Med-Surg 1

Question 1

A client with expressive aphasia. The team decided on which intervention to help with communication?

a) make sure all staff know to speak slowly and in short sentences
b) make sure all staff assist the pt with use of a picture board which is pt driven

Answer 1

b
expressive aphasia is when the client knows what they want to say but has trouble saying it. For that reason, the use of a picture board is helpful to clients with expressive aphasia.

a)
this may be helpful, it is not the most therapeutic intervention listed.
remember expressive aphasia does not affect cognition or intelligence, only the ability to express oneself.

Question 2

Interventions for ititial plan of care for a pt with suspected embolic stroke?

Answer 2

obtain CT scan SATA
Perform neuro assessment
Prepare alteplase(tPA) within 4.5 hrs

Question 3

Pt with TIA is discharge. Which medication would the nurse anticipate being ordered for the pt?
a) An aral anticoagulant
b) A beta blocker
c) A thrombolytic

Answer 3

a
such as warfarin to help prevent thrombi formation

c) to disslove a clot,it may ordered during ititial tratment but not at discharge
TIA-transisent ischemic attack

Question 4

The pt with a mild concussion being discharge. What instruction should the nurse teach?
a) Awake the pt every 2hrs
b) Monitor for ICP
c) Offer the pt food every 3-4 hrs

Answer 4

a
awaking a ot q2 allows the identification of headache, dizzeness,lethargy, irratability
these are postconcussion syndrome need to go back ED

Question 5

the pt with a closed head injury is admitted to the rehabilitation. Which med order would the nurse question?
a) a SBQ anticoagulant
b) An IV osmotic diuretic
c) An oral anticonvulsant
d) An oral PPI

Answer 5

b
this will order in acute pahse, should not be order in rehab
a) for DVT, rehab pt risk at DVT
c) post-traumatic pt are @ risk seizures
d) pt risk @ stress so PPI for ulcer

Question 6

What is most likely affected by coup-contrecoup brain injury?

Answer 6

coup(oneside)
coup-countrecoup(both)
Memory,speech,vision
Frontlobe-memory,speech
Occipital-vision

Question 7

Teaching about s/s of concussions, needs further instruction when which statement is expressed?
a) Vision loss can occur
b) Headache is common s/s
c) Retrograde amnesia common s/s
d) Brief loss of consciousness can occur

Answer 7

a
Vision loss is, a change in mental status or projectile vomiting are not expected signs of concussion and further investigation is needed into the cause.

Concussions are classified as a closed-head injury and the common symptoms are brief loss of consciousness, retrograde amnesia(a form of memory loss ) and headache.

Question 8

The nurse is aware that the patient with which set of vital signs (VS) is most indicative for Cushing’s triad in a 7 year old patient?
a) Temp 36.6, HR 68, RR 22, BP 125/60
b) Temp 37.8, HR 58, RR 20, BP 138/45
c) Temp 37.4, HR 90, RR 24, BP 130/68

Answer 8

b
Cushing’s triad is indicative of severely increased intracranial pressure (ICP) and is concerning for impending herniation. The triad consists of bradycardia, systolic hypertension, and widening pulse pressure.Respirations and temperature are to be monitored but are not a part of Cushing’s triad

Question 9

Pt with a stroke is reporting a severe headache. Which intervention should the nurse implement first?
a) Prepare for SATA MRI
b) Start an intravenous infusion with DE at 100ml/hr
c) Complete a neurological assessment

Answer 9

c
must done this first to hlp determine the cause of the headache before taking any further action

Question 10

What includes cognitive deficits?

Answer 10

Judgment, memory, reasoning, impaired focus

Question 11

Which clinical manifestation occurring within 24 hours of a spinal cord injury is an indicator of neurogenic shock?SATA
a) severe HTN
b) sever tachycardia
c) sever hypotension
d) sever bradycardia
e) dysregulation of body temp
f) warm lower extremities

Answer 11

c,d,e,f
Remember that neurogenic shock presents differently than other types of shock. The blood pressure and the heart rate will be decreased.This complication usually occurs in the client that has sustained a spinal cord injury at or above T6.

f) neurogic shock cause peripheral vasodilation below the evel of the injury.

