Custom:PN VATI Medical Surgical Re-evaluation Assessment

A nurse is caring for a client who just had a endoscopic procedure. Which of the following is the monitoring priority for this client? A) Pain B) Nausea C) Gag reflex D) Level of consciousness - ANSWER C) Gag refle ...

A nurse is caring for a client who just had a endoscopic procedure. Which of the following is the monitoring priority for this client? A) Pain B) Nausea C) Gag reflex D) Level of consciousness - ANSWER C) Gag reflex A nurse is reinforcing discharge teaching for a client who has chronic pancreatitis. Which of the following statements by the nurse is appropriate? A)"You should decrease your caloric intake when abdominal pain is present." B) "You should increase your daily protein intake." C) "You should increase fat intake when experiencing loose stools." D) "You should limit alcohol intake to 2-2 drinks per week." - ANSWER B) "You should increase your daily protein intake." A nurse collects data on a client who returned to the unit four hr ago following a partial colectomy. Which of the following conditions should the nurse attend to first? A) Change the moderately saturated dressing. B) Administer analgesic medication for incisional pain. C) Catheterize for a distended bladder. D) Cough and deep breathe client. - ANSWER B) Administer analgesic medication for incisional pain. Rationale: Administer pain medication to establish comfort and then attend to the other reported condition. A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching? A) Resting in a supine position B) Elevating arms while performing ADLs C) Breathing in through the nose and out through pursed lips. D) Increasing oxygen delivery to 5 L/min during times of distress. - ANSWER C) Breathing in through the nose and out through pursed lips. A nurse is assessing a client who is African-American and who is jaundice. Which of the following areas are the most reliable for the nurse to inspect? A) Palms of hands B) Hard palate C) Sclera D) Nail beds - ANSWER Hard palate A nurse is reinforcing teaching with a client who has ulcerative colitis and requires a low fiber diet. The nurse should instruct the client to avoid which of the following foods? A) Cooked carrots B) Dried apricots C) Ripe bananas D) White rice - ANSWER B) Dried apricots A nurse is caring for a client who has a large wound that has a vacuum-assisted closure device placed over it. Which of the following findings by the nurse indicated healing of the wound. A) Granulation tussue on the surface of the wound B) Musty odor from the foam dressing upon removal C) Sanguineous drainage in the suction device. D) Peeling of the edges of the transparent dressing - ANSWER A) Granulation tussue on the surface of the wound A nurse is caring for a toddler admitted to the hospital with acute gastroenteritis. Which of the following findings has the highest priority? A) Weightloss 3% of total body weight. B) Blood glucose 150 mg/dL C)Potassium 2.5 mEq/L D) Urine specific gravity 1.035 - ANSWER C)Potassium 2.5 mEq/L A nurse is reinforcing teaching about preventing long-term complications of retinopathy and neuropathy with an older adult client who has diabetes mellitus. Which of the following actions is the most important for the nurse to include in the teaching? A) "Plan to have an eye examination once per year." B) "Examine your feet carefully every day". C) "Wear closed toed shoes daily." D) "Maintain stable blood glucose levels." - ANSWER D) "Maintain stable blood glucose levels." A nurse is reinforcing teaching to the family of a client who has multiple myeloma and is admitted to the unit with a WBC count of 2,200/mm3. Which of the following food items brought by the family should the nurse prohibit from being given to the client? A) Fried chicken B) Bagels C) A factory-sealed box of chocolates D) Fresh fruit basket - ANSWER D) Fresh fruit basket A nurse is reviewing the preadmission laboratory test results of a client who is scheduled for a carotid endarterectomy in 3 days. Which of the following results should the nurse resport to the provider? A) Sodium 151 mEq/L B) Chloride 105 mEq/L C) Potassium 3.8 mEq/L D) Calcium 9.6 mEq/L - ANSWER A) Sodium 151 mEq/L A nurse is caring for a client who has unilateral leg edema with associated pain and a low-grade temperature. Which of the following action should the nurse take? A) Elevate the affected leg B) Apply cold compresses to the client's leg C) Place a pillow