NCLEX Practice Test For Medical Surgical Nursing 3(Practice Mode)- Www.Rnpedia.Com

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1. Myra is ordered laboratory tests after she is admitted to the hospital for angina. The isoenzyme test that is the most reliable early indicator of myocardial insult is:

Explanation

The cardiac marker, Creatinine phosphokinase (CPK) isoenzyme levels, especially the MB sub-unit which is cardio-specific, begin to rise in 3-6 hours, peak in 12-18 hours and are elevated 48 hours after the occurrence of the infarct. They are therefore most reliable in assisting with early diagnosis. The cardiac markers elevate as a result of myocardial tissue damage.

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2. After the acute phase of congestive heart failure, the nurse should expect the dietary management of the client to include the restriction of: 

Explanation

Restriction of sodium reduces the amount of water retention that reduces the cardiac workload

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3. Before a post- thyroidectomy client returns to her room from the OR, the nurse plans to set up emergency equipment, which should include: 

Explanation

Acute respiratory obstruction in the post-operative period can result from edema, subcutaneous bleeding that presses on the trachea, nerve damage, or tetany.

Submit
4. Joey asks the nurse why he is receiving the injection of Morphine after he was hospitalized for severe anginal pain. The nurse replies that it:

Explanation

Morphine is a specific central nervous system depressant used to relieve the pain associated with myocardial infarction. It also decreases anxiety and apprehension and prevents cardiogenic shock by decreasing myocardial oxygen demand.

Submit
5. The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the ff. as a priority in the plan of care?

Explanation

Immunodeficiency is an absent or depressed immune response that increases susceptibility to infection. So it is the nurse’s primary responsibility to protect the patient from infection.

Submit
6. The laboratory results of the client with leukemia indicate bone marrow depression. The nurse should encourage the client to: 

Explanation

Suppression of red bone marrow increases bleeding susceptibility associated with thrombocytopenia, decreased platelets. Anemia and leucopenia are the two other problems noted with bone marrow depression.

Submit
7. The nurse knows that a client with Pernicious Anemia understands the teaching regarding the vitamin B12 injections when she states that she must take it: 

Explanation

Since the intrinsic factor does not return to gastric secretions even with therapy, B12 injections will be required for the remainder of the client’s life.

Submit
8. In the evaluation of a client’s response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organs is: 

Explanation

A rate of 30 ml/hr is considered adequate for perfusion of kidney, heart and brain.

Submit
9. A client undergoes below the knee amputation following a vehicular accident. Three days postoperatively, the client is refusing to eat, talk or perform any rehabilitative activities. The best initial nursing approach would be to: 

Explanation

The withdrawal provides time for the client to assimilate what has occurred and integrate the change in the body image. Acceptance of the client’s behavior is an important factor in the nurse’s intervention.

Submit
10. In dealing with a dying client who is in the denial stage of grief, the best nursing approach is to: 

Explanation

This does not take away the client’s only way of coping, and it permits future movement through the grieving process when the client is ready. Dying clients move through the different stages of grieving and the nurse must be ready to intervene in all these stages.

Submit
11. The most significant initial nursing observations that need to be made about a client with myasthenia include: 

Explanation

Muscle weakness can lead to respiratory failure that will require emergency intervention and inability to swallow may lead to aspiration

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12. An early finding in the EKG of a client with an infarcted mycardium would be:

Explanation

This is a typical early finding after a myocardial infarct because of the altered contractility of the heart. The other choices are not typical of MI.

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13. Ana is diagnosed to have Pernicious anemia. The physician orders 0.2 mg of Cyanocobalamin (Vitamin B12) IM. Available is a vial of the drug labeled 1 ml= 100 mcg. The nurse should administer: 

Explanation

First convert milligrams to micrograms and then use ratio and proportion (0.2 mg= 200 mcg) 200 mcg : 100 mcg= X ml : ml 100 X= 200 X = 2 ml. Inject 2 ml. to give 0.2 mg of Cyanocobalamin.

Submit
14. The key factor in accurately assessing how body image changes will be dealt with by the client is the: 

Explanation

It is not reality, but the client’s feeling about the change that is the most important determinant of the ability to cope. The client should be encouraged to his feelings.

