Med Surg vati assessment Questions with Answers|Graded A
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Med Surg vati assessment
A nurse is preparing to discharge a client who is postoperative following a total hip arthroplasty. Which of the following equipment should the nurse ensure that the client has available at home prior to discharge?
Continuous passive motion device
Elevated toilet sea...
a nurse is preparing to discharge a client who is postoperative following a total hip arthroplasty which of the following equipment should the nurse ensure that the client ha
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Med Surg vati assessment
A nurse is preparing to discharge a client who is postoperative following a total hip arthroplasty. Which
of the following equipment should the nurse ensure that the client has available at home prior to
discharge?
A client who is postoperative following a total hip arthroplasty is at risk for dislocation of the hip
prosthesis. Limitations on hip flexion and adduction decrease the risk. The client should avoid flexing the
hip greater than 90° and should avoid using toilet seats that are low to the ground. An elevated toilet
seat should be in place in the client's home prior to the client's discharge.
A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations
should the nurse expect? (select all that apply)
Elevated WBC count
Elevated amylase level
Rebound tenderness
Ascites
Anorexia Ans: Elevated WBC count
A client who has acute appendicitis will show a moderate elevation of the WBC count from 10,000 to
18,000/mm3. If the WBC count is greater than 20,000/mm3, it can indicate a perforated appendix.
Rebound tenderness
A client who has appendicitis develops localized pain over the right lower quadrant of the abdomen.
When the area is palpated, pain occurs during release of pressure on the client's abdomen.
Anorexia
A client who has acute appendicitis experiences nausea, vomiting, and reduced appetite.
A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following
statements by the client indicates an understanding of the teaching?
"I am aware that my diabetes is caused by an autoimmune disorder."
"I know that my diabetes developed slowly over several years."
"If I lose weight, I may be able to stop taking insulin."
"I have developed a resistance to insulin." Ans: "I am aware that my diabetes is caused by an
autoimmune disorder."
Type 1 diabetes mellitus is an autoimmune disorder that destroys pancreatic beta cells. This
autoimmune reaction is often triggered by a viral infection.
A nurse is caring for a male client who has a new prescription for cyclosporine following a kidney
transplant. Which of the following findings should the nurse identify as an adverse effect of this
therapy?
,WBC count 8,000/mm3
RBC count 6 million/mm3
BUN 24 mg/dL
Potassium 3.5 mEq/L Ans: BUN 24 mg/dL
A BUN of 24 mg/dL is above the expected reference range of 10 to 20 mg/dL, indicating renal
impairment. An adverse effect of cyclosporine is nephrotoxicity. The nurse should monitor the client for
increases in BUN and creatinine and report any elevation to the provider. A rise in BUN could indicate
transplant rejection.
A nurse in a long-term care facility is caring for a client who has dementia. Which of the following
actions should the nurse take?
Give detailed directions when addressing the client.
Provide finger food at mealtime.
Use written signs to redirect the client.
Seat the client at a large table for meals. Ans: Provide finger food at mealtime.
The nurse should provide the client who has dementia with fingers foods. Clients who have dementia
can have difficulty sitting still and tend to wander, which makes weight loss and malnutrition a concern.
Therefore, foods that the client can hold while ambulating are ideal.
A nurse is caring for a client immediately following intubation with an endotracheal (ET) tube. Which of
the following methods should the nurse identify as the most reliable for verifying placement of the ET
tube?
Feel for exhaled air emerging from the endotracheal tube.
Assess for bilateral breath sounds.
Observe for symmetric chest movement.
Check for end-tidal carbon dioxide levels. Ans: Check for end-tidal carbon dioxide levels.
According to evidence-based practice, the most reliable method for verifying ET tube placement is
checking for end-tidal carbon dioxide levels by using capnometry. A chest x-ray is another reliable
method for verifying placement.
A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy. Which of
the following client statements indicates an understanding of the teaching? (select all that apply)
"I will avoid crowds."
"I will wash my toothbrush weekly."
"I will change my cat's litter box twice weekly."
"I will take my temperature daily."
"I will eat plenty of fresh fruits and vegetables." Ans: "I will avoid crowds."
The client who is immunocompromised should avoid crowds while undergoing chemotherapy to reduce
the risk of infection.
"I will take my temperature daily."
The client who is immunocompromised should take daily temperature readings and report an elevated
temperature to the provider.
, A nurse is planning care for a. client who has a lump in their right breast. Which of the following findings
increases the client's risk of developing breast cancer?
Menarche started at age 15
First born child was at 20 years of age
History of a fibrocystic breasts
Menopausal obesity Ans: Menopausal obesity
During menopause, increased fat tissue can lead to higher stores of estrogen. Higher levels of estrogen
in the body increase the risk for postmenopausal breast cancer.
A nurse is teaching a client who is scheduled to receive radioactive iodine therapy for treatment of
hyperthyroidism. Which of the following instructions should the nurse include in the teaching?
Remain 0.3 m (1 ft) away from children.
Limit the time spent around women who are pregnant to 10 min daily.
Use disposable utensils for meals.
Use an absorbent pad if incontinent. Ans: Use disposable utensils for meals.
The client who receives radioactive iodine has radioactivity in the body fluids, including saliva, for
several weeks following treatment. The nurse should instruct the client to use disposable utensils,
plates, and cups during this time period to decrease the risk for radiation exposure to other members of
the household.
A nurse is providing discharge teaching to a client following a loop electrosurgical excision procedure
(LEEP) for the treatment of cervical cancer. Which of the following statements by the client indicates an
understanding of the teaching?
"I can resume sexual intercourse in 48 hours."
"I can expect some heavy vaginal bleeding for 24 hours."
"I can use tampons when my period comes in a week."
"I may have mild cramping for several hours." Ans: "I may have mild cramping for several hours."
The client should expect very little discomfort from the LEEP procedure, which is performed in
ambulatory care using a painless electrical current.
A nurse is providing teaching to a client who has a new prescription for cephalexin oral suspension.
Which of the following statements by the client indicates an understanding of the teaching?
"I will increase my consumption of foods high in potassium."
"I will apply lotion to my skin if I feel any itching."
"I will avoid sun exposure while taking this medication."
"I will keep the medication refrigerated." Ans: "I will keep the medication refrigerated."
A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should identify
which of the following findings as an indication of a microvascular complication?
Coronary artery disease
Retinopathy
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