under the client's knees. D) Massage the painful area of the leg. - ANSWER A) Elevate the affected leg A nurse is reinforcing teaching with a class about preventing deep-vein thrombosis. The nurse should include in the teaching that which of the following is a risk factor for this disorder? Select all that apply. - Dehyrdration - Oral contraceptive use - Hypertension - High calcium intake - Immobility - ANSWER -Dehydration -Oral contraceptive - Immobility A nurse is caring for a client who has an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following is the most important nursing action for this client? A) Preventing skin breakdown B) Maintain fluid and electrolyte balance C) Providing emotional support D) Promoting physical mobility - ANSWER B) Maintain fluid and electrolyte balance A nurse is assigned to care for a client suspected of having diabetes insipidus. The nurse should frequently check the client for the development of : A) hypotension B) polyphagia C) hyperglycemia D) bradycardia - ANSWER A) hypotension A nurse is caring for a client following a CT scan with dye who has an anaphylaxis reaction. Which of the following conditions requires a priority nursing response? A) Urticaria B) Stridor C) Tachypnea D) Angioedema - ANSWER B) Stridor A nurse in a health clinic is assisting in the planning of an educational program on skin cancer. Which of the following statements should be included in the presentation? A) Squamous cell carcinoma occurs most often on the face and trunk B) Radiation therapy is the treatment of choice for mestatic skin cancer. C) Sun exposure as a child is a significant risk factor for skin cancer. D) Basal cell carcinoma is an aggressive cancer with a high rate of metastasis. - ANSWER C) Sun exposure as a child is a significant risk factor for skin cancer. A nurse is collecting data from a client who has atrial fibrillation. When documenting the quality of the client's pulse, which of the following terms should the nurse use? A) Slow B) Not palpable C) Irregular D) Bounding - ANSWER C) Irregular A nurse is reinforcing teaching for a middle-age client who is at high risk for osteoporosis and is taking a calcium supplement. Which of the following instructions should the nurse include? A) Take the calcium suplement on an empty stomach. B) Take vitamin D supplements. C) Take the calcium supplement with green tea. D) Take iron supplements - ANSWER B) Take vitamin D supplements. A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrates decoricate posturing. Which of the following findings should the nurse expect to observe? A) Extension of the extremities B) Pronation of the hands C) Plantar flexion of the legs D) External rotation of the lower extremities. - ANSWER C) Plantar flexion of the legs A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure which of the following nursing actions should the nurse complete first? A) Auscultate lung fields B) Assess pulse and respirations C) Assess characteristics of her sputum. D) Reinforce teaching to slowly exhale with purse lips. - ANSWER A) Auscultate lung fields A nurse is reinforcing teaching for a client discharged from the hospital after treatment for poor circulation in the lower extremities. Which of the following statements by the client indicates a need for further teaching? A) "I will avoid crossing my legs at the knees." B) "I will use a thermometer to check the temperature of the bath water." C) "I will wear shoes instead of sandals." D) "I will wear stockings wiht elastic tops." - ANSWER D) "I will wear stockings wiht elastic tops." A nurse is caring for a client in a body cast. Which of the following is the priority action the nurse should recommend for inclusion in the plan of care? A) Auscultate lung sounds B) Palpate peripheral pulses C) Monitor urinary output D) Assess the abdomen - ANSWER D) Assess the abdomen A nurse is caring for a client who had an open reduction and internal fixation of a fractured femur. Which of the following findings has the highest pirority? A) Altered level of consciousness B) Oral temperature 37.7 C (100 F) C) Muscle spasms D) Headache - ANSWER A) Altered level of consciousness A nurse is planning possible interventions in the care for a client who may need for total parenteral nutrition (TPN). Which of the following clients should benefit form TPN? A) A client who has acute gastritis B) A client who has a complete bowel obstruction C) A client who has been vomiting for the