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15. To promote continued improvement in the respiratory status of a client following chest tube removal after a chest surgery for multiple rib fracture, the nurse should: 

Explanation

This nursing action prevents atelectasis and collection of respiratory secretions and promotes adequate ventilation and gas exchange.

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16. Joy, an obese 32 year old, is admitted to the hospital after an automobile accident. She has a fractured hip and is brought to the OR for surgery. 
After surgery Joy is to receive a piggy-back of Clindamycin phosphate (Cleocin) 300 mg in 50 ml of D5W. The piggyback is to infuse in 20 minutes. The drop factor of the IV set is 10 gtt/ml. The nurse should set the piggyback to flow at: 

Explanation

To get the correct flow rate: multiply the amount to be infused (50 ml) by the drop factor (10) and divide the result by the amount of time in minutes (20)

Submit
17. Jude develops GI bleeding and is admitted to the hospital. An important etiologic clue for the nurse to explore while taking his history would be:

Explanation

Some medications, such as aspirin and prednisone, irritate the stomach lining and may cause bleeding with prolonged use

Submit
18. Ana, 55 years old, is admitted to the hospital to rule out pernicious anemia. A Schilling test is ordered for Ana. The nurse recognizes that the primary purpose of the Schilling test is to determine the client’s ability to:

Explanation

Pernicious anemia is caused by the inability to absorb vitamin B12 in the stomach due to a lack of intrinsic factor in the gastric juices. In the Schilling test, radioactive vitamin B12 is administered and its absorption and excretion can be ascertained through the urine.

Submit
19. The initial nursing goal for a client with myasthenia gravis during the diagnostic phase of her hospitalization would be to: 

Explanation

Until diagnosis is confirmed, primary goal should be to maintain adequate activity and prevent muscle atrophy

Submit
20. In the early postoperative period following a transurethral surgery, the most common complication the nurse should observe for is: 

Explanation

After transurethral surgery, hemorrhage is common because of venous oozing and bleeding from many small arteries in the prostatic bed.

Submit
21. A chest tube with water seal drainage is inserted to a client following a multiple chest injury. A few hours later, the client’s chest tube seems to be obstructed. The most appropriate nursing action would be to 

Explanation

This assists in moving blood, fluid or air, which may be obstructing drainage, toward the collection chamber

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22. Dennis receives a blood transfusion and develops flank pain, chills, fever and hematuria. The nurse recognizes that Dennis is probably experiencing: 

Explanation

This non-judgmentally on the part of the nurse points out the client’s behavior.This results from a recipient’s antibodies that are incompatible with transfused RBC’s; also called type II hypersensitivity; these signs result from RBC hemolysis, agglutination, and capillary plugging that can damage renal function, thus the flank pain and hematuria and the other manifestations.

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23. Forty-eight hours after a burn injury, the physician orders for the client 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide: 

Explanation

This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes)

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24. The nurse recognizes that a client understood the demonstration of crutch walking when she places her weight on: 

Explanation

The palms should bear the client’s weight to avoid damage to the nerves in the axilla (brachial plexus)

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25. Larry is diagnosed as having myelocytic leukemia and is admitted to the hospital for chemotherapy. Larry discusses his recent diagnosis of leukemia by referring to statistical facts and figures. The nurse recognizes that Larry is using the defense mechanism known as: 

Explanation

People use defense mechanisms to cope with stressful events. Intellectualization is the use of reasoning and thought processes to avoid the emotional upsets.

Submit
26. A client with colostomy refuses to allow his wife to see the incision or stoma and ignores most of his dietary instructions. The nurse on assessing this data, can assume that the client is experiencing: 

Explanation

As long as no one else confirms the presence of the stoma and the client does not need to adhere to a prescribed regimen, the client’s denial is supported

Submit
27. A client jokes about his leukemia even though he is becoming sicker and weaker. The nurse’s most therapeutic response would be:

Explanation

This non-judgmentally on the part of the nurse points out the client’s behavior.

