement by the client indicates understanding of the instructions? -I should take my medication before meals 28. The nurse instructs a client about prevention of lyme disease. Which statement by the client indicates a need for further teaching? -A symptom of lyme disease is a fine, raised rash on the palm of the hands 29. The nurse cares for an 80 year old diagnosed with dehydration. What will the nurse expect to observe? -Urine output of 20mL per hour 30. The nurse cares for a client diagnosed with left sided stroke. What will the nurse expect to observe? -Impaired speech 31. The nurse cares for a client who developed atrial fibrillation with atroventricular rate of 150 beats per minute. What is the question a nurse should ask? -“Are you experiencing any dizziness at this time?” 32. The nurse instructs a client diagnosed with Hepatitis A. The spouse asks the nurse how to avoid getting hepatitis from the client. What is the best response by the nurse? -Use good hand washing technique 33. The nurse instructs a client with cataracts. Which should be included in the nursing instructions -Some itching and redness of the eyes is expected after surgery 34. The nurse instructs a client diagnosed with chronic renal failure. Which foods are appropriate for this client? -Rice cereal and strawberries 35. The nurse cares for a client diagnosed with ulcerative colitis. What will the nurse expect the client to report? -Mild lower abdominal pain with the episodes of diarrhea 36. The nurse plans a care for a client who is recovering from a gunshot wound. Which food combination is best for the client? -Turkey meat, mashed potatoes and ice cream 37. The nurse cares for a client who is to have peritoneal dialysis. Which action should the nurse take first? -Weigh the client 38. The nurse cares for a client with a chest tube drainage system. What observation requires an intervention by the nurse? -Continuous bubbling in the water seal chamber 39. The nurse cares for a client diagnosed with a stroke 48 hours ago. What is the most appropriate position for this client? -Supine with the head of the bed elevated 15-30 degrees 40. Total hip arthroplasty is scheduled for a client diagnosed with degenerative joint disease of the left femoral head. How should the nurse position the client’s left leg following the surgery? -Abducted with the toes pointing upward 41. The nurse cares for a client 72 hours after repaired of intestinal obstruction. Which assessment most concerns the nurse? -Abdominal distention and pressure 42. The nurse instructs a client who is to have trans-esophageal echocardiogram (TEE). Which statement by the client indicates understanding of instructions? -I will not be able to eat or drink for several hours after the test is completed 43. The nurse cares for an 80 year old diagnosed with Alzheimer’s disease after surgical repair of a fractured hip. What is the MOST appropriate action for the nurse to take? -Give the client a teddy bear from home and check on the client every few minutes 44. The nurse cares for a client with a fractured left hip. What is the best explanation of the purpose of Buck’s traction used for treatment of this fracture? -Decrease muscle spasm 45. The nurse teaches a client about surgical repair of a detached retina. What instructions should be included in the teaching? -Avoid reading and writing for one week 46. The nurse instructs a client diagnosed with obstructive pulmonary disease (COPD) andupper respiratory tract infection (URI). Which statement indicates a need for further teaching? -“I will limit myself to 3 cigarettes a day.” 47. The nurse cares for a client immediately after a cardiac catherization using the left femoral artery. Which finding requires an immediate intervention by the nurse? -The left extremity is cooler to touch than the right extremity 48. The nurse cares for a 32 year old client diagnosed with bacterial meningitis. Which observation requires an immediate action by the nurse? -Oral temperature 101.2 F 49. The nurse cares for a client immediately after a colonoscopy. What is the priority action the nurse should take at this time? -Ask the client to describe the location and intensity of the pain 50. The nurse cares for a 75 year old client who has limited mobility. Which of the following most concerns the nurse? -An area over the coccyx blanches with pressure 51. The nurse cares for a client who is to have surgery for an ileal conduit. Which statement by the client indicates understanding of the procedure? -My urine will pass through a small portion of the small intestine before it drains out through a hole in my abdomen 52. The nurse prepares a client for bone marrow separation and biopsy procedure. The nurse should place the client in which position? -Prone with the head of the bed flat 53. The nurse teaches a client diagnosed with sickle cell anemia. Which statement made by the client indicates a need for further teaching? -“I should restrict my intake of oral fluid.” 54. The nurse cares for a client with a diagnosis of Bell’s Palsy. During the visit, the client burst’s into tears and states “I am so ugly now, I just want to hide.” What is the best response for the nurse? -“You seem upset today, tell me how you feel.” 55. The nurse instructs a client who wants to begin hemodialysis. The client has arteriovenousfistula in the right arm. Which statement should be included in the teaching? (select all that apply) -You should not use your right arm to carry any heavy objects -Your blood pressure should be checked on the left arm 56. A client recently diagnosed with Type 1 Diabetes Mellitus reports awakening with headaches, frequent nightmares and increase perspiration during the night. What is the best action for the nurse to take? -Instruct the client to check blood glucose between 2 and 4 am 57. The nurse cares for a client diagnosed with thrombophlebitis receiving heparin infusion. Which laboratory test should the nurse monitor? -Erythrocyte sedimentation rate (ESR) [Show More]

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