Med-Surge 2

1. The nurse is caring for a client with severe RA. She becomes combative and abusive to the staff when she is unable to perform personal care independently. What is the best statement the nurse can make at this time?

You seem frustrated. Would like to try to dress again in a few minutes?

I will have to restrain your hands if you cannot keep them to yourself

I will ask your doctor for a psych to talk about your anger

Would you like me to get an order of a med to help settle you down?

2. A client returns to the med-surge unit after a total hip replacement with a large wedge pillow between his legs. The client's daughter asks the nurse why the pillow is in place. What is the nurse's best response?

It will keep the new hip from becoming dislocated

It will help prevent nerve damage and foot drop

It will prevent bedsores from developing

It will prevent him from climbing out of bed

3. The nurse is caring for a young woman at a primary health clinic. Which assessment finding leads the nurse to question the client about risk factors for HIV

Unable to become pregnant for 2 years

Very heavy periods and breakthrough bleeding

Six vaginal yeast infections in the last 12 months

Severe cramping and irregular periods

4. When obtaining a sexual history from a client in the clinic, the nurse notes that the client appears uncomfortable and pauses for a long time before answering the questions. What is the nurse's best response?

These are making you uncomfortable, we'll finish next time

Take your time, I realize this is a private subject to talk about

I am sorry that my questions are making you uncomfortable

Don't worry. We'll be done with these questions in no time.

5. The nurse is teaching a community health class about health promotion techniques. Which statement by a student indicates a strategy to help prevent the development of osteoarthritis?

I will have a family tree done

I will switch to low-tar cigarettes

I will keep my BMI below 24

I will start jogging twice a week

6. The nurse is caring for a patient who has had hip replacement surgery 2 days before. The patient reports sever pain at the surgical site despite having received 2 vicodin 2 hours previously. The client is requesting IV pain meds. What is the priority intervention?

Reassure the client that the vicodin will work soon

Apply a large ice bag to the operative site

Assess the surgical site for signs of infection

Administer 2 more vicodin tablets

7. A client with angioedema of the lower face needs the nurse to assess what next?

Pulse ox

Chest wall symmetry

Breath sounds

Airway patency

8. A client comes to the ED with a fever, diarrhea, and general malaise. What info does the nurse give immediately to the health care provider?

The client having just returned from a 14 day trip to Asia

Allergy to aspirin

A blood transfusion 12 years ago

Blood pressure of 110/90

9. The home care nurse is making a follow up visit to a client who had a total hip replacement surgery 2 weeks ago. Which client statement indicates a need for clarification regarding post-op routine?

I take 200 mg of Motrin at bedtime so I can sleep

Each day, I try to increase my walking at least by 10 minutes

Now that my hip doesn't hurt, I can cross my legs like a lady

My daughter helps me put on my TED hose every day

10. The nurse is working with a client who will be taking 20 mg of prednisone daily for RA. Which precautions does the nurse give the client taking this med?

Take medication at bedtime it will make you sleepy

Eat a high-fiber diet with lots of lean meats

Wash your face twice a day with an antibacterial soap

Take a calcium and vitamin D supplements daily

11. A client with selective IgA deficiency has an order for an infusion of IV IgG. What is the nurses best action?

Call the physician to clarify the order

Start a second line for the antibiotics

Review the client's renal panel before staring med

Obtain baseline VS and another after 15 minutes

12. The nurse asks a young adult client if she is sexually active. The client asks why she needs to know. What is the best response?

I have to fill in answers to all questions on the health history form

If you are sexually active we should talk about ways to prevent HIV

I will notify your partner is you have a STD

I just need to make sure that your are providing reliable information

13. What client is most at a increased risk of developing an infection?

Adolescent using analgesics for migraines

Young adult who wears contacts

Adult with type 1 DM

Adult with hypersensitivity to latex

14. The nurse is caring for a client who is 1 day post-op from total hip replacement. The nurse is instructing the client about how to perform quadriceps-setting exercises correctly. Which direction does the nurse provide to the client?

Straighten legs and push back of knees into the mattress

Bend each knee and rapidly point your toes downward and then upward

Straighten your legs and bring each leg separately off the mattress 6 inches

Raise each leg 10 inches off the bed, keep it straight and make ankle circles

15. A client with chronic had a total knee replacement this morning and has a continuous passive motion machine. What activity related to CPM does the nurse delegate to the UAP?