Question 12

The nurse in the neuro-intensive care is caring for a pt with a new C7 SCI and breathing independently. Which nursing interventions should be implemented? SATA
a) Monitor pulse oximetry reading
b) Provide purred food 6 times a day
c) Encourage coughing and deep breathing
f) Assess for autonomic dysreflexia
e) Administer intravenous corticosteroids

Answer 12

a,b,e
b-This increase the strength muscle

f-Pay attention to where the pt is receiving care!! This occur 3-6M after injury

Question 13

The 34-year-old male pt with an SCI is worried about finding employment after discharge. Which agency nurse should refer?
a) American Spinal Cord Injury Association
b) State Vocational rehabilitation agency
c) Asl the social worker about applying for disability

Answer 13

b
a-appropriate with this condition but itdoes not help find gainful emploument
c-The pt not asking about disability

Question 14

The pt is scheduled for an EEG. Which pre-procedure teaching should the nurse implement? SATA
a) Tell the pt to take any routine antiseizure med before EEG
b) Tell the pt not to eat anything for 8hrs
c) Instruct the pt to sleep only 4-5 hrs
d) Explain to the pt that there will be some discomfort during the procedure
e) Tell the pt to avoid hair products, such as hairspray and gels, before

Answer 14

c,e

Question 15

The pt is prescribed phenytoin for a seizure disorder. Which statement indicates the pt understands the discharge teaching concerning this medication?
a) I will brush my teeth after every meal
b) I will check my phenytoin level daily

Answer 15

a
-gum masage, daily flossing and regular detntal care can prevent or control gingival hyperplasia(over growth gum)

b-monthly at first and then every 6 month

Question 16

Pt with diagnosed with an epidural hematoma. What action should take? SATA
a) Maintatin HOB 60
b) Administer stoll softner
c) Ensure the pulse oximeter reading is higher than 93%
d) perform deep nasal suction q2hrs
e) assess neuro statsu q1-2 hrs

Answer 16

b (prevent Inc ICP)
c (dec oxygen levels inc cerebral edema)
e (yes, should perform)

DO NOT elevate HOB more than 30
Check glucose level too

Question 17

A client who is admitted with a mild TBI following a motor vehicle accident (MVA). The client has notable injuries to the scalp and remains conscious.
Which clinical manifestation (s) should be reported to the health care provider (HCP) immediately?SATA
a) Amnesia of the exact events leading to the injury.
b) Cobweb-like appearance across the field of vision
c) Occasional twitching of right and left eyelids.
d) Reports of flashes of light across the visual field.
e) Reports of a frontal headache with a pain rating of 4/10 using a numeric scale.

Answer 17

b,d
Retinal detachment is an ocular emergency and often associated with head trauma

Question 18

The pt has been diagnosed with a brain tumor.
Which presenting manifestation helps to localize the tumor position?
a) Winding pulse pressure and bounding pulse
b) Diplopia and decrease visual acuity
c) Bradykinesia and scanning speech
d) hemiparesis and personality changes

Answer 18

d
hemiparesis=unilateral paresis, is weakness on one side
a-this indicate Inc ICP
b-this indicate papilledema
c-this indicarte parkinson= slowness of movement

Question 19

The pt with a brain tumor has a diminished gag response and weakness on the left side of the body, Which intervention should the nurse implement?
a) Make the pt NPO until seen by the HCP
b) Position the pt in low Fowler’s position for al meals
c Please the pt on mechanically ground diet
d) Teach the pt to direct food and fluid toward the right side

Answer 19

d
This can prevent aspiration
a-NPO will not help the ot to swallown
c-the consistency of the food is not an issue, the pt wil have difficulty swalliwing this food as weel as regular consisitency food

Question 20

The RN is assessing the pt with meningitis. Which assessment data would warrant notifying the HCP?
a) Purpuric lesions on the face
b) Reports of light hunting the eyes
c) Dull, aching, frontal headache
d) Not remembering head y of the week

Answer 20

a
purpuric lesions over the face and extremity, fever are s/s of Water house Friedrichsen syndrome which is fatal in 55-60% of case
-adrenal glands fail due to bleeding into the glands
b,c,d are expecting

Purpuric
a skin rash in which small spots of blood appear on the skin

Question 21

The pt with IBD has a potassium level of 3.4, which action should be taken first?
a) Notify the HCP
b) Assess the pt for muscle weakness
c) Request telemetry for the pt
d) Prepare to administer potassium IV

Answer 21

b

Question 22

The nurse caring for a pt with meningitis. Which collaborative intervention should be included?
a) Administer antibiotics
b) Obtain a sputum culture
c) Monitor the pulse oximeter
d) Assess intake and output

