Capstone Med Surg Assessment 2023/2024 | Latest (Graded)

A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates the client might be experiencing a hemolytic transfusion reaction. Hypertension Report of urticarial Distended neck veins Report of chest pain 34) A nurse is caring for a client who had surgery 2 days ago and reports incisional pain. Which of the following actions should the nurse take first? Determine the time the last dose of pain medication was administered. Reposition the client to assist with reduction of pain. Ask the client to describe the pain and rate it on a scale of 0 to 10. Para mi Check the client's medical record for type of PRN pain medication. 35) A nurse is teaching strategies to prevent carpal tunnel syndrome to a group of oce workers. Which of the following instructions should the nurse include? (Select all that apply.) "Raise your chair height so that you lean over to type." "Use a wrist rest when working at a computer station." "Stretch your ngers and wrists periodically while working." "Position your keyboard at shoulder height." "Take breaks from the repetitive activity." 36) A nurse is assessing a client who has a tension pneumothorax following blunt chest trauma. Which of the following findings should the nurse expect? Tracheal deviation to the unaffected side Pleural friction rub Frothy, pink-tinged sputum Increased breath sounds on the affected side 37) A nurse is caring for an adult client who asks about vaccinations against communicable diseases. The nurse should inform the client that which of the following vaccines are available? (Select all that apply) Hepatitis A vaccine Hepatitis B vaccine Pneumococcal vaccine Hepatitis C vaccine Helicobacter pylori vaccine 38) A nurse is teaching a client who has angina pectoris about nitroglycerin sublingual tablets. Which of the following statements should indicate to the nurse that the client understands the teaching? "I will keep the tablets in the original container." "I should keep the container in my shirt or pants pocket." "I should begin to feel relief within 20 minutes of taking the medication." "I will drive myself to the emergency room if three nitroglycerin tablets do not relieve my pain." 39) A nurse is preparing to administer epoetin to a client who has anemia due to chemotherapy. Which of the following actions should the nurse plan to take? Review the client's Hgb level prior to administration. Use the Z-tract method when administering the medication. Shake the vial for 30 seconds prior to withdrawing the medication. Ensure the client is not taking iron supplements while on this medication. 40) A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse report to the provider immediately? Decreasing leg strength Decreasing voice volume Decreased deep tendon reflexes Decreased sensation in the arm 41)A nurse is assessing a client who has Addison's disease. Which of the following manifestations should indicate to the nurse that the client is experiencing an Addisonian crisis? Hypothermia Increased deep tendon reflexes Hypotension Erythema of the neck and chest 42) A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is the nurse's priority? Provide assistance with ambulation. Facilitate retention of facts by repeating instructions. Place the client in a darkened room. Speak slowly and clearly. 43) A nurse is providing teaching to a newly licensed nurse about caring for a client who is receiving a ealed radioactive implant. Which of the following information should the nurse include in the teaching? Place soiled linens in a lead container. • Allow children who are over 10 years old to visit. Limit visitors to 1 hr per day. Wear a lead apron during care 44) A nurse is assessing a client who is postoperative following a kidney transplant. Which of the following findings indicates the client is experiencing a transplant rejection? Polyuria • Hypothermia Hypertension Hypovolemia 45) A nurse is providing teaching to a client who is scheduled for a bone marrow biopsy taken from the iliac crest. Which of the following information should the nurse include? "Avoid taking warm baths following the procedure." • "You will lie on your back during the procedure." "You will receive general anesthesia for the procedure." "Take acetaminophen as prescribed for pain relief after the procedure." 46) A nurse is providing discharge instructions to a client who has a peptic ulcer. Which of the following dietary modications should the nurse include? Provide a snack at bedtime. • Choose decaeinated coee. Restrict intake of fried foods. Avoid drinking liquids with meals 47) A nurse is assessing a client following a hypophysectomy. Which of the following findings indicates the client might be developing diabetes insipidus? Urine ketones Hyperglycemia • Halo or ring-shaped dressing drainage Low urine specic gravity 48) A nurse is assessing a client who has a history of migraine headaches with aura and reports feeling "a migraine coming on." The nurse should expect the client to report which of the following manifestations? Visual disturbances • Photophobia Nasal congestion Phonophobia 49) A nurse is reviewing laboratory values for a client who has Cushing's disease. Which of the following values should the nurse expect? Blood glucose 65 mg/dL • Serum calcium 12.2 mg/dL Potassium 5 mEq/L Sodium 150 mEq/L 50) A nurse is assessing a client who has had a left-hemisphere stroke. Which of the following findings should the nurse expect? Expressive aphasia • Poor impulse control Left hemiparesis Disorientation to place 51) A nurse is assessing a client who has a mild traumatic brain injury. The nurse should report which of the following findings as a complication of this injury? (Select all that apply.) Bradycardia Vomiting Drainage from the ear para mi Unequal pupils Pruritus 52) A nurse is providing discharge teaching to a client who has multiple sclerosis. Which of the following instructions should the nurse include in the teaching? "It is important to engage in a strenuous aerobic exercise program to build strength and endurance." "It is important with this disease to relax muscles in a hot tub or spa." "It is important to engage in social activity, and volunteering to read to schoolchildren will keep you active." "It is important to develop a daily schedule that reduces fatigue and conserves energy."