Submit
28. Lucy is admitted to the surgical unit for a subtotal thyroidectomy. She is diagnosed with Grave’s Disease. When assessing Lucy, the nurse would expect to find: 

Explanation

Classic signs associated with hyperthyroidism are weight loss and restlessness because of increased basal metabolic rate. Exopthalmos is due to peribulbar edema.

Submit
29. Twenty four hours after admission for an Acute MI, Jose’s temperature is noted at 39.3 C. The nurse monitors him for other adaptations related to the pyrexia, including:

Explanation

Fever causes an increase in the body’s metabolism, which results in an increase in oxygen consumption and demand. This need for oxygen increases the heart rate, which is reflected in the increased pulse rate. Increased BP, chest pain and shortness of breath are not typically noted in fever.

Submit
30. When doing colostomy irrigation at home, a client with colostomy should be instructed to report to his physician : 

Explanation

Difficulty of inserting the irrigating tube indicates stenosis of the stoma and should be reported to the physician. Abdominal cramps and passage of flatus can be expected during colostomy irrigations. The procedure may take longer than half an hour.

Submit
31. The nurse applies mafenide acetate (Sulfamylon cream) to Clara, who has second and third degree burns on the right upper and lower extremities, as ordered by the physician. This medication will: 

Explanation

Sulfamylon is effective against a wide variety of gram positive and gram negative organisms including anaerobes

Submit
32. Eddie, a plane crash victim, undergoes endotracheal intubation and positive pressure ventilation. The most immediate nursing intervention for him at this time would be to: 

Explanation

It is a primary nursing responsibility to evaluate effect of interventions done to the client. Nothing is achieved if the equipment is working and the client is not responding

Submit
33. A client has been in a coma for 2 months. The nurse understands that to prevent the effects of shearing force on the skin, the head of the bed should be at an angle of:

Explanation

Shearing force occurs when 2 surfaces move against each other; when the bed is at an angle greater than 30 degrees, the torso tends to slide and causes this phenomenon. Shearing forces are good contributory factors of pressure sores.

Submit
34. Rene, age 62, is scheduled for a TURP after being diagnosed with a Benign Prostatic Hyperplasia (BPH). As part of the preoperative teaching, the nurse should tell the client that after surgery:

Explanation

An indwelling urethral catheter is used, because surgical trauma can cause urinary retention leading to further complications such as bleeding.

Submit
35. Mr. Ong is admitted to the hospital with a diagnosis of Left-sided CHF. In the assessment, the nurse should expect to find: 

Explanation

Pulmonary congestion and edema occur because of fluid extravasation from the pulmonary capillary bed, resulting in difficult breathing. Left-sided heart failure creates a backward effect on the pulmonary system that leads to pulmonary congestion.

Submit
36. Helen is diagnosed with myasthenia gravis and pyridostigmine bromide (Mestinon) therapy is started. The Mestinon dosage is frequently changed during the first week. While the dosage is being adjusted, the nurse’s priority intervention is to: 

Explanation

Peak response occurs 1 hour after administration and lasts up to 8 hours; the response will influence dosage levels.

Submit
37. When observing an ostomate do a return demonstration of the colostomy irrigation, the nurse notes that he needs more teaching if he:

Explanation

The irrigation bag should be hung 12-18 inches above the level of the stoma; a clothes hook is too high which can create increase pressure and sudden intestinal distention and cause abdominal discomfort to the patient.

Submit
38. A client with multiple injury following a vehicular accident is transferred to the critical care unit. He begins to complain of increased abdominal pain in the left upper quadrant. A ruptured spleen is diagnosed and he is scheduled for emergency splenectomy. In preparing the client for surgery, the nurse should emphasize in his teaching plan the: 

Explanation

rains are usually inserted into the splenic bed to facilitate removal of fluid in the area that could lead to abscess formation.

Submit
39. The meal pattern that would probably be most appropriate for a client recovering from GI bleeding is: 

Explanation

Presence of food in the stomach at regular intervals interacts with HCl limiting acid mucosal irritation. Mucosal irritation can lead to bleeding.