Teaching the client's family the rationale for the CPM

Assessing the client's response to the CPM

Placing the controls out of the reach of confused clients

Assessing neurovascular status of the leg in the CPM

16. The nurse is working with a client who has severe RA in her hands. The clients states she is frustrated at mealtime because it is difficult for her to manage cups and silverware. What is the best response?

Let's see if OT can provide you with some utensils

I'll have the techs set up your meal trays while you are in the hospital

Let's see if PT can suggest some muscle strengthening tips

I'll arrange for a home nurse asst. to help with meals after discharge

17. What intervention does the nurse implement to provide for client safety during intradermal allergy testing?

Stay with the client and ensure that emergency equipment is in the room.

Apply oxygen by mask or cannula before injecting test agent

Pretreat the skin area to be tested with a cortisone-based cream

Cover the exam table with plastic or ultrafine mesh

18. The nurse is caring for an older client who had his hip replaced 2 days prior. Which assessment is the best indicator that he does not need pain meds at this time?

The client's vitals are stable

The client received 2 pain pills 2 hours ago

The client is sleeping quietly

The client states he has no pain

19. Which intervention is most important for the nurse to teach the client who is recovering from an allergic reaction to a bee sting?

Keep bendryl available

Avoid contact with allergen

Wear a medical alert bracelet

How to use an EpiPen

20. A client is scheduled to undergo radiation therapy for breast cancer asks why 6 weeks of daily treatment is necessary. What is the best response?

Research has shown that more cancer is killed in small doses over a longer period of time

Your cancer is widespread and requires more than usual amount

Giver larger doses for radiation for a short amount of time has worse side effects

It is likely that your hair will fall out

21. A client has late-stage colon cancer with metastasis to the spine and bones. What nursing intervention is best to add the the care plan to address a priority problem?

Provide 6 small meals and day with snacks

Give the client pain meds around the clock

Ensure that the client gets adequate rest

Offer prune juice twice a day

22. The nurse is teaching a client with RA about joint protection principles. What info is included?

Sit most often in a reclining chair

Use assistive-adaptive devices

Bend at your knees to lift objects

Use smaller joints to rest larger ones

Hold objects with two hands, not one.

Submit

23. An older adult client is admitted with an infection. Upon assessment the client is slightly confused. VS are as follows: T 99.2 BP 100/60 HR 100 RR 20. What action is most appropriate?

Assess the client's pain level and treat if needed

Preform a mini-mental

Assess the client for other signs of infection

Document and continue to monitor

24. A client undergoing radiation therapy says "I will be glad when this is over and I don't have to worry about my skin". What is the most appropriate response?

You can get prescription lotions to reduce the effects of radiation

Unfortunately your skin will be permanently damaged from the radiation

You're having problems with your skin? That is unusual, let me take a look

You need to protect your skin from the sun for at least a year afterward

25. The nurse provides discharge teaching for a client to prevent gout attacks. Which statement indicates that additional teaching is required?

Citrus juices and milk may keep me from having kidney stones

If I get a headache, I will take Tylenol instead of aspirin

I hate to start limiting my fluid intake so much

I will keep a food symptom diary for a few weeks

26. The nurse is caring for a client with AIDS who has just been diagnosed with cryptococcal meningitis. What is the best intervention for this client?

Initiate resp. isolation for the next 72 hours

Administer IV Pentam

Initiate seizure precautions with padded siderails

Thicken the client's liquids to honey consistency

27. The nurse is teaching a client how to reduce the pain that she often experiences with fibromyalgia. Which statement does the nurse include?

Make sure that you get enough sleep every night

Avoid exercising when your muscles

Stay out of the sun as much as possible

Wear gloves outdoors in cooler temperature

28. The nurse is caring for an older adult client who will be discharged after being hospitalized for a total hip replacement. Which statement indicates that arrangements may have to be made to have the client's meds supervised at home?

I prepare all my pills for the week and will place them in a labeled medi-set

My wife takes iron too so we will take our meds together

If my legs get swollen I will take an extra coumadin

I will take my coumadin every day pill everyday just before the news

29. The nurse prioritizes which intervention in a client with xerostomia secondary to radiation therapy to the neck area?

Monitoring vitals every 4 hours

Applying lotions and oils to the affected areas

Providing oral care after meals and at bedtime

Wearing a hat to decrease heat loss

30. A mother brings her child to the clinic requesting genetic testing to determine whether her child suffers from the same multiple allergies as herself. What is the nurse's most appropriate response?

