Exam (elaborations)
Adult Medical Surgical (1)
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Adult Medical Surgical (1)
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Adult Medical SurgicalMaintain abduction of the client's right leg while in bed. - ANS-A nurse is caring for a
client who is 3 days postoperative following a total right hip arthroplasty. Which of the
following actions should the nurse take?
"You feel like you want to discontinue treatment?" - ANS-A nurse is caring for a client
who has terminal pancreatic cancer. The client states, "I don't think I can go on any
longer." Which of the following responses should the nurse make?
"Are you experiencing abdominal pain?"
"You should talk about this with the people you're closest to."
"Many people who have cancer feel this way."
"You feel like you want to discontinue treatment?"
Implement recommendations from the speech-language pathologist. - ANS-A nurse is
contributing to the plan of care for a client who is having difficulty eating following a
stroke. Which of the following actions should the nurse take first?
Collaborate with a dietitian.
Ensure that the client is provided with a high-ber diet.
Implement recommendations from the speech-language pathologist.
Request a referral for an occupational therapist.
Keep the client in a side-lying position.
Greatest risk to the client following a stroke is aspiration. The nurse should position the
client in a lateral, or side-lying, position to allow any secretions to drain out of the mouth,
decreasing the risk for aspiration. Additionally, the nurse should have suction equipment
available in the event that any secretions are present in the oral cavity. - ANS-A nurse is
contributing to the plan of care for a client who was admitted to the neurological unit
following a stroke 3 hr ago. Which of the following interventions should the nurse
identify as the priority?
Herpes zoster for 60 years of age and older.
Meningococcal vaccine to college students and military recruits who are living in shared
housing.
HPV vaccine for clients who are 9 to 26 years of age.
,MMR vaccine to clients who are 62 years of age. - ANS-A nurse is participating in a
health fair for older adult clients. Which of the following vaccines should the nurse
recommend for this age group?
Instruct the client to swish the medication in their mouth. - ANS-A nurse is contributing
to the plan of care for a client who has a new prescription for nystatin suspension for
oral candidiasis. Which of the following interventions should the nurse include in the
plan?
Use a commercial mouthwash before taking the medication.
Instruct the client to swish the medication in their mouth.
Discontinue the medication as soon as the lesions are healed.
Combine the medication with applesauce
intermittent straight catheter (clear tube with blue top) - ANS-A nurse is preparing to
perform intermittent urinary catheterization for a female client who has been unable to
void following surgery 6 hr ago. Which of the following catheters should the nurse use to
perform this procedure?
Hyperactive bowel sounds
Normal bowel sounds, the nurse should expect to hear 5-35 gurgles and clicks in 1 min.
- ANS-A nurse is preparing to auscultate the bowel sounds of a client who has a
mechanical bowel obstruction in the descending colon. When listening in the left upper
quadrant, the nurse should identify this sound as which of the following?
Encourage the client to complete ADLs. - ANS-A nurse is contributing to the plan of
care for a client who has multiple sclerosis and is taking dantrolene to manage muscle
spasms. Which of the following interventions should the nurse include?
Apply hot packs to the client's muscles.
Schedule physical therapy in the afternoon
Encourage the client to complete ADLs.
Administer valerian to promote sleep
Monitor the insertion site for bleeding is
Maintain the pressure dressing
Check the client's peripheral pulses - ANS-A nurse is assisting with the care of a client
who had a cardiac catheterization via the right femoral artery. Which of the following
actions should the nurse take to prevent postprocedure complications?
, Monitor the insertion site for bleeding
Position the affected extremity at a 45º
Restrict the client's fluid intake
Maintain the pressure dressing
Check the client's peripheral pulses
"Do not allow visitors to smoke cigarettes in your home." - ANS-A home health nurse is
reinforcing teaching about preventing asthma attacks with a client who has asthma.
Which of the following instructions should the nurse include in the teaching?
"Cover the floor of your bedroom with carpet."
"Do not allow visitors to smoke cigarettes in your home."
"Breathe cold air to ease feelings of shortness of breath."
"Open the windows in your home during the spring to increase air flow."
Decreases pain during urination - ANS-A nurse is caring for a client who has a
prescription for phenazopyridine. Which of the following findings should the nurse
identify as a therapeutic effect of the medication?
Reduces bacteria in the urinary tract
Suppresses urge to void
Prevents nerve stimulation to the bladder muscle
Decreases pain during urination
Abdominal cramps - ANS-A nurse is monitoring a client who is taking acarbose. Which
of the following findings should the nurse identify as an adverse effect of the
medication?
Polyuria
Abdominal cramps
Renal insufficiency
Insomnia
Compartment Syndrome - ANS-A nurse is caring for a client who has a new cast on
their left forearm and reports severe pain in the affected arm with numbness in the
ngers. The nurse nds the skin is pale and cold with sluggish capillary refill. Which of the
following fracture complications should the nurse suspect?
Compartment syndrome
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