Final Assessment I. Med- Surgical Nursing. Adult care.

A nurse is interpreting a client’s ECG strip. If the PR interval measures four small blocks, how many seconds is the PR interval?

Which topics will the nurse plan to include in discharge teaching for a client who has admitted with heart failure? Select all that apply.

Which finding in a client with aortic stenosis will be most important for the nurse to report to the health care provider?

A client who has just arrived in the emergency department reports substernal and left arm discomfort that has been going on for about 3 hours. Which laboratory test will be most useful in determining whether the nurse should anticipate implementing the acute coronary syndrome standard protocol?

When the nurse is monitoring a 53-year-old client who is undergoing a treadmill stress test, which finding will require the most immediate action?

The health care provider prescribes these actions for a client who was admitted with acute substernal chest pain. Which actions are appropriate to assign to an experienced LPN/LVN who is working in the emergency department? Select all that apply.

A nurse is caring for a client with Raynaud’s phenomenon secondary to systemic lupus erythematosus (SLE). Which client statement confirms that client teaching has been effective? Select all that apply.

Which client is best for the coronary care charge nurse to assign to a float RN who has come for the day from the general medical-surgical unit?

A nurse is evaluating the 12-lead ECG of a client experiencing an inferior wall myocardial infarction (MI). While conferring with the heath care team, which ECG changes associated with an evolving MI does the nurse correctly identify? Select all that apply.

The nurse has finished receiving the morning change-of-shift report. Which client should the nurse assess first?

The nurse is working with an experienced unlicensed assistive personnel (UAP) and an LPN/LVN on the telemetry unit. A client who had an acute myocardial infarction 3 days ago has been reporting fatigue and chest discomfort when ambulating. Which nursing activity included in the care plan is best assigned to the LPN/LVN?

A patient with sickle cell disease is admitted with splenic sequestration. The blood pressure is 86/40 mm Hg, and heart rate is 124 beats/min. Which of these actions will the nurse take first?

When administering a blood transfusion to a patient, which action can the nurse delegate to the unlicensed assistive personnel (UAP)?

Which of these patients who have just arrived at the emergency department should the nurse assess first?

The female client diagnosed with type 2 diabetes and a urinary tract infection (UTI) describes frequent UTIs. Which interventions should the nurse implement? Select all that apply.

The nurse is providing care for a patient diagnosed with laryngeal cancer who is receiving radiation therapy. The patient tells the nurse that he is experiencing hoarseness and difficulty with speaking. What is the nurse’s best response?

The nurse is supervising a nursing student providing care for a patient with shortness of breath who has expressed interest in smoking cessation. Which questions would the nurse suggest the student ask to determine nicotine dependence? Select all that apply.

The RN clinical instructor is discussing a patient’s oxygen-hemoglobin dissociation curve with a student. The student states that the patient’s oral body temperature is elevated at 100.8°F (38.2°C). Which statement by the student indicates a correct understanding of this patient’s curve shift?

The nurse received the a.m. shift report on the following clients. Which client should the nurse assess first?

The nurse is evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns the nurse immediately?

A nurse assesses a client with suspected bacterial meningitis. Which documented findings of meningeal irritation suggest this diagnosis? Select all that apply.

A nurse is assessing a client’s extraocular eye movements as part of evaluating neurological functioning. This documents the status of which cranial nerves? Select all that apply.

A nurse is comparing the neurological status of a client who suffered a head injury with the status on the previous shift. Using the Glasgow Coma Scale, the nurse determines that the client’s score has changed from 11 to 15. Which responses did the nurse assess in this client? Select all that apply.

A nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and blood pressure of 174/100 mm Hg. The client reports a severe, pounding headache. Which nursing interventions would be appropriate for this client? Select all that apply.

The nurse is caring for a client who is experiencing an exacerbation of gout. When providing instruction, which dietary modifications are stressed? Select all that apply.

The nurse is caring for a client who is scheduled to undergo computed tomography (CT) scan to assess recent symptoms of muscle weakness and tingling in the extremities. Which information would the nurse include in a preprocedural teaching plan? Select all that apply.

