Medical-Surgical: Final
Question 1 loaded rationals provided
Question: 1 of 50
1. A nurse in an emergency department is caring for a client who reports developing severe right eye pain
with a gritty sensation while sawing wood. Which of the following actions should the nurse take first?
Instill proparacaine hydrochloride eyedrops.
Perform ocular irrigation of the right eye.
Place the client in a supine position with the head turned toward the affected side.
Ask the client about first aid performed at the scene.
2. A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should the
nurse include in the client's plan of care?
Maintain the client's knees and hips in a flexed position.
Apply cold compresses to painful joints.
Withhold opioids until the crisis is resolved.
Encourage increased fluid intake.
3. A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions
should the nurse take?
Have the client gently blow clots from the nose every 5 min.
Instruct the client to sit with his head hyperextended.
, Apply ice compresses to the back of the client's neck.
Apply lateral pressure to the client's nose for 10 min.
4. A nurse is performing an admission assessment for a client who has asthma and reports several food allergies.
Which of the following actions should the nurse take first?
Document the client's food allergies on the medical record.
Ask the client to identify the specific food allergies.
Monitor the client for indications of anaphylaxis.
Have epinephrine available for administration.
5. A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the following actions should the
nurse take? (Select all that apply.)
Place the client on respiratory isolation.
Monitor vital signs every 2 hr.
Assess neurological status every 4 hr.
Maintain the client in a modified Trendelenburg position.
, Keep the client's room darkened.
6. A nurse is caring for a client who is to have his chest tube removed. Which of the following actions should the nurse
take?
Cover the insertion site with a hydrocolloid dressing after removal.
MY ANSW ER Provide pain medication immediately after removal.
Instruct the client to perform the Valsalva maneuver during removal.
Delegate removal of the chest tube to a licensed practical nurse (LPN).
7. A nurse is providing teaching to a client who has gout and urolithiasis. The client asks how to prevent future uric acid
stones. Which of the following suggestions should the nurse make? (Select all that apply.)
Take allopurinol as prescribed.
Exercise several times a week.
Limit intake of foods high in purine.
Decrease daily fluid intake.
Avoid citrus juices.
8. A nurse is planning care for a client who had a stroke. The client has hemiplegia and occasional urinary
incontinence. Which of the following actions should the nurse include in the client's plan of care?
Question 1 loaded rationals provided
Question: 1 of 50
1. A nurse in an emergency department is caring for a client who reports developing severe right eye pain
with a gritty sensation while sawing wood. Which of the following actions should the nurse take first?
Instill proparacaine hydrochloride eyedrops.
Perform ocular irrigation of the right eye.
Place the client in a supine position with the head turned toward the affected side.
Ask the client about first aid performed at the scene.
2. A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should the
nurse include in the client's plan of care?
Maintain the client's knees and hips in a flexed position.
Apply cold compresses to painful joints.
Withhold opioids until the crisis is resolved.
Encourage increased fluid intake.
3. A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions
should the nurse take?
Have the client gently blow clots from the nose every 5 min.
Instruct the client to sit with his head hyperextended.
, Apply ice compresses to the back of the client's neck.
Apply lateral pressure to the client's nose for 10 min.
4. A nurse is performing an admission assessment for a client who has asthma and reports several food allergies.
Which of the following actions should the nurse take first?
Document the client's food allergies on the medical record.
Ask the client to identify the specific food allergies.
Monitor the client for indications of anaphylaxis.
Have epinephrine available for administration.
5. A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the following actions should the
nurse take? (Select all that apply.)
Place the client on respiratory isolation.
Monitor vital signs every 2 hr.
Assess neurological status every 4 hr.
Maintain the client in a modified Trendelenburg position.
, Keep the client's room darkened.
6. A nurse is caring for a client who is to have his chest tube removed. Which of the following actions should the nurse
take?
Cover the insertion site with a hydrocolloid dressing after removal.
MY ANSW ER Provide pain medication immediately after removal.
Instruct the client to perform the Valsalva maneuver during removal.
Delegate removal of the chest tube to a licensed practical nurse (LPN).
7. A nurse is providing teaching to a client who has gout and urolithiasis. The client asks how to prevent future uric acid
stones. Which of the following suggestions should the nurse make? (Select all that apply.)
Take allopurinol as prescribed.
Exercise several times a week.
Limit intake of foods high in purine.
Decrease daily fluid intake.
Avoid citrus juices.
8. A nurse is planning care for a client who had a stroke. The client has hemiplegia and occasional urinary
incontinence. Which of the following actions should the nurse include in the client's plan of care?