past 4 hrs D) A client who has undergone a cholecystectomy - ANSWER B) A client who has a complete bowel obstruction A nurse notes a small section of bowel protruding from the abdominal incision of a postoperative client. Which of the following actions should the nurse perform first? A) Cover the client's wound with a moist sterile dressing B) Determine the client's pain level C) Check the client's vital signs D) Obtain a culture and sensitivity of the client's wound drainage. - ANSWER A) Cover the client's wound with a moist sterile dressing A nurse is reviewing the laboratory report of a client who is receiving treatment for a high fever and a viral infection. Which of the following findings should the nurse expect? A) Elevated T-cell count B) Decreasedf leukocyte count C) Elevated hemoglobin level D) Decreased albumin level - ANSWER A) Elevated T-cell count A nurse is caring for a client who is receiving a unit of packed RBC's. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the clietn is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations? A) Urticaria B) Muscle pain C) Hypotension D) Distended neck veins - ANSWER C) Hypotension A nurse is caring for a postthoracotomy client who has just returned from the operating room. Which of the following is the nurse's priority action? A) Administer oxygen via nasal cannula B) Monitor urinary output C) Measure urinary output D) Maintain IV access at a rate of 75 mL/hour - ANSWER A) Administer oxygen via nasal cannula A nurse finds radioactive pellets on the surgical unit suite floor. Which of the following should be the nurse's priority action? A) Follow material safety data sheet (MSDS) instructions B) Place pellets in the biohazard area C) Contact environment services D) Notify the surgical department director. - ANSWER A) Follow material safety data sheet (MSDS) instructions A nurse is caring for a client who has a respiratory rate of 7/min. Which of the following is an appropriate interpretation of the client's arterial blood gas ABG's? A) Metabolic acidosis B) Respiratory acidosis C) Metabolic alkalosis D) Respiratory alkalosis - ANSWER B) Respiratory acidosis A nurse is planning care for a client who has a GI bleed. Which of the following actions should the nurse take first? A) Assess orthostatic blood pressure B) Explain the procedure for an upper GI series C) Administer pain medication D) Test hte emesis for blood - ANSWER A) Assess orthostatic blood pressure A community health nurse is assisting with planning an immunization clinic for older adult clients. The nurse should advise the clients to receive an influenza vaccine A) only if they are in a high-risk group B) every 10 yrs C) annually D) if the clietn has never had influenza - ANSWER C) annually A nurse is collecting data from a client who has a respiratory disorder and displays manifestations of hypoxia. Which of the following findings should the nurse report? A) Bradycardia B) Bradypnea C) Pallor D) Cyanosis - ANSWER D) Cyanosis A nurse is collecting data from a client who has Paget's disease. Which of the following findings should the nurse expect? (Select all that apply). A) Cranial enlargement B) Skeletal pain C) Waddling gait D) Cold extremities E) Muscle weakness - ANSWER A) Cranial enlargement B) Skeletal pain C) Waddling gait A nurse in the emergency department is assisting with the care of a client who is comatose. The provider suspects ketoacidosis. Which of the following findings should the nurse expect? A) Malignant hypertension B) Acetone odor to breath C) Cheyne-Stokes breathing D) Blood glucose level below 40 mg/dL - ANSWER B) Acetone odor to breath A nurse is reinforcing teaching to a client who wants to increase daily intake of omeg-3 type fatty acids. Which of the following foods should the nurse suggest the client increase? A) Blueberries B) Soybean oil C) Citrus fruits D) Green tea - ANSWER B) Soybean oil A nurse is caring for a client who has primary open-angle glaucoma. The client questions the nurse about the purpose of the tonometry ecamination. The nurse should explain that this test is used to A) evaluate peripheral vision B) identify the width of the angle between the iris and cornea. C) inspect the optic disc for signs of degeneration. D) measure intraocular pressure - ANSWER D) measure intraocular pressure A nurse is planning to care for a client who has acute dysphagia. Which of the following is appropriate to include in the plan of care? A) Use of