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

A 20- year- old college student who lives in a dormitory is admitted to the emergency department with complaints of headache, nausea, vomiting, stiff neck, and a rash. The nurse should perform which action based on the information given?

The RN primary nurse and unlicensed assistive personnel (UAP) is caring for a client diagnosed with right-sided paralysis. Which action by the UAP requires the RN to intervene?

A nurse is performing range-of-motion exercises with a client who had a brain attack. The nurse places the client’s hand in the position exhibited in the picture. This position is known as:

A nurse has a four-patient assignment in the medical step-down unit. When planning care for the clients, which client would have the following treatment goals: fluid replacement, vasopressin replacement, and correction of underlying intracranial pathology?

The client has a three-way closed continuous catheter irrigation system. Which information should be included in the documentation for this client? Select all that apply.

The charge nurse in the ICU receives a call from the ED. They have three patients who require a bed. Which patient should be transferred first?

The client’s physician orders a blood transfusion for a client whose hemoglobin level is 5.0 mg/ dL. The nurse informs the client that blood will be drawn for a type and cross- match prior to the blood transfusion. The client avoids eye contact with the nurse, and then states, ” I am a Jehovah’s Witness. I thought that was on my chart.” The nurse demonstrates the role of client advocate by which response to the client?

The circulating nurse prepares the sterile field in the operating room ( OR). Fifteen minutes later, the nurse is informed that the surgery is delayed for 20 minutes because the surgeon is working at another hospital. Which is the best action for the nurse to take?

The nurse cares for a client who has undergone a bone marrow transplant. While the nurse assesses the client’s IV site, the client’s sister complains of a low-grade fever. The nurse should:

The nurse assists a physician in draining a client’s large abscess at the bedside. The nurse holds the client to prevent the client from jerking during the procedure. The nurse should wear which personal protective equipment?

The nurse admits a client to the hospital who was involved in an automobile accident. Upon assessment, the nurse notes the client is wearing soft restraints. The client continues to be combative and is compromising the airway. Which type of restraint is most appropriate for this client?

The nurse and UAP are working together with four patients. Which patient should the nurse assign the UAP?

The nurse cares for a client diagnosed with HIV whose chest x-ray results are abnormal. The nurse suspects tuberculosis ( TB). Which precautions should the nurse implement when caring for this client?

The metabolic panel of a client reveals a calcium level of 6.5 mg/dL. Based on this laboratory finding, which additional data specific to this calcium level should the nurse collect? Select all that apply.

A primary nurse is caring for a 70-year-old adult who suffered a brain attack 10 days ago and is unresponsive. The patient did not sign a legal instrument identifying which adult child should make healthcare decisions in the event of incapacitation. Two of the adult children are adamant about not wanting a feeding tube inserted for nutritional support and two of the adult children are just as firm about wanting a feeding tube inserted. What should the nurse do to best help resolve this situation?

Which client should the telemetry nurse assess first after receiving the a.m. shift report?

A 70-year-old client who has been treated for cellulitis of the leg asks the nurse how to improve resistance to infection. Which measures should the nurse reinforce in the teaching plan? Select all that apply.

A client is to be monitored for residual urine every 8 hours. Which are the appropriate nursing actions for the nurse to complete this task? Select all that apply.

A client being seen in a health care provider’s office has just been scheduled for a barium swallow the next day. The nurse writes down which instructions for the client to follow before the test?

The nurse is planning to administer an oral glucose tolerance test (OGTT) to a client to rule out or confirm diabetes mellitus. The nurse knows that the client needs more information when the client makes which statement? Select all that apply.

The nurse states on shift handoff that the client has an elevated uric acid level of 8.2 mg/dl (487.8 mmol/L). Which inflammatory process would the nurse assess for during client assessment?

The nurse has reinforced postprocedure instructions to a client who has undergone a colonoscopy. The nurse determines that the client needs further teaching if the client makes which statement?

At a health fair, a nurse encourages an older adult male to be screened for prostate cancer. The client is apprehensive and asks the nurse about the methods used to detect prostate cancer. The nurse explains that the detection process involves:

The nurse is performing oral care for a newly admitted client who is undergoing chemotherapy for thyroid cancer. The nurse should take which actions while performing oral care? Select all that apply.

The nurse is told that a client will be admitted to the hospital for a radiation implant for bladder cancer. The nurse is asked to prepare for the admission of the client and plans which measure for this client?

A nurse in the telemetry unit is caring for a client with a diagnosis of postoperative coronary artery bypass graft (CABG) surgery from 2 days ago. On assessment, the nurse notes a paradoxical pulse of 88. Which surgical complication would the nurse suspect?

After administering a medication through a nasogastric tube connected to suction, what action should the nurse take first?

At 7 a.m. a client with diabetes is conscious, with a serum glucose level of 50 mg/dl. To effectively manage this client’s care, what should the nurse administer?

A resident in a skilled nursing facility only demonstrates confusion at the end of the evening shift. Which nursing intervention should be implemented to help reduce the incidence of this client’s confusion?

After a traumatic injury, a 12-year-old client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). In the early stages of this disorder, which finding should the nurse expect this client to exhibit?

Analysis of a client’s renal calculi reveals that they are formed from uric acid. What dietary instruction should the nurse include in the teaching plan of this client?

Based on the change of shift report, the client with which signs and symptoms should be assessed by the nurse first?