Answer 22

a
ebcause HCP must write an order for the intervention.
collaborative intervention is dependent on another member of the health care team
Droplet

Question 23

PT with CKD, which statement by the pt would indicate a correct understanding of teaching?
a) I am using a salt substitute because I should not use table salt
b) I can eat raisin and bran cereal with milk for breakfast
c) I drink water, instead of soft drinks or cola, with my meals
d) I use fresh herbs instead of salt to season my food when cooking meals
e) I usually snack on a small package of peanut butter and saltine crackers

Answer 23

c,d
CKD pt should avoid excess sodium, potassium and phosphorus
Salt substitutes are made from potassium
Dairy products are high in phosphorus

Question 24

Which one should see first?
a) HF who has SOB and cough productive of pink, frothy sputum
b) A left-sided pleural effusion who has diminished breath sounds in the left lower lobe

Answer 24

a
Pulmonary edema s/s dyspnea, pink frothy sputum. Pulmonary edema can progress to life-threatening acute respiratory distress

b-this is expected findings

Question 25

A client who reports sharp stabbing chest pain, diaphoresis, and shortness of breath. Which laboratory test should the nurse anticipate will be prescribed by the healthcare provider (HCP) as it is most specific to the diagnosis of an acute myocardial infarction (MI)?
a) Creatine Kinase-MB
b) C-reactive protein
c) Troponin

Answer 25

c
Specifically for damage to cardiac muscle.
Trauma=T=Troponin
a-use also diagnosis of MI but troponin is more specific
b-nonspecific indicator of inflammation

Question 26

The nurse is instructing a client on the collection of a clean catch urine specimen. Which teaching point should the nurse include? SATA
a) Cleanse the perineal area from back to front with soap and water.
b) Open the labia using your nondominant pointer finger and thumb.
c) Fill the specimen container until the urine stream completely stops.
d) Begin urinating before placing the container under your urine stream.
e) Wash your hands, open the specimen container, and place the lid upward.

Answer 26

b,d,e

Question 27

Before breakfast arrives for a client who is diagnosed with type 1 DM that received glargine, the nurse performs a finger stick to check the blood glucose level, which is 270 mg/dL . Which is the correct action by the nurse?
a) A prescription from the healthcare provider (HCP) to increase the current dose of glargine insulin.
b) A prescription from the health care provider (HCP) for insulin aspart.

Answer 27

b
This client requires a prescription for a short-acting insulin to address the current hyperglycemia, such as insulin aspart;
Clients who are diagnosed with type 1 DM require consistent insulin administration. Often, these clients require both a short-acting and an intermediate- or long-acting insulin to prevent hyperglycemia

Question 28

The nurse is caring for a client who is diagnosed with obstructive sleep apnea (OSA).
Which client finding(s) are consistent with this client’s medical diagnosis? SATA
a) Feeling overly sleepy during the day.
b) Difficulty being awakened.
c) Headaches upon waking up.
d) Loud snoring at night.
e) Observed episodes of the cessation of breathing during sleep.
f) Orthostatic hypotension.

Answer 28

a,c,d,e
c-when O2 levels drops d/t intermittent breathing

b-Frequent arousal（起きてしまう事）from sleep is s/s of OSA

Question 29

The nurse is observing a client use crutches while going upstairs. correct order?
1) While in the tripod position, place full body weight on the crutches.
2) Raise the leg that is affected and crutch up onto the step.
3) Transition body weight on the unaffected leg and lift the body to the next stair.
4) Put the leg that is unaffected on the stairs first.

Answer 29

1432
(Choice 1) This action stabilizes the client to begin walking up the steps. 逆三角
(Choice 4) unaffected first
This allows the good leg to stabilize body weight in preparation for the next step.
(Choice 2) affected is the last

Question 30

A a client who is unable to determine sensation when touching various objects. Which area of the brain should the nurse document as the likely area of injury based on the current data?
a) Frontal lobe.
b) Occipital lobe
c) Parietal lobe.
d) Temporal lobe

Answer 30

c
a- high-order cognitive activities
b- visual data
d- auditory input

Question 31

The pt with an acute exacerbation of ulcerative colitis, Which intervention should the nurse implement?
a) Provide a low-residue diet
b) Rest the pt’s bowel
c) Assess vital signs daily
d) Administer antacid orally

Answer 31

b
Whenever pt has acute exacerbation GI disorder, the first intervention is to place the bower rest=NPO