Submit
40. Mr. Ong, a client with CHF, has been receiving a cardiac glycoside, a diuretic, and a vasodilator drug. His apical pulse rate is 44 and he is on bed rest. The nurse concludes that his pulse rate is most likely the result of the:

Explanation

A cardiac glycoside such as digitalis increases force of cardiac contraction, decreases the conduction speed of impulses within the myocardium and slows the heart rate.

Submit
41. Clara is a 37-year old cook. She is admitted for treatment of partial and full-thickness burns of her entire right lower extremity and the anterior portion of her right upper extremity. Her respiratory status is compromised, and she is in pain and anxious. Performing an immediate appraisal, using the rule of nines, the nurse estimates the percent of Clara’s body surface that is burned is: 

Explanation

The entire right lower extremity is 18% the anterior portion of the right upper extremity is 4.5% giving a total of 22.5%

Submit
42. The nurse would know that dietary teaching had been effective for a client with colostomy when he states that he will eat:

Explanation

There is no special diets for clients with colostomy. These clients can eat a regular diet. Only gas-forming foods that cause distention and discomfort should be avoided.

Submit
43. Eddie, 40 years old, is brought to the emergency room after the crash of his private plane. He has suffered multiple crushing wounds of the chest, abdomen and legs. It is feared his leg may have to be amputated. When Eddie arrives in the emergency room, the assessment that assume the greatest priority are: 

Explanation

Respiratory and cardiovascular functions are essential for oxygenation. These are top priorities to trauma management. Basic life functions must be maintained or reestablished

Submit
44. Arthur Cruz, a 45 year old artist, has recently had an abdominoperineal resection and colostomy. Mr. Cruz accuses the nurse of being uncomfortable during a dressing change, because his “wound looks terrible.” The nurse recognizes that the client is using the defense mechanism known as: 

Explanation

Projection is the attribution of unacceptable feelings and emotions to others which may indicate the patients nonacceptance of his condition.

Submit
45. The physician orders on a client with CHF a cardiac glycoside, a vasodilator, and furosemide (Lasix). The nurse understands Lasix exerts is effects in the:

Explanation

This is the site of action of Lasix being a potent loop diuretic.

Submit
46. Mr. Ong weighs 210 lbs on admission to the hospital. After 2 days of diuretic therapy he weighs 205.5 lbs. The nurse could estimate that the amount of fluid he has lost is:

Explanation

One liter of fluid weighs approximately 2.2 lbs. Therefore a 4.5 lbs weight loss equals approximately 2 Liters.

Submit
47. The nurse teaches Joy, an obese client, the value of aerobic exercises in her weight reduction program. The nurse would know that this teaching was effective when Joy says that exercise will: 

Explanation

Increased exercise builds skeletal muscle mass and reduces excess fatty tissue.

Submit
48. The nurse performs full range of motion on a bedridden client’s extremities. When putting his ankle through range of motion, the nurse must perform:

Explanation

These movements include all possible range of motion for the ankle joint

Submit
49. Routine postoperative IV fluids are designed to supply hydration and electrolyte and only limited energy. Because 1 L of a 5% dextrose solution contains 50 g of sugar, 3 L per day would apply approximately: 

Explanation

Carbohydrates provide 4 kcal/ gram; therefore 3L x 50 g/L x 4 kcal/g = 600 kcal; only about a third of the basal energy need.

Submit
50. Clara, a burn client, receives a temporary heterograft (pig skin) on some of her burns. These grafts will: 

Explanation

The graft covers nerve endings, which reduces pain and provides a framework for granulation that promotes effective healing.

Submit
51. Jane, a 20- year old college student is admiited to the hospital with a tentative diagnosis of myasthenia gravis. She is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. In preparing her for this procedure, the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces: 

Explanation

Tensilon acts systemically to increase muscle strength; with a peak effect in 30 seconds, It lasts several minutes.

Submit
52. Oxygen 3L/min by nasal cannula is prescribed for Joey who is admitted to the hospital for chest pain. The nurse institutes safety precautions in the room because oxygen: 

Explanation

The nurse should know that Oxygen is necessary to produce fire, thus precautionary measures are important regarding its use.

