Med Surg Homework

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No Timer Mar. 13 Night Med-Surg 11 hwk - 06

1. A client is scheduled to receive morphine sulfate. Which of the following is an
appropriate nursing action?
Monitor the pulse rate and withhold administration if <60 bpm.
Monitor the respiratory rate and withhold administration if <12/min.
Monitor the temperature and administer if >101F (38.3C).
Monitor the BP and administer if <90/60 mm Hg.
2. Which of the following most accurately exemplifies documentation of objective data?
Respirations appear shallow and noisy
The client seems to be depressed today
Dressing was changed, and incision is clean and healing with 2 cm of serosanguineous
drainage.
The client has complaints of pain in her left lower quadrant (LLQ), not relieved by medication
3. A 3-year-old was admitted with aseptic meningitis. The physician ordered 40 mg of
chewable tables of acetaminophen. On hand were S0 mg tablets. How many tablets
will the nurse administer?
tablet
1 tablet
1 tablet
2 tablets
4. The nurse is changing the dressing covering an infected abscess that has been drained.
The gauze is saturated with a foul-smelling yellow exudate, The nurse removes the
dressing:
With bare hands
After donning nonsterile gloves
After donning sterile gloves
After double-gloving
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. An S0-year-old man states that he experiences dribbling of clear yellow urine,
hesitancy in starting urination, and a sensation of incomplete emptying of the bladder.
The nurse identifies which of the following as the most likely cause of the symptoms?
The aging process
An enlarged prostate gland
A T
Chronic constipation
. An 1S-year-old client is experiencing a sickle cell crisis. Which of the following
interventions is indicated for this client?
RO M eercises every 2 hours
Fluid restriction of <1 L/day
Administration of antidiarrheal medications
Pain assessments every hours
. A client who has received continuous enteral tube feedings for a week has pulled her
tube out. Within an hour, she develops tachycardia, diaphoresis, and tremors of her
hands. The nurse correctly identifies her symptoms as:
Hypoglycemia
Hyperglycemia
Hypokalemia
Hyperkalemia
S. After a lumbar puncture, the nurse will position the client:
In semi-fowler s position to allow for drainage of CSF
Flat for about 6 hours to prevent a possible spinal headache
In a prone position to prevent post-test meningeal irritation
On the side, with the head of the bed slightly elevated to prevent aspiration
. uring an emergency situation, the nurse used a tuberculin syringe to draw up 30
units of humulin regular -100 insulin. How much did the nurse draw up?
0.10 ml
0.20 ml
0.30 ml
0.0 ml
10. The nurse is reaching a class on wound healing. Which of the following is an accurate
statement concerning wound healing?
Accumulation of blood in a wound becomes a growth medium for infection.
A tight dressing increases the blood supply carrying nutrients to the area.
Clients taking steroids have a heightened inflammatory response.
Activity promotes wound healing.
11. The client was experiencing severe pain secondary to a migraine headache. The
physician s orders read:
ive morphine sulfate 12 mg M stat for pain. On hand was morphine 1 mgml.
How many milliliters did the nurse draw up?
0.2 ml
0. ml
0.6 ml
0.8 ml
12. After a thyroidectomy, a client develops spasms of the hands and feet accompanied by
muscle twitching. The nurse identifies these symptoms as signs of:
Hypocalcemia
Hypercalcemia
Hypokalemia
Hyperkalemia
13. our units of regular insulin are given subcutaneously to a client at 4 M for an
elevated glucose level. The client is at greatest risk for rebound hypo glycemia at:
01 PM
8 PM
Midnight
6 AM the following morning
14. A client has been given a diagnosis of esophageal stricture. t is important for the
nurse to teach him to:
Eat hot, spicy foods to relax the stricture.
Lie supine after eating.
Eat ust before bedtime.
Ear small amounts frequently
1. The client was diagnosed with strep throat. The physician ordered benzathine penicillin
icillin 2,400,000 unit s implementation stat. The pharmacy sent a 10-ml vial of
icillin containing 00,000 unitsml. How many milliliters will the nurse give?
1 ml
2 ml
3 ml
ml
1. When planning for care of the client with a percutaneous endoscopic gastrostomy
tube, it would be important for the nurse to include which of the following:
Nasal assessment for skin irritation from the tube
Securing the tube to the client s cheek
Assessing for tube displacement after coughing or suctioning
Assessing bowel elimination patterns
1. A child sustains a burn injury when a boiling pot of water is knocked off a stove. The
skin on the child s chest appears sunburned and is dry. The nurse describes the burn
injury as a:
Smoke inhalation inury
Superficial (first-degree) injury
Partial-thickness (second-degree) inury
Full-thickness (third-degree) inury
1S. The physician ordered amikacin Amikin 40 mg every S hours for a 2 year-old child.
On hand is a 100 mg2-ml vial. How many milliliters will the nurse administer?
0. ml
0.6 ml
0.8 ml
1.0ml
1.
An adult client with angina has a radial pulse of S bpm. This slow rate is considered
below normal and is called:
Tachycardia
Arrhythmia
Sinus rhythm
Bradycardia
20. When discharging a client with a prescription for warfarin oumadin , the nurse
instructs the client not to take aspirin because aspirin:
Can cause irritation to the lining of the stomach
Frequently has delayed effects and is not readily absorbed in the body
Interferes with clot formation and could precipitate bleeding
Is not very effective and causes more side effects than most medications
21. The physician has ordered a urinalysis for a client. The nurse gives which of the
following instructions?
Women should cleanse the perineum from hack to front.
Hands should he washed before collecting the specimen.
The container should be pressed gently against the genitalia.
The first portion of the voiding should not be collected.
22. A client with A is unable to cough because of weakness and fatigue. The client is at
risk for:
Impaired gas echange
Pain
Altered thought processes
Ineffective airway clearance
23. The nurse is assessing the client for hypovolemic shock. Which of the following
symptoms would the nurse expect to find?
A slow, thready pulse
Deep, slow respirations
Cold, moist skin
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24. A neighbor, who is working in the yard burning leaves, suddenly begins screaming for
help. His clothing is on fire and he is screaming uncontrollably. The nurses first action
is to:

25. A client states that his eyes and skin itch 10 minutes after a penicillin derivative is
administered. Hives are noted on the dents arms, trunk, and legs. The nurse can
anticipate that which of the following may occur?

26. Erik Erikson defines the developmental stage of late adulthood {age60 years or older)
as:

27. The nurse is to make an entry on a clients chart at 4 PM using military time. The time
the nurse enters is:_____
{Hint: type numbers only e.g. 200)
1400
2S. A 57-year-old client recovering from a peptic ulcer and asks about foods. The nurses
directions include:

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2. A 77-year-old client seeks the nurses advice on constipation. hich of the following is
not good advice?

0. A male client has a diagnosis of herpes genitalis infection. The nurse should instruct
him to:

1. A client has been placed on oral anticoagulants after an Ml. hich of the following
instructions should the nurse give to the client?

2. A client is evaluated in the clinic 2 years after having a kidney transplant. The nurse
epects this client to be most concerned about:

. uring the physical assessment of a woman with an eacerbation of systemic lupus
erythematosus {E), the nurse is likely to note which of the following?


4. n arrival at the hospital, the primary focus for a client with a thermal inury is:

5. A client has received steroid therapy for 1 year. hich of the following is caused by
long-term steroid therapy?

6. The apgar scale is an assessment tool that rates the physiological characteristics of the
newborn infant. The ma imum total score is ____
10
7. hich of the following statements made by a client indicates that a complication of
peritoneal dialysis is occurring?

S. A client with a T suddenly cries out with sharp, stabbing pains in the chest and
becomes dyspneic, anious, and cyanotic. The nurse correctly identifies this as which
of the following?


. A client has a diagnosis of epiglottitis. t would be most important for the nurse to
keep which of the following at the bedside?

40. A 44-year-old male client recently had a lumbosacral laminectomy to repair a herniated
nucleus pulposus. The nurse would:

41. A client is placed on hemodialysis best assess the clients progress by: The nurse would

42. A 66-year-old client is seen at the clinic. he has had nausea and vomiting for 2 days
and is complaining of diiness. he thinks she has food poisoning. Evaluating her vital
signs, the nurse would also include:

4. A female client has an indwelling urinary catheter. The nurse notices that the urine has
a strong odor and cloudy. The nurse s net action is to:

44. A 2-year-old client had a cholecystectomy 2 hours ago. The client weighs 250 lb and
had general anesthesia. The client is complaining of pain. Priority nursing diagnosis at
this time is:

45. lassic subective complaints of a T are:

46. The most appropriate position for giving a client a back rub at the hour of sleep is:

47. A nurse is conducting a physical assessment on a client. hich of the following
characteristics of a mole on the skin warrants further evaluation by a physician?

