exit med surg qr code Flashcards
A nurse is contributing to the plan of care for a client who has a new diagnosis of diabetes mellitus. Which of the following interventions should the nurse include in the plan?
Select all that apply.
a. reduce cholesterol and saturated fat intake
b. increase the amount of protein in the diet
c. question the client about tobacco abuse
d. sustain hyperglycemia to reduce deterioration of nerve cells
e. maintain optimal control of bp to prevent kidney damage
a. reduce cholesterol and saturated fat intake
c. question the client about tobacco abuse
e. maintain optimal control of bp to prevent kidney damage
a nurse is collecting data from a client who has malnutrition. which of the findings should the nurse identify as an indication?
a. increased tendon reflexes
b. increased muscle tone
c. decreased risk of infection
d. decreased mental status
d. decreased mental status
a nurse is reinforcing teaching with a client who is about to begin chemotherapy and is prescribed a medication that causes alopecia. Which of the statements should the nurse make?
a. hair loss following chemotherapy is, unfortunately a permanent change
b. if you choose to select a head covering, it would be best to do so before hair loss occurs
c. if you apply a heating pad to your head during chemotherapy it can reduce hair loss
d. hair loss is a minor effect of medication compared to the problems cancer can cause
b. if you choose to select a head covering, it would be best to do so before hair loss occurs. (this helps pt to find something that will match existing hair)
a nurse is reinforcing teaching with a client who is schedule to have an ileostomy. Which of the following information should the nurse include in the teaching?
a. an NG tube will be inserted 2 days prior to surgery
b. the liquid output from the stoma is to be measured
c. the stoma will appear purple in color following surgery
d. prepare to take laxatives 1 week prior to surgery
b. the liquid output from the stoma is to be measured (calculated q8h to ensure client is hydrated and nutritional intake is stable)
a nurse is reviewing the ABG findings of client with COPD and admitted with pneumonia. which of the results should nurse anticipate
a. pH 7.48, paCO2 33, HCO3 32
b. pH 7.33, PACO 58, HCO3 25
c. pH 7.52, paCO2 22, HCO3 22
d. pH 7.32, paCO2 38, HCO3 20
b. pH 7.33, PACO 58, HCO3 25
nurse reinforcing teaching with client who has grad I (mild) ankle sprain. which instruction should nurse include SATA.
a. immobilize the ankle for 4-6 wks
b. elevate the ankle above level of the heart
c. take a muscle relaxant as needed
d. wrap ankle in an elasticized compression bandage
e. apply an intermittent cold compress to the hand for first 24-48 hr
b. elevate the ankle above level of the heart
d. Wrap the ankle with an elasticized compression bandage is correct
e. apply an intermittent cold compress to the hand for first 24-48 hr
a nurse is caring for a client who is 36 hr postop following thyroidectomy and reports severe lower extremity muscle spasm. which of the following actions should the nurse make?
A. Check the pedal pulses.
B. Attempt to elicit Chvostek’s sign.
C. Request a prescription for a muscle relaxant.
D. Administer an oral potassium supplement.
B. Attempt to elicit Chvostek’s sign. (pt at risk for hypocalemia due to disruption of parathyroid gland during surgery.)
a nurse is contributing to the plan of care for a client who has neutropenia following chemotherapy. which of the following interventions should the nurse recommend for the client’s plan of care?
Encourage the client to use a disposable razor for shaving.
Increase fresh uncooked produce in the client’s diet.
Reinforce teaching about deep breathing exercises.
Insert an indwelling urinary catheter.
Reinforce teaching about deep breathing exercises. (pt at risk for infection, deep breathing promotes lung expansion and clear secretions that could cause infection)
a nurse is assisting a charge nurse with the care of a young adult client who has a prescription for one unit of packed RBC stat. which of the following supplies should the nurse obtain?
18-gauge IV catheter
IV piggyback tubing
250 mL dextrose in water (D5W)
Medication label
18-gauge IV catheter
nurse caring for a client who has been receiving potassium chloride after being admitted with a serum potassium of 3.1. what findings should nurse identify as a therapeutic response?
Decreased bowel sounds
Positive Trousseau’s sign
Positive Chvostek’s sign
Increased muscle strength
Increased muscle strength (as hypokalemia can cause muscle weakness)
a nurse is assisting with the care of a client who has right sided chest tube to closed drainage. the nurse notes a rise in fluid level of the water seal chamber when the client inhales. which of the actions should the nurse take?
Continue to monitor the client.
Retape the chest tube connections.
Reposition the client toward the left side.
Clamp the chest tube near the water seal.
Continue to monitor the client.
a nurse is reviewing the plan of care for a client who is at risk for increased ICP following closed head injury, which intervention should nurse identify as CI for this client?
Assist the client to cough and deep breathe.
Elevate the head of the client’s bed to 30°.
Perform passive arm range-of-motion exercises for the client.
Log roll the client slowly when repositioning.
Assist the client to cough and deep breathe. (a closed head injury is caused by blunt trauma to the head. the client should avoid this due to increasing ICP)
a nurse caring for a client who is scheduled for a cardiac catherterization with coronary angiography. the client has a hx of coronary artery disease and takes cardiac medications. which action should nurse take
Instruct the client to take nothing by mouth 12 hr before the procedure.
Palpate and mark peripheral pulses.
Withhold the client’s cardiac medications before the procedure.
Inform the client that an urge to void will occur following the injection of the contrast dye.
Palpate and mark peripheral pulses. (this establishes a baseline and facilitate ongoing monitoring of peripheral perfusion during procedure)
nurse reinforcing teaching w client who has cancer about reducing the risk of infection. which client statements indicated an understanding of the instructions?
“I will eat a salad daily to increase my intake of vitamin K.”
“I can work in my flower garden as long as I wear gardening gloves.”
“I will clean my toothbrush using a hydrogen peroxide solution.”
“I should take a shower every other day using antibacterial soap.”
“I will clean my toothbrush using a hydrogen peroxide solution.”
a nurse is determining a client’s ability to perform self-care following a stroke. which of the following findings should nurse identify as the priority.
Weak grip
Vision impairment
Aphasia
Emotional lability
vision impairment (risk for fall/injury)