Submit
53. A client with a history of recurrent GI bleeding is admitted to the hospital for a gastrectomy. Following surgery, the client has a nasogastric tube to low continuous suction. He begins to hyperventilate. The nurse should be aware that this pattern will alter his arterial blood gases by: 

Explanation

Hyperventilation results in the increased elimination of carbon dioxide from the blood that can lead to respiratory alkalosis.

Submit
54. Lucy undergoes Subtotal Thyroidectomy for Grave’s Disease. In planning for the client’s return from the OR, the nurse would consider that in a subtotal thyroidectomy: 

Explanation

Remaining thyroid tissue may provide enough hormone for normal function. Total thyroidectomy is generally done in clients with Thyroid Ca.

Submit
55. When a post-thyroidectomy client returns from surgery the nurse assesses her for unilateral injury of the laryngeal nerve every 30 to 60 minutes by: 

Explanation

If the recurrent laryngeal nerve is damaged during surgery, the client will be hoarse and have difficult speaking.

Submit
56. Jose, who had a myocardial infarction 2 days earlier, has been complaining to the nurse about issues related to his hospital stay. The best initial nursing response would be to:

Explanation

This provides the opportunity for the client to verbalize feelings underlying behavior and helpful in relieving anxiety. Anxiety can be a stressor which can activate the sympathoadrenal response causing the release of catecholamines that can increase cardiac contractility and workload that can further increase myocardial oxygen demand.

Submit
57. When preparing to teach a client with colostomy how to irrigate his colostomy, the nurse should plan to perform the procedure: 

Explanation

Irrigation should be performed at the time the client normally defecated before the colostomy to maintain continuity in lifestyle and usual bowel function/habit.

Submit
58. Thrombus formation is a danger for all postoperative clients. The nurse should act independently to prevent this complication by: 

Explanation

Inactivity causes venous stasis, hypercoagulability, and external pressure against the veins, all of which lead to thrombus formation. Early ambulation or exercise of the lower extremities reduces the occurrence of this phenomenon

Submit
59. The transurethral resection of the prostate is performed on a client with BPH. Following surgery, nursing care should include:

Explanation

Patency of the catheter promotes bladder decompression, which prevents distention and bleeding. Continuous flow of fluid through the bladder limits clot formation and promotes hemostasis

Submit
60. On a post-thyroidectomy client’s discharge, the nurse teaches her to observe for signs of surgically induced hypothyroidism. The nurse would know that the client understands the teaching when she states she should notify the physician if she develops:

Explanation

Dry skin is most likely caused by decreased glandular function and fatigue caused by decreased metabolic rate. Body functions and metabolism are decreased in hypothyroidism.

Submit
61. An unconscious client is admitted to the ICU, IV fluids are started and a Foley catheter is inserted. With an indwelling catheter, urinary infection is a potential danger. The nurse can best plan to avoid this problem by: 

Explanation

Promoting hydration, maintains urine production at a higher rate, which flushes the bladder and prevents urinary stasis and possible infection

Submit
62. The nurse would know that a post-TURP client understood his discharge teaching when he says “I should:” 

Explanation

Urethral mucosa in the prostatic area is destroyed during surgery and strictures my form with healing that causes partial or even complete ueinary obstruction.

Submit
63. The physician orders non-weight bearing with crutches for Joy, who had surgery for a fractured hip. The most important activity to facilitate walking with crutches before ambulation begun is: 

Explanation

These sets of muscles are used when walking with crutches and therefore need strengthening prior to ambulation.

Submit
64. During and 8 hour shift, Mario drinks two 6 oz. cups of tea and vomits 125 ml of fluid. During this 8 hour period, his fluid balance would be: 

Explanation

The client’s intake was 360 ml (6oz x 30 ml) and loss was 125 ml of fluid; loss is subtracted from intake

Submit
65. Helen, a client with myasthenia gravis, begins to experience increased difficulty in swallowing. To prevent aspiration of food, the nursing action that would be most effective would be to: 

Explanation

Dysphagia should be minimized during peak effect of Mestinon, thereby decreasing the probability of aspiration. Mestinon can increase her muscle strength including her ability to swallow.

