Medical Surgical - Caring for Adults

Caring for Adults 1. To detect early signs or symptoms of inadequate oxygenation, the nurse would examine the patient for a. b. c. d. 2. A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? a. b. c. d. 3. Dyspnea and hypotension Apprehension and restlessness Cyanosis and cool, clammy skin Elevated temperature and diaphoresis Sit the patient upright, leaning over the bedside table Administer benzocaine spray to the patient’s throat Obtain arterial blood gases from the patient Be certain that the patient has remained NPO for 4 hrs. The nurse is assessing breath sounds. Where should the nurse place the diaphragm of the stethoscope to listen to the apex of the left lung? a. b. c. d. In the mediastinal area Just below the clavicle Within the parietal pleura Resting on the diaphragm 4. While performing an admission assessment on a patient, the nurse notes vesicular breath sounds over most of the lung fields. What should the nurse do next? a. b. c. d. 5. Repeat the assessment several times Instruct the patient to breathe more deeply Document the assessment in the patient’s chart Notify the health care provider, immediately A client with acute pharyngitis is seen at the clinic with fever and severe throat pain that has affected her ability to swallow. The throat is reddened and edematous with patchy exudates on exam. The nurse anticipates that collaborative management will first include a. b. c. d. Treatment with antibiotics Administration of antifungal medication A throat culture or rapid strep antigen test Oral salt water gargles and rinses 6. What does the nurse teach the patient with intermittent allergic rhinitis is the most effective way to decrease allergic symptoms? a. b. c. d. Undergo weekly immunotherapy injections Identify