Low residue diet=low-fiber diet

Question 32

A client with new diagnosis of peripheral artery disease (PAD), which client statement indicates to the nurse an accurate understanding of the information presented? SATA
a) I have contacted a friend and we walk at least 15 to 30 minutes a day
b) I will elevate my legs as much as possible to reduce swelling around my ankles.
c) I will only take my cholesterol-lowering medication every other day in the afternoon
d) With this problem, I may not have to shave my legs as often

Answer 32

a
it will help to improve peripheral circulation
d
Due to decreased peripheral perfusion, hair loss in the extremities may result

Question 33

The nurse is caring for a team of clients.
Which client should the nurse see first?
a) A client with suspected peritoneal cancer with new-onset ascites who is awaiting a diagnostic paracentesis.
b) A client with hematochezia, pain in the abdomen, and history of ulcerative colitis awaiting diagnostic radiology.

Answer 33

b
Hematochezia and abdominal pain is cause for concern as it can indicate an ulcerative colitis flare-up which can lead to complications such as hypotension and infection, which can both be life-threatening

hemato-related blood

Question 34

Which situation requires the nurse to complete an incident report? SATA
a) An intradermal injection administered using an 18 gauge needle.
b) The administration of thalidomide to a client who is 10 weeks’ pregnant.
c) A client who has redness to the chest and face after taking oral nolvadex.
d) A client who reports itching after 2 mg of morphine sulfate is administered by intravenous push (IVP).
e) A client who has a documented history of anaphylaxis from penicillin administration is given intravenous (IV) cefazolin.

Answer 34

a,b,e

a- like TB test need to use A 26 or 27-gauge needle
e- Many clients who are allergic to penicillin will also be allergic to cephalosporins;

Question 35

Which is the most important intervention for the nurse to perform upon observing multiple, irregularly shaped bruises on the trunk and extremities on an older adult, homebound client?
a) Assess client safety and access to proper nutrition and basic hygienic needs.
b) Question the client about the cause of irregularly shaped bruises.
c) Report the case of elder abuse to the local authorities.
d) Have a discussion with the client and the client’s caregiver about the nature of the bruises.

Answer 35

a
Client injuries that are not consistent with the given explanation, or that are in various stages of healing, should cause the nurse concern for the client’s safety. When physical abuse is suspected, the nurse must validate data and determine the extent of the physical abuse and/or neglect that is occurring; therefore the most appropriate action by the nurse is a

b and d
-the nurse must first gather more information to determine appropriate interventions.

Question 36

A client who is admitted for debility and Ménière’s disease exacerbation.
Which priority intervention will the registered nurse implement for this client?
a) Decrease neurostimulation
b) Maintain bedrest
c) Provide antiemetic drugs
d) Maintain hydration

Answer 36

b
During a debilitating attack, the client experiences extreme whirling/dizziness.

debility=weakness

Question 37

A female client during the assessment process increases the risk for fertility difficulties? SATA
a) Body mass index (BMI) of 32 kg/m2.
b) Endometriosis.
c) Current age is greater than 35 years.
d) A history of pelvic inflammatory disease (PID).
e) Polycystic ovarian syndrome.

Answer 37

a,b,c,d,e
fertility difficulties=unable to get pregnant after trying

Question 38

client who is postoperative for a left radical mastectomy. Which position is appropriate for this client based on the current data?
a) The head of bed should be elevated to 90 degrees with the left arm resting on a pillow.
b) The head of bed should be elevated to 30 degrees with the left arm elevated on pillows.
c) The head of bed should be elevated to 45 degrees with the left arm lying flat on the bed.

Answer 38

b
Lymphedema is a complication that is associated with radical mastectomy. It occurs when lymph fluid collects in the arm causing edema. Positioning in the postoperative period can decrease the swelling

Mastectomy=removes one or both breasts
Metastasis＝The spread of cancer cells

Question 39

A client describes the right breast as “looking like an orange peel” during a recent self-examination.
Which statement by the nurse is best?
a) You should only be concerned with lumps when performing self examinations”
b) Breast tissue varies greatly from person to person. You should not be concerned
c) This is concerning as it could be a sign of breast cancer

Answer 39

c
The skin should be flat, even, and free of color or texture changes over time.
Any findings that appear abnormal or any difference between the breasts should be reported to the HCP