While preparing a client for an upper GI endoscopy (esophagogastroduodenoscopy), the nurse would be correct to implement which intervention? Select all that apply.

A nurse is calling a report to the medical-surgical floor staff regarding a client with acute diverticulitis. Which symptoms does the nurse anticipate? Select all that apply.

A client is admitted with inflammatory bowel syndrome (Crohn’s disease). When planning care for the health care team, which would be included? Select all that apply.

The nurse is completing a head-to-toe assessment on a client diagnosed with breast cancer and notes a systolic murmur that the nurse was not informed of during report. Which action should the nurse implement first?

The nurse is evaluating how a client with hepatitis A understands the discharge teaching given. Which client statements indicate that further teaching is needed? Select all that apply.

A nurse is caring for a client with chronic renal failure. The laboratory results indicate hypocalcemia and hyperphosphatemia. When assessing the client, the nurse would be alert for which occurrence? Select all that apply.

The nurse has just received the shift report. Which client should the nurse assess first?

A client requires behavioral therapies to decrease or eliminate urinary incontinence. Which procedures would the nurse expect to include in the teaching plan for this client? Select all that apply.

A nurse is explaining self-catheterization to a female client who has been diagnosed with neurogenic bladder. Which instructions would the nurse include in the home teaching? Select all that apply.

The nurse is caring for a client with nephropathy. The health care provider orders a 24-hour urine collection. Which actions are necessary to ensure the proper collection of the specimen? Select all that apply.

A nurse is caring for a client newly diagnosed with osteoporosis. Which statements would the nurse include when teaching the client about the disease? Select all that apply.

A nurse is preparing discharge instructions for an above-the-knee amputation client. Which instructions would be a priority for home care? Select all that apply.

Which client would the charge nurse assign to the step-down unit nurse who was floated to the intensive care unit for the day?

A nurse is putting groceries in the car when an older adult client falls off of a curb. The nurse assesses the client and has a bystander call for an ambulance. Which assessment findings provide data of a suspected right hip fracture? Select all that apply.

The nurse is admitting an older adult client to the acute care medical unit. Which assessment factor alerts the nurse that this client has a risk for acid-base imbalances?

A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instructions would the nurse include in the teaching plan? Select all that apply.

A nurse is planning care for a client with human immunodeficiency virus (HIV). The registered nurse (RN) is delegating responsibilities to a licensed practical/vocational nurse (LPN/VN). Which statements by the LPN/VN indicate an understanding of HIV transmission? Select all that apply.

A nurse is caring for a client with moderate rheumatoid arthritis (RA). Which nonpharmacological interventions would a nurse include in the care plan? Select all that apply.

The nurse is caring for a client who is scheduled to undergo a bone marrow aspiration to assess the progression of a hematologic disorder. Which interventions would the nurse include as part of the preprocedural teaching plan? Select all that apply.

The nurse is providing discharge teaching for a client with a compromised immune system and on neutropenic precautions. When discussing types of fruits and vegetables that the client likes, which are encouraged? Select all that apply.

A nurse is caring for a client who is being discharged after a thyroidectomy. Which discharge instructions would be appropriate for this client? Select all that apply.

The student nurse, under the supervision of an RN, is reviewing a client’s arterial blood gas results and notes an acute increase in the arterial partial pressure of carbon dioxide (Paco2) to 51 mm Hg compared with the previous results. Which statement by the student nurse indicates an accurate understanding of acid-base balance for this client?

The nurse is caring for four clients who are receiving IV infusions of normal saline. Which client is at the highest risk for bloodstream infection?

A client is brought to the emergency department after wandering on the street. The client is confused and verbalizes double vision, headache, and shakiness. Laboratory data reveal a serum blood glucose of 52 mg/dl (52 mmol/L). Which questions, asked by the nurse, may reveal more data related to the client’s condition? Select all that apply.

A client with Addison’s disease is scheduled for discharge after being hospitalized for an adrenal crisis. Which statements by the client would indicate that the nurse’s teaching has been effective? Select all that apply.