Submit
66. Twenty-four hours after TURP surgery, the client tells the nurse he has lower abdominal discomfort. The nurse notes that the catheter drainage has stopped. The nurse’s initial action should be to:

Explanation

Milking the tubing will usually dislodge the plug and will not harm the client. A physician’s order is not necessary for a nurse to check catheter patency.

Submit
67. A client with burns on the chest has periodic episodes of dyspnea. The position that would provide for the greatest respiratory capacity would be the: 

Explanation

The orthopneic position lowers the diaphragm and provides for maximal thoracic expansion

Submit
68. The diet ordered for a client with CHF permits him to have a 190 g of carbohydrates, 90 g of fat and 100 g of protein. The nurse understands that this diet contains approximately: 

Explanation

There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein

Submit
69. The day after her surgery Joy asks the nurse how she might lose weight. Before answering her question, the nurse should bear in mind that long-term weight loss best occurs when: 

Explanation

For weight reduction to occur and be maintained, a new dietary program, with a balance of foods from the basic four food groups, must be established and continued

Submit
70. Jose, who is admitted to the hospital for chest pain, asks the nurse, “Is it still possible for me to have another heart attack if I watch my diet religiously and avoid stress?” The most appropriate initial response would be for the nurse to: 

Explanation

To help the patient verbalize and explore his feelings, the nurse must reflect and analyze the feelings that are implied in the client’s question. The focus should be on collecting data to minister to the client’s psychosocial needs.

Submit
71. The observation that indicates a desired response to thoracostomy drainage of a client with chest injury is: 

Explanation

The chest tube normalizes intrathoracic pressure and restores negative intra-pleural pressure, drains fluid and air from the pleural space, and improves pulmonary function

Submit
72. Health teachings to be given to a client with Pernicious Anemia regarding her therapeutic regimen concerning Vit. B12 will include:

Explanation

Deep IM injections bypass B12 absorption defect in the stomach due to lack of intrinsic factor, the transport carrier component of gastric juices. A monthly dose is usually sufficient since it is stored in active body tissues such as the liver, kidney, heart, muscles, blood and bone marrow

Submit
73. A client’s exopthalmos continues inspite of thyroidectomy for Grave’s Disease. The nurse teaches her how to reduce discomfort and prevent corneal ulceration. The nurse recognizes that the client understands the teaching when she says: “I should:

Explanation

The mask may irritate or scratch the eye if the client turns and lies on it during the night.

Submit
74. Following prostate surgery, the retention catheter is secured to the client’s leg causing slight traction of the inflatable balloon against the prostatic fossa. This is done to:

Explanation

The pressure of the balloon against the small blood vessels of the prostate creates a tampon-like effect that causes them to constrict thereby preventing bleeding.

Submit
75. Joey is a 46 year-old radio technician who is admitted because of mild chest pain. He is 5 feet, 8 inches tall and weighs 190 pounds. He is diagnosed with a myocardial infarct. Morphine sulfate, Diazepam (Valium) and Lidocaine are prescribed. 
The physician orders 8 mg of Morphine Sulfate to be given IV. The vial on hand is labeled 1 ml/ 10 mg. The nurse should administer: 

Explanation

Using ratio and proportion 8 mg/10 mg = X minims/15 minims 10 X= 120 X = 12 minims The nurse will administer 12 minims intravenously equivalent to 8mg Morphine Sulfate

