PN VATI MEDSURG EXAM NEWEST EXAM | ALL
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES | GRADED A+ | VERIFIED
ANSWERS | JUST RELEASED
A nurse is caring for a client who has burns to the face, neck, and upper
chest. The client has expressed concerns regarding the change to their
physical appearance. Which of the following actions should the nurse take?
------CORRECT ANSWER---------------Encourage the client to ask questions
about their treatment
The nurse should assist the client through the grief process by
encouraging them to ask questions and verbalize concerns. Including
the client in the treatment plan provides the client with a sense of
control.
A nurse is caring for a client who is receiving peripheral IV therapy. The
nurse notes that the IV site is red, warm, and painful to the touch. Which of
the following actions should the nurse take? ------CORRECT ANSWER------
---------Discontinue the IV and apply a warm, moist compress to the site.
These complications include pain at the IV site, along with redness
and warmth. The nurse should stop the infusion, remove the IV,
inspect the catheter to ensure Complications of intravenous therapy
involve inflammation of the vein, phlebitis, and can include the
presence of clots or thrombophlebitis. Manifestations of it is intact,
and apply a warm, moist compress to the area.
A nurse is caring for a client who has deep vein thrombosis. Which of the
following actions should the nurse take to promote venous return? ------
,CORRECT ANSWER---------------Maintain the use of compression
stockings except when bathing the client.
The antiembolic stockings should be removed for short periods (30 to 60
min) when bathing
A nurse is reviewing the medical record for a client who has a new
prescription for combined oral contraception. Which of the following
findings is a risk factor for the development of thromboembolism? ------
CORRECT ANSWER---------------Cigarette smoking
The concurrent use of combined oral contraceptive and tobacco
increases the risk of thromboembolism or pulmonary embolus. The
nurse should inform the client about this risk and shoulf reinforce
teaching about methods of smoking cessation with the client
A nurse is reinforcing teaching with a client who has chronic renal failure
and is prescribed epoetin alfa. Which of the following information should
the nurse include in the teaching? ------CORRECT ANSWER---------------
"Eppetin alfa can reduce your need for a blood transfusion.
Epoetin alfa is a hormone that stimulates the production of red blood
cells. It is used in the treatment of specific types of anemia.
Therapeutic effects are indicated by an increase in hematocrit
resulting in a decreased requirement for blood transfusions.
A nurse is preparing to assist with a client who is scheduled for a
bronchoscopy. Which of the following actions should the nurse take? ------
CORRECT ANSWER---------------Administer supplemental oxygen.
,Prior to the procedure, the nurse should administer oxygen and then
continue to monitor the client's oxygen saturation level throughout
and following the bronchoscopy. A bronchoscopy is performed as
either a diagnostic ora therapeutic procedure and involves visualizing
the larynx and tracheobronchial tree.
A nurse is contributing to the plan of care for a client who had a stroke and
is experiencing dysphagia. Which of the following interventions should the
nurse include in the plan? ------CORRECT ANSWER---------------Keep the
client's glasses of liquid at least two-thirds full.
The nurse should keep the client's glasses of liquid at least two-thirds
full so the client can drink the liquids without tilting their head back,
which can increase the risk for aspiration.
A nurse is contributing to the plan of care for a client who is in skeletal
traction. Which of the following interventions should the nurse include? -----
-CORRECT ANSWER---------------Keep the client's body centered in the
bed.
The nurse should keep the client's body centered on the bed to
maintain alignment of the body with the direction of the pull of
traction. This will ensure continued alignment of the bone.
A nurse is contributing to the plan of care for a client who has dysphagia
following a stroke. Which of the following actions should the nurse include
in the plan of care to prevent aspiration? ------CORRECT ANSWER-----------
----Keep the client upright for 30 min after a meal.
The nurse should keep the client upright for 30 to 60 min after a meal
to reduce the risk for aspiration.
, A nurse is reinforcing postoperative teaching with a client who is scheduled
for cataract surgery on his right eye. Which of the following instructions
should the nurse include? ------CORRECT ANSWER---------------"Wear a
protective eye shield while sleeping
The nurse should remind the client to wear an eye shield while
sleeping. This protects the operative eye from injury due to rubbing or
pressure from the pillow.
A nurse is collecting data from a client who was admitted with a Glasgow
coma scale (GCS) of 3. Which of the following findings should the nurse
expect? ------CORRECT ANSWER---------------Nonresponsive to commands
A client who has a GCS of less than 8 has evidence of severe head
injury and is in a comatose state. The GCS is a standardized tool that
allows for the evaluation of a client's level of consciousness. The test
is divided into three sections that evaluate eye opening, motor
response, and verbal response. The GCS ranges from a high score of
15 (fully alert) to a low score of 3 (fully comatose).
A nurse is caring for a client who has type 1 diabetes mellitus and has
undergone a below-the-knee amputation. Which of the following is the
nighest priority finding? ------CORRECT ANSWER---------------Skin flap of
the residual limb is cool to the touch
When using the urgent vs. nonurgent approach to client care, the
nurse should determine that the priority finding is that the skin flap of
the residual limb is cool to the touch. The nurse should immediately
report this finding to the provider. The skin flap of the residual limb
should be warm to the touch, indicating adequate tissue perfusion.
