A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition?
- bounding pedal pulse
- capillary refill less than 2 seconds
- pain that increases with passive movement
- area...
medsurg practice test B Questions &
Answers
A nurse is assessing for compartment syndrome in a client who has a short leg cast.
Which of the following findings should the nurse identify as a manifestation of this
condition?
- bounding pedal pulse
- capillary refill less than 2 seconds
- pain that increases with passive movement
- areas of warmth on the cast - ANSWERSPain that increases with passive movement
The nurse should identify that a client who has compartment syndrome experiences
pain that increases with passive movement. Compartment syndrome results from a
decrease in blood flow in the extremity caused by a decrease in the muscle
compartment size due to a cast that is too tight.
A nurse is providing teaching to a client who has a severe form of stage II Lyme
disease. Which of the following statements made by the client reflects an understanding
of the teaching?
- "I will need to take antibiotics for 1 year"
- "my partner will need to take an antiviral medication"
- "my joints ache because I have Lyme disease"
- "I bruise easily because I have Lyme disease" - ANSWERS"My joints ache because I
have Lyme disease"
Lyme disease is a vector-borne illness transmitted by the deer tick. The disease course
occurs in three stages beginning with joint and muscle pain in stage I. If left untreated,
these symptoms continue throughout stage II and, by stage III, become chronic. Other
chronic complications include memory problems and fatigue.
A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount
available is oral solution 125 mg/5 mL. How many mL should the nurse administer?
(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not
use a trailing zero.) - ANSWERS24 mL
5 x = 24
A nurse is caring for a client who has an arterial line. Which of the following actions
should the nurse take?
- flush the line before administering antibiotics
,- position the client in Trendelenburg to obtain measurements
- have the client bear down when readings are obtained
- place a pressure bag around the flush solution - ANSWERSplace a pressure bag
around the flush solution
The nurse should place a pressure bag around the flush solution of 0.9% sodium
chloride because the pressure from an artery is greater than that of the line.
A nurse is updating the plan of care for a client who is receiving chemotherapy. Which
of the following findings should the nurse identify as the priority?
- report of sore throat
- report of memory loss
- alopecia
- mucositis - ANSWERSReport of sore throat
which could be a manifestation of an infection. The client is at risk for neutropenia due
to myelosuppression; therefore, an infection could lead to sepsis. [the rest are expected
findings from chemotherapy]
A nurse is reviewing the medical record of a client who has systemic lupus
erythematosus (SLE). Which of the following findings should the nurse expect?
A butterfly rash is a manifestation of SLE. It appears as a dry, red rash on the client's
cheeks and nose and can disappear during times of remission.
A nurse is planning care for a client who is postoperative following a parathyroidectomy.
Which of the following actions should the nurse identify as the priority?
- use pillows to support the client's head and neck
- offer opioid medication
- place a tracheotomy tray at the bedside
- place the client in semi-fowler's position - ANSWERSPlace a tracheostomy tray at the
bedside
in case of airway obstruction
A nurse is assessing a client who has diabetes insipidus. Which of the following findings
should the nurse expect?
Decreased water reabsorption by the renal tubules is caused by an alteration in
antidiuretic hormone release or the kidneys' responsiveness to the hormone. [1.005-
1.030 is normal]
A nurse is providing teaching to a client who has stage II cervical cancer and is
scheduled for brachytherapy. Which of the following instructions should the nurse
include?
- "you will have an implant placed twice each month for the duration of the treatment"
- "you should remain at least 6 feet away from others between treatments"
- "you should expect to have blood in your urine for a few days after treatment"
- "you will need to stay still in the bed during each treatment session" - ANSWERSYou
will need to stay still in the bed during each treatment session.
The nurse should instruct the client that they will need to remain on bed rest with very
limited movement because excessive movement can cause the radioactive source to
become dislodged.
A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the
following interventions should the nurse include in the plan?
- encourage the client to take deep breaths after the procedure
- assist the client to hold their arms up during the procedure
- instruct the client to remain NPO after midnight prior to the procedure
- keep the client on bed rest for 8 hr following the procedure - ANSWERSEncourage the
client to take deep breaths after the procedure
After a thoracentesis, the client should deep breathe to re-expand the lung.
A nurse is caring for a client who is receiving a blood transfusion. The client becomes
restless, dyspneic, and has crackles noted to the lung bases. Which of the following
actions should the nurse anticipate taking?
- administer an antihistamine
- slow the infusion rate
- give the client a corticosteroid
- elevate the client's lower extremities - ANSWERSSlow the infusion rate
circulatory overload. The nurse should slow or stop the infusion to improve the client's
ability to breathe, place the client in an upright position, and notify the provider. The
provider might prescribe a diuretic to alleviate the fluid overload.
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