a straw t oconsume liquids B) Encourage large bites C) Place the client in semi-Fowlers position during meals. D) Instruct the client to tilt head forward when swallowing - ANSWER D) Instruct the client to tilt head forward when swallowing A nurse is evaluating a client who sustained severe burn injuries in a grease fire. The nurse shades in the diagram indicating to nurned surface area. What percentage of body surface area does the nurse estimate the client has burned? Left arm: 9% 1/2 of right arm: 4.5% Front torso: 18% - ANSWER 9 + 4.5 + 18 = 31.5% A nurse is caring for a client following the application of an aquatermia pad. Which of the following is the first indication that the client is experiencing a thermal injury to the application site? A) Blistering B) Erythema C) Edema D) Pain - ANSWER B) Erythema While admitting a client for a cardiac catheterization, the nurse asks the client about allergies. The client states, "I always get a rash when I eat shellfish." Which of the following is the priority nursing intervention? A) Notify the provider of the client's allergy B) Attach a wrist band indicating the client's allergy C) Ask the client if any other foods cause such a reaction D) Notify dietary department of the client's allergy - ANSWER A) Notify the provider of the client's allergy A nurse is caring for a client who has end-stage renal disease and must limit protein intake. Which of the following foods should the nurse plan to include in the client's diet? A) Eggs B) Dried beans C) Nuts D) Green vegetables - ANSWER A) Eggs A nurse is monitoring a client's peripheral circulation. Identify where the nurse will palpate to check the posterior tibial pulse. - ANSWER The posterior tibial pulse is located on the inner ankle one third of the way along a line between the tip of the medial malleolus (end of the tibia) and the point of the heel. It is most easily palpated about 2.5 cm (1 inch) higher where it runs behind the medial malleolus. A nurse is collecting data from a client who is receiving chemotherapy and is showing manifestations of malnutrition. Which of the following indicates a Vitamin C deficiency? A) Dry, red conjunctiva B) Swollen, bleeding gums C) Inflammation of the tongue D) Pale, brittle nales - ANSWER B) Swollen, bleeding gums A nurse is collecting data from a client who has diabetes and is overweight. The client tells the nurse that she wants to start an exercise program. Which of the following actions should the nurse take first? A) Determine the client's usual pattern of activity. B) Assist the client to develop a healthy eating plan C) Encourage the client to join a support group. D) Provide the client with a list of signs and symptoms to report to the provider. - ANSWER A) Determine the client's usual pattern of activity. A nurse is caring for a client diagnosed with myasthenia gravis. Which of the following findings indicates the client is experiencing an advanced symptom of this disease? A) Confusion B) Incontinence C) Headache D) Hypertension - ANSWER B) Incontinence A nurse is admitting a client with suspected appendicitis. Identify where the nurse should palpate to monitor for pain at McBurney's point. (Selectable areas / Hot spots) - ANSWER Right lower quadrant O O X O A nurse is collecting data on a client who has renal failure for fluid volume increase. Which of the following assessment methods is most reliable? A) Daily weight B) Serum sodium C) Tissue turgor D) Intake and output - ANSWER A) Daily weight A nurse is contributing to the plan of care for a client who has a pressure ulcer on his heel. Which of the following should the nurse include in the planning? A) Keep the ulcer bed dry B) Clean the wound from the outer edge towards the center C) Provide the client a diet high in Vitamin C D) Reposition the client at least every 4 hrs - ANSWER C) Provide the client a diet high in Vitamin C A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions hsould the nurse perform first? A) obtain a throat culture specimen B) Perform a complete blood count C) Check the client's temperature D) Administer an oral analgesics - ANSWER C) Check the client's temperature A nurse is caring for a client with Alzheimer's disease who is hospitalized for treatment of pneumonia. During the night shift, the client is found lcimbing into the bed of another client, who becomes upset and frightened. Which of the following actions should the nurse take? A) Asisst the client to his room