4S. A client has been diagnosed with epilepsy. hich of the following is an appropriate
action for the nurse to take when a client is having a seiure?

49. The nurse is developing a plan of care for a client who has a diagnosis of actite
pancreatitis. The rationale for maintaining the client on bed rest is to:

50. A second-day postoperative client is having incisional pain. The client was medicated
an hour ago. Which of the following noninvasive nursing interventions will best aid in
decreasing pain at this time?

51. A client has light-colored stools and dark urine. The nurse correctly identifies these
symptoms as being associated with:

52. A 74-year-old woman is admitted with symptoms of vaginal bleeding. The nurse
identifies this bleeding as most likely a result of:

5 .
A 24-year-old woman is pregnant for the first time. The term for a first pregnancy is:

54. A client in a nursing home is at high risk to develop pressure ulcers because of
immobility incontinence and low serum albumin. Which of the following would the
nurse assess for as a first sign of a pressure ulcer?

55. A client is admitted with a diagnosis of peptic ulcer disease . Which of the
following symptoms would alert the nurse that the ulcer has perforated?
The client complains of chronic continuous pain persisting for a week.

5 . Which of the following is an applicable nursing diagnosis for a client admitted with
renal stones?

57. A client with a history of recurrent T s is being evaluated in the clinic. Which of the
following actions indicates that the client is adhering to instructions?


5 . A 4-year-old recently married man is admitted for an ileal conduit urinary
diversion.The nurse should:

59. Which of the following statements made by a client indicates a need for additional
diabetic teaching?

0. n giving dietary discharge instructions to a client with a recent myocardial infarction
the nurse instructs him to avoid foods that:

1. An 1 -year-old client sustained a compound fracture of the left tibia while skiing and is
admitted to the emergency room . The rationales for cleaning the wound from the
area of least contamination to the area of greatest contamination are to:

2. An 0-year-old client who had a left cerebrovascular accident A is e periencing
continuous oo ing of small amounts of li uid stool and has not had a bowel movement
in 4 days. e eats only 20 of meals served to him. The oo ing of stool is most likely a
result of:

. A client has a bowel movement that consists of dark tarry stools. The nurse would
e pect that the client is e periencing bleeding from:

4. The nurse is assessing a client who has recently been found to be hyperthyroid. The
nurse would e pect to find which of the following symptoms?

5. The nurse is doing discharge planning with a uadriplegic client. Which of the
following instructions should be given to the client with an indwelling urinary catheter
connected to gravity drainage?

. A 4-year-old child is admitted with a fever of 105. 40.5 and a potential
diagnosis of infectious meningitis. The physician has ordered a lumbar puncture. The
purpose of this test is:

7. After a liver biopsy the nurse should place the client in which of the following
positions?

. The nurse identifies which of the following as care of the client during the
rehabilitation phase of burn care?

9. A nurse is working in the and receives a frantic phone call from a mother whose
2-year-old child has swallowed a bottle of aspirin about 20 tables . The nurse
instructs her to:

70. A fre uent site and cause of nosocomial infection is the:

71. When positioning a postoperative client who has had a total hip replacement the
nurse is careful to keep the operative leg:


72. A 53-year-old client with a recent stroke is very frustrated because he will not be able
to return to his occupation as an airline pilot. He is very angry today and refuses his
medication. What should the nurse understand?

73. A 19-year-old primigravida is admitted with preeclampsia. The nurse will monitor her
very closely for:

74. An infant whose respirations are slow and irregular at 1 and 5 minutes after birth will
receive an Apgar respiratory score of:

75. A 50-year-old man complains of chills, low back pain, and nausea 10 minutes after a
blood transfusion has begun. An hour later, his temperature increases to 102F (38.8
C), he is hypotensive, and he voids urine red in color. Which type of blood transfusion
reaction is occurring?

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No Timer Mar. 13 Night Med-Surg 11 hwk - 06

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