A client comes to the clinic verbalizing a weight loss of 20 lb (9.1 kg) over the last month, even with a “ravenous” appetite and no change in activity level. The client is diagnosed with Graves’ disease. Which other signs and symptoms of Graves’ disease would the nurse assess? Select all that apply.

The nurse has received the shift report. Which client should the nurse assess first?

A client presents at the health care provider’s office with gray-brown burrows with epidermal curved ridges and follicular papules of the skin. The health care provider diagnoses scabies. Which teaching points would a nurse review with the client? Select all that apply.

A nurse is caring for a client who is admitted from home to a long-term care facility. During the admission assessment, the nurse documents a stage II pressure ulcer and places a referral to the enterostomal therapist (ET). When gathering supplies for a stage II ulcer, what characteristics would the ET anticipate? Select all that apply.

A client returns from the operating room with a partial-thickness skin graft on the left arm. The donor tissue was taken from the left hip. In planning immediate postoperative care, which interventions would the nurse include? Select all that apply.

Which client should the nurse assess first after receiving the p.m. shift assessment?

The nurse is caring for clients on a neurological intensive care unit. Which client should be assessed first?

A nurse is caring for a terminally ill cancer client who is being transferred to hospice care. Which information regarding hospice care would the nurse include in the teaching plan? Select all that apply.

A client with laryngeal cancer has undergone a laryngectomy and is now receiving radiation therapy to the head and neck. The nurse would monitor the client for which adverse effects of external radiation? Select all that apply.

A patient admitted with an elevated ST-segment myocardial infarction (MI) on oxygen per nasal cannula for his diagnosed influenza is complaining of shortness of breath with an oxygen saturation of 88%. Respiratory therapy administers an albuterol treatment that provides no change in the oxygen saturation. What is the next best action by the RN is best?

A patient admitted with an elevated ST-segment myocardial infarction on oxygen per nasal cannula for his diagnosed influenza continues to experience shortness of breath and has no ECG changes. What is the next best action by the RN is best?

The nurse is providing care for a patient diagnosed with laryngeal cancer who is receiving radiation therapy. The patient tells the nurse that he is experiencing hoarseness and difficulty speaking. What is the nurse’s best response?

The RN is admitting a client with benign prostatic hyperplasia (BPH) to an acute care unit. The client describes an oral intake of about 1400 mL/day. What is the RN’s priority concern?

Which postoperative client is manifesting the most serious negative effect of inadequate pain management?

When scheduling a patient for skin testing for allergies, which information is most important for the allergy clinic nurse to include in  patient teaching?

The clinic nurse is evaluating a client who had coronary artery stenting through the right femoral artery a week previously and is taking metoprolol, clopidogrel, and aspirin. Which information reported by the client is most important to report to the health care provider?

The nurse is assessing a client with a neurologic health problem and discovers a change in the level of consciousness from alert to lethargic. What is the nurse’s best action?

The nurse is working in an ambulatory care clinic. A client calls to report redness of the sclera, itching of the eyes, and increased lacrimation for several hours. What should the nurse direct the caller to do first?

The nurse is caring for a patient who had a dual-energy x-ray absorptiometry (DEXA) scan and is now prescribed calcium with vitamin D twice a day. The patient asks the nurse about the purpose of this drug. What is the nurse’s best response? Select all that apply.

The charge nurse is reviewing the medication administration records for several clients. Which situation needs to be brought to the attention of the prescribing health care provider?

The nurse is caring for an older patient with type 1 diabetes and diabetic retinopathy. What is the nurse’s priority concern for assessing this patient?

The nurse is caring for a 25-year-old patient admitted to the acute care unit with an extra-strong thirst, and dilute, excessive straw-colored urine output (up to 15 L/day). What does the nurse suspect?

Which actions will the nurse use when treating a client with a venous ulcer on the right lower leg? Select all that apply.

The nurse is reviewing the lab values for a patient with risk for urinary problems. Which finding is of most concern to the nurse?