Have the mother list her allergies and symptoms

Ask the mother about specific symptoms the child may have had

Provide a referral to an allergist so the child can be tested

Refer to a geneticist to have the child tested

31. A client has be admitted for the second time to treat TB. Which referral does the nurse initiate?

Visiting nurses to arrange directly observed therapy on dismissal

Psych nurse liaison to assess for noncompliance

Social worker to see if client can afford meds

Infection control nurse to arrange for testing of drug resistance

32. The nurse is caring for a patient who has right total knee replacement surgery 3 days ago. During the assessment, the nurse notes that the client's right lower leg is twice the size of the left. What is the nurse's priority intervention?

Assess the client's respiratory status

Check the client's pedal pulses

Apply TED stockings

Elevate the client's right leg

33. A client is suspected to have RA. Which manifestations does the nurse assess most carefully for?

Numbness and tingling in the client's fingers

Client has cool feet, with peak pedal pulses

Crepitus when the client moves the shoulders

Low grade fever, fatigue, anorexia with weight loss

34. The nurse is caring for a female client who has a history of chronic fatigue syndrome. Which finding is the nurse surprised to see in the client's record?

Multiple tender lymph nodes

Newly red, swollen, warm knee

Serum creatinine, 0.9mg/dL

Hemoglobin, 7.2 g/dL

35. The nurse is teaching a client with AIDS how to avoid infection at home. Which statement indicates additional teaching is needed?

I will run my toothbrush in the dishwasher every evening

I will make sure to have my own tube of toothpaste

I will be sure to eat lots of fresh fruits and veggies everyday

I will wash my hands when I get home from work

36. The nurse is caring for an HIV patient. The client has become confused over the shift and the pupils are no longer reacting to light. The nurse anticipates an order for which med?

Pentam

Nizoral

Bactrim

Deltazone

37. A client has scabies. In addition to standard precautions which info is most important to communicate with visitors and health care providers?

Keep head covered when providing care

Do not allow children to visit

Wear a mask when within 3 feet

Wear gloves when entering the room

38. The nurse is caring for a client newly diagnosed as HIV+ who will be taking Fuzeon. Which precaution is most importnant for the nurse to communicate to this patient?

Take this med with a snack or meal

Rotate sites of the injection

Do not drive or operate heavy machinery while taking this med

Stop taking if you have a fever

39. A client is receiving an IV infusion of an antibiotic. The client calls the nurse about feeling uneasy and uncomfortable owing to congestion. Which action by the nurse is most appropriate?

Have another nurse call the rapid response team

Slow the IV infusion rate

Elevate the head of the bed to 45 degrees

Prepare to administer benedryl

40. How does the type V hypersensitivity reaction differ from other reactions?

It results in more severe tissue damage than is caused by other types

It produces a stimulatory response in normal tissues

It is an immediate response rather than a delayed response

It is cell mediated rather than antibodies

41. A client with chronic gout takes Benemid and comes to the clinic with frequent severe headaches and a new gout flare. The client is frustrated because the gout was previously controlled. What question is most helpful?

Have you switched from wine to beer lately?

Are you following your diet?

Do you know what triggers your gout?

What do you take for your headaches?

42. A client with AIDS has been admitted with fever, night sweats, and weight loss of 6 pounds in 2 weeks. His PPD test placed 3 days ago is negative. What action is most appropriate?

Initiate a 3 day calorie count

Facilitate a chest x-ray

Start an IV of NS

Place on airborne precautions

43. The nurse is teaching a client how to prevent transmitting HIV to his partner. Which statement indicates further teaching is needed?

Water based lubes are best to prevent condom breakage

I can throw condoms in the trash after using them

The condom needs to stay on until I withdraw

I will store condoms in my wallet

44. A nurse suspects a client to have serum sickness. For which manifestation does the nurse assess the client?

Joint pain

Allergic Rhinitis

Stridor

Wheezing

45. What is the priority problem for a client experiencing chemo-induced anemia?

Fatigue related to decreased oxygenation

Body Image problems related to skin color changes

Inadequate nutrition related to anorexia

Risk for injury related to fatigue

46. A client and his family are waiting on results determining if a client has an infection. They are becoming anxious. What is the most important assessment the nurse should make of the client and his family?

Use of appropriate coping mechanisms for anxiety

Understanding the infectious disease process

Understand diagnostic procedures

Understanding insurance