Submit
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Myra is ordered laboratory tests after she is admitted to the hospital...
After the acute phase of congestive heart failure, the nurse should...
Before a post- thyroidectomy client returns to her room from the OR,...
Joey asks the nurse why he is receiving the injection of Morphine...
The nurse is assisting in planning care for a client with a diagnosis ...
The laboratory results of the client with leukemia indicate bone...
The nurse knows that a client with Pernicious Anemia understands the...
In the evaluation of a client’s response to fluid replacement...
A client undergoes below the knee amputation following a vehicular...
In dealing with a dying client who is in the denial stage of grief,...
The most significant initial nursing observations that need to be made...
An early finding in the EKG of a client with an infarcted mycardium...
Ana is diagnosed to have Pernicious anemia. The physician orders 0.2...
The key factor in accurately assessing how body image changes will be...
To promote continued improvement in the respiratory status of a client...
Joy, an obese 32 year old, is admitted to the hospital after an...
Jude develops GI bleeding and is admitted to the hospital. An...
Ana, 55 years old, is admitted to the hospital to rule out pernicious...
The initial nursing goal for a client with myasthenia gravis during...
In the early postoperative period following a transurethral surgery,...
A chest tube with water seal drainage is inserted to a client...
Dennis receives a blood transfusion and develops flank pain, chills,...
Forty-eight hours after a burn injury, the physician orders for the...
The nurse recognizes that a client understood the demonstration of...
Larry is diagnosed as having myelocytic leukemia and is admitted to...
A client with colostomy refuses to allow his wife to see the incision...
A client jokes about his leukemia even though he is becoming sicker...
Lucy is admitted to the surgical unit for a subtotal thyroidectomy....
Twenty four hours after admission for an Acute MI, Jose’s...
When doing colostomy irrigation at home, a client with colostomy...
The nurse applies mafenide acetate (Sulfamylon cream) to Clara, who...
Eddie, a plane crash victim, undergoes endotracheal intubation and...
A client has been in a coma for 2 months. The nurse understands that...
Rene, age 62, is scheduled for a TURP after being diagnosed with a...
Mr. Ong is admitted to the hospital with a diagnosis of Left-sided...
Helen is diagnosed with myasthenia gravis and pyridostigmine bromide...
When observing an ostomate do a return demonstration of the colostomy...
A client with multiple injury following a vehicular accident is...
The meal pattern that would probably be most appropriate for a client...
Mr. Ong, a client with CHF, has been receiving a cardiac glycoside, a...
Clara is a 37-year old cook. She is admitted for treatment of partial...
The nurse would know that dietary teaching had been effective for a...
Eddie, 40 years old, is brought to the emergency room after the crash...
Arthur Cruz, a 45 year old artist, has recently had an...
The physician orders on a client with CHF a cardiac glycoside, a...
Mr. Ong weighs 210 lbs on admission to the hospital. After 2 days of...
The nurse teaches Joy, an obese client, the value of aerobic exercises...
The nurse performs full range of motion on a bedridden client’s...
Routine postoperative IV fluids are designed to supply hydration and...
Clara, a burn client, receives a temporary heterograft (pig skin) on...
Jane, a 20- year old college student is admiited to the hospital with...
Oxygen 3L/min by nasal cannula is prescribed for Joey who is admitted...
A client with a history of recurrent GI bleeding is admitted to the...
Lucy undergoes Subtotal Thyroidectomy for Grave’s Disease. In...
When a post-thyroidectomy client returns from surgery the nurse...
Jose, who had a myocardial infarction 2 days earlier, has been...
When preparing to teach a client with colostomy how to irrigate his...
Thrombus formation is a danger for all postoperative clients. The...
The transurethral resection of the prostate is performed on a client...
On a post-thyroidectomy client’s discharge, the nurse teaches her to...
An unconscious client is admitted to the ICU, IV fluids are started...
The nurse would know that a post-TURP client understood his discharge...
The physician orders non-weight bearing with crutches for Joy, who had...
During and 8 hour shift, Mario drinks two 6 oz. cups of tea and vomits...
Helen, a client with myasthenia gravis, begins to experience increased...
Twenty-four hours after TURP surgery, the client tells the nurse he...
A client with burns on the chest has periodic episodes of dyspnea. The...
The diet ordered for a client with CHF permits him to have a 190 g of...
The day after her surgery Joy asks the nurse how she might lose...
Jose, who is admitted to the hospital for chest pain, asks the nurse,...
The observation that indicates a desired response to thoracostomy...
Health teachings to be given to a client with Pernicious Anemia...
A client’s exopthalmos continues inspite of thyroidectomy for...
Following prostate surgery, the retention catheter is secured to the...
Joey is a 46 year-old radio technician who is admitted because of mild...
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