A nurse is reinforcing teaching about the prevention of sexually transmitted
infections (STIS) with a client who is sexually active. Which of the following
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES | GRADED A+ | VERIFIED
ANSWERS | JUST RELEASED
A nurse is caring for a client who has burns to the face, neck, and upper
chest. The client has expressed concerns regarding the change to their
physical appearance. Which of the following actions should the nurse take?
------CORRECT ANSWER---------------Encourage the client to ask questions
about their treatment
The nurse should assist the client through the grief process by
encouraging them to ask questions and verbalize concerns. Including
the client in the treatment plan provides the client with a sense of
control.
A nurse is caring for a client who is receiving peripheral IV therapy. The
nurse notes that the IV site is red, warm, and painful to the touch. Which of
the following actions should the nurse take? ------CORRECT ANSWER------
---------Discontinue the IV and apply a warm, moist compress to the site.
These complications include pain at the IV site, along with redness
and warmth. The nurse should stop the infusion, remove the IV,
inspect the catheter to ensure Complications of intravenous therapy
involve inflammation of the vein, phlebitis, and can include the
presence of clots or thrombophlebitis. Manifestations of it is intact,
and apply a warm, moist compress to the area.
A nurse is caring for a client who has deep vein thrombosis. Which of the
following actions should the nurse take to promote venous return? ------
,CORRECT ANSWER---------------Maintain the use of compression
stockings except when bathing the client.
The antiembolic stockings should be removed for short periods (30 to 60
min) when bathing
A nurse is reviewing the medical record for a client who has a new
prescription for combined oral contraception. Which of the following
findings is a risk factor for the development of thromboembolism? ------
CORRECT ANSWER---------------Cigarette smoking
The concurrent use of combined oral contraceptive and tobacco
increases the risk of thromboembolism or pulmonary embolus. The
nurse should inform the client about this risk and shoulf reinforce
teaching about methods of smoking cessation with the client
A nurse is reinforcing teaching with a client who has chronic renal failure
and is prescribed epoetin alfa. Which of the following information should
the nurse include in the teaching? ------CORRECT ANSWER---------------
"Eppetin alfa can reduce your need for a blood transfusion.
Epoetin alfa is a hormone that stimulates the production of red blood
cells. It is used in the treatment of specific types of anemia.
Therapeutic effects are indicated by an increase in hematocrit
resulting in a decreased requirement for blood transfusions.
A nurse is preparing to assist with a client who is scheduled for a
bronchoscopy. Which of the following actions should the nurse take? ------
CORRECT ANSWER---------------Administer supplemental oxygen.
,Prior to the procedure, the nurse should administer oxygen and then
continue to monitor the client's oxygen saturation level throughout
and following the bronchoscopy. A bronchoscopy is performed as
either a diagnostic ora therapeutic procedure and involves visualizing
the larynx and tracheobronchial tree.
A nurse is contributing to the plan of care for a client who had a stroke and
is experiencing dysphagia. Which of the following interventions should the
nurse include in the plan? ------CORRECT ANSWER---------------Keep the
client's glasses of liquid at least two-thirds full.
The nurse should keep the client's glasses of liquid at least two-thirds
full so the client can drink the liquids without tilting their head back,
which can increase the risk for aspiration.
A nurse is contributing to the plan of care for a client who is in skeletal
traction. Which of the following interventions should the nurse include? -----
-CORRECT ANSWER---------------Keep the client's body centered in the
bed.
The nurse should keep the client's body centered on the bed to
maintain alignment of the body with the direction of the pull of
traction. This will ensure continued alignment of the bone.
A nurse is contributing to the plan of care for a client who has dysphagia
following a stroke. Which of the following actions should the nurse include
in the plan of care to prevent aspiration? ------CORRECT ANSWER-----------
----Keep the client upright for 30 min after a meal.
The nurse should keep the client upright for 30 to 60 min after a meal
to reduce the risk for aspiration.
, A nurse is reinforcing postoperative teaching with a client who is scheduled
for cataract surgery on his right eye. Which of the following instructions
should the nurse include? ------CORRECT ANSWER---------------"Wear a
protective eye shield while sleeping
The nurse should remind the client to wear an eye shield while
sleeping. This protects the operative eye from injury due to rubbing or
pressure from the pillow.
A nurse is collecting data from a client who was admitted with a Glasgow
coma scale (GCS) of 3. Which of the following findings should the nurse
expect? ------CORRECT ANSWER---------------Nonresponsive to commands
A client who has a GCS of less than 8 has evidence of severe head
injury and is in a comatose state. The GCS is a standardized tool that
allows for the evaluation of a client's level of consciousness. The test
is divided into three sections that evaluate eye opening, motor
response, and verbal response. The GCS ranges from a high score of
15 (fully alert) to a low score of 3 (fully comatose).
A nurse is caring for a client who has type 1 diabetes mellitus and has
undergone a below-the-knee amputation. Which of the following is the
nighest priority finding? ------CORRECT ANSWER---------------Skin flap of
the residual limb is cool to the touch
When using the urgent vs. nonurgent approach to client care, the
nurse should determine that the priority finding is that the skin flap of
the residual limb is cool to the touch. The nurse should immediately
report this finding to the provider. The skin flap of the residual limb
should be warm to the touch, indicating adequate tissue perfusion.
A nurse is reinforcing teaching about the prevention of sexually transmitted
infections (STIS) with a client who is sexually active. Which of the following