Question 40

A client with high cholesterol with a new prescription for atorvastatin. Which statement indicates understands teaching? SATA
a) I should weigh myself each day while taking this medication.”
b) I will not eat any grapefruit while taking this medication.
c) I will call my doctor if I notice fever, unusual fatigue, or dark urine.
d) This medication may turn my urine blue or green in color.
e) I should not become pregnant while taking this medication

Answer 40

b,c,e

Question 41

A client who is recovering from acute otitis media.
Which instruction(s) are important for this client?
a) Limit head movement to decrease ear pain
b) Avoid sleeping on the affected ear
c) Avoid blowing your nose or coughing

Answer 41

a

Question 42

Pt with ulcerative colitis, intervention? SATA
a) Discuss plans to decrease stress
b) Give analgesics as prescribed
c) Limit fluid to 500ml per day
d) Increase protein foods with meals
e) Monitor I&O closely
f) Recommend high fiber and low calorie diet

Answer 42

a,b,d,e

Question 43

The pt with IBD is prescribed TPN. Which intervention should the nurse implement?
a) Check the patient’s glucose level
b) Administer an oral hypoglycemic
c) Assess the peripheral intravenous site
d) Monitor the pt’s oral food intake

Answer 43

a
TPN is high in dextrose, which is glucose

The TPN must be administered via a central line e so not a peripheral intravenous site
Remember!
the words check and monitor are also meaning assess

Question 44

The pt with ulcerative colitis has an ileostomy. Which statement indicated the pt needs more teaching?
a) My stoma should be pink and moist
b) I will irrigate my ileostomy every day
c) If I get a red, bumpy, itchy rash, I will call my HCO
d) I will change my pouch if it starts leaking

Answer 44

b
An ileostomy will drain liquid all the time and should not routinely be irrigated.

Sometimes filliping the question-“Which interventions indicate the pt understands the teaching? can assist in identifying the correct answer

Question 45

The pt with Crohn’s disease. Which statement by the pt supports this diagnosis?
a) My pain is on the right lower side of my abdomen
b) I have bright red blood in my stool
c) I have episodes of diarrhea and constipation
d) My abdomen is hard an rigid, and I have a fever

Answer 45

a
c-this may manifestation of colon cancer
d-this is a manigestation of peritonitis

Question 46

A client who had a permanent sigmoid colostomy is learn about irrigation. Which instructions should the nurse teach the client about irrigation? SATA
a)Must irrigate colostomy every day at the same time
b) Should use 500-1000ml of warm water
c) Cold water creates cramping and should be avoid
d) The irrigation solution should be raised above the pt’s shoulder level

Answer 46

a,b,c,d
It is best to irrigate 30 minutes to 1 hour after eating breakfast.
The entire process takes about 1-1.5 hours.

Question 47

The nurse is caring for a client who is recovering from deep-partial thickness burns to 54% of the body
Which assessment data is expected during the first 24 to 72 hours of care? SATA
a) ECG with tall, peaked T waves
b) Hematocrit level of 58%
c) Hemoglobin level of 14 g/dL
d) Serum potassium of 2.5 mEq/L
e) Serum sodium of 130 mEq/L

Answer 47

a,b,e
a-Hyperkalemia causes ECG changes, including tall, peaked T waves.
b-Burn injuries damage the tissues thus causing fluid shifts and increased vascular permeability (i.e., third spacing) immediately (i.e., within the first 24 to 72 hours) after a burn. The blood becomes thicker resulting in an increased hemoglobin and hematocrit

c-should increase
d-should increase

Question 48

The pt with glaucoma, Which symptoms should the nurse expect the pt to report?
a) Loos of peripheral vision
b) Floating spots in the vision
c) A yellow haze around everything
e) A curtain coming across the vision

Answer 48

a
Peripheral vision: anything not directly in front of where you’re looking
Only could see in center
b,e-retinal detachement
c-digoxin toxicity

Question 49

Macular Degeneration, Cataracts and Glaucoma
a) Pain
b) Blurry vision
c) Central loss of vision
d) Seeing halos
f) Difficult seeing in dim light

Answer 49

a) G
b) All
c) M
d) C,G
f) All

Amsler grid test can be used every day to quickly identify any changes in vision
This doesn’t improve vision

Question 50

A pt with COPD. Which data require immediate intervention by the nurse?

a) Large amounts of thick white sputum
b) Oxygen flowmeter set on 8L
c) Use accessory muscles during inspiration
d) presence of barrel chest and dyspnea

Answer 50

b
O2 should decrease 2-3 L
a,c,d are expected findings