A young adult male client is admitted to the emergency room with a bleeding abdominal wound following a motor vehicle collision. He is crying out with pain. His friends report that he often uses cocaine. What nursing diagnosis has the greatest priority?

During a mental status examination, the nurse is planning to assess a
client? ‘s abstract thinking. Which direction should the nurse provide the
client to make this assessment?

During a preoperative appointment at an ambulatory surgery center, a client expresses anxiety to the nurse about the impending surgery. How should the nurse respond?

During the night shift the nurse observes an older client? ‘s respiratory
rate change while asleep. The client abruptly coughs and opens the eyes.
The client is unable to return to sleep and then turns on the television.
What does this older client? ‘s sleep behavior suggest to the nurse?

During a home visit, the nurse observes a client with a foot wound wearing clean clothing and sitting in a living area that is neat and tidy. The nurse plans to provide care to address the self-actualization level of Maslow? ‘s hierarchy of needs. What care will the nurse provide?

A male client diagnosed with hypertension has a nursing goal of, "The client will be able to verbalize ways to decrease blood pressure." What statement by the client indicates that this outcome has been met?

A male client diagnosed with peptic ulcer disease has a nasogastric tube in place. Suddenly he complains of severe abdominal pain and the nurse notes that his abdomen is rigid. What action should be implemented first?

A female client tells the nurse how happy she is that her family brought a small bag of home-grown herbs to the hospital and placed them under her pillow. What action should the nurse take?

A client with late stage rheumatoid arthritis frequently drops the silverware while eating. Which resource would be of greatest value to this client?

A male client who has a serum potassium level of 5.9 mEq tells the nurse that he has decided to leave the hospital, even though his healthcare provider has not discharged him. He states that he does not care if he is discharged, he is refusing all treatments. It is most important for the nurse to ensure that the client understands which fact prior to leaving the facility?

A family member brings a garden salad and fresh fruit to a client who is receiving
chemotherapy for a malignancy and has an absolute neutrophil count of 500. How should the nurse respond?

A male client with a kidney stone is complaining of severe discomfort in the left flank area. He grimaces upon movement, is hesitant to move about, and has shallow respirations at 20/minute. His wife expresses concern over his expected absence from work and loss of revenue. What diagnosis has the highest priority at this time?

A middle-aged man walks into the Emergency Center and collapses at the triage desk. What action should the nurse implement first?

A client who is immunosuppressed because of treatment for systemic lupus erythematosus (SLE) delivers a viable infant at 37-weeks gestation by cesarean section. Four days later she has a fever of 102.6 F and diarrhea. A stool specimen is positive for Clostridium Difficile. What action should the nurse take?

A nurse seeks to alter a provision of a state’s Nurse Practice Act regarding nurse-client ratios, which the nurse believes to be unsafe. What action is most likely to impact a ruling by the state’s Board of Nursing?

A hospitalized client with peripheral arterial disease (PAD) is instructed regarding leg and foot care. Which statement by the client indicates to the nurse that effective learning has occurred?

Which of the following delegations by the RN would require an immediate intervention by the charge RN?

The nurse is caring for a client who is in a comatose state and needs a nasopharyngeal airway for suctioning. After the airway is inserted, the client gags and coughs. Which action would the nurse take?

A client’s family, stung by a bee, has rushed the client to the emergency room. The client is experiencing hives and redness at the site. Upon arrival, the client states, “I feel a lump in my throat, and I am sweating. I can’t breathe! I think I am going to die!” The nurse anticipates which emergency treatment next?

A client has a cast applied to the left leg after sustaining a femur fracture during a skiing accident. Which interventions would the nurse provide to avoid complications from the cast application? Select all that apply.

A nurse is providing nutritional teaching for a client with a family history of colon cancer. Which food choice by the client demonstrates an understanding of the best diet to follow?

The nurse is caring for a client with a head injury. Which client goal is most appropriate for the acute phase of a neurological injury?

The orthopedic nurse is providing discharge instructions to a surgical client. Which action, by the client, would demonstrate proper touchdown weight bearing?

The RN charge nurse is making assignments for clients in a cardiac unit. Which client should the RN charge nurse assign to a new graduate nurse (GN)?

The 79-year-old male client is 2 days post-ureterosigmoidostomy for cancer of the bladder. Which assessment does data warrant the RN oncology nurse notifying the HCP?

The nurse is caring for clients in the post-anesthesia care unit (PACU). Which client requires immediate intervention by the PACU nurse?

The client diagnosed with hypothyroidism and diagnosis of myxedema coma is admitted to the critical care unit. Which assessment does data warrant immediate intervention by the nurse?

A client has an indwelling urinary catheter and is prescribed physical therapy. As the client is being placed in a wheelchair, which action by the assistant would need further clarification by the nurse?

A child is admitted to the hospital for an asthma exacerbation. The nursing history reveals this client was exposed to varicella (chickenpox) 1 week ago. When, if at all, would this client require isolation?

A nurse is employed in a medical unit specializing in blood cancers. According to a standard staging classification of Hodgkin’s lymphoma, which criterion reflects stage II?

A healthy client presents to the clinic for a routine examination. When auscultating lower lung lobes, the nurse anticipates which type of breath sound?

A client arrives at a public health clinic worried that she has breast cancer after finding a lump in her breast. When assessing the breast, which assessment finding provides an indication that the lump is more typical of fibrocystic breast disease?

A client is ready to be discharged after arthroscopic knee surgery. Which information would the nurse expect the health care provider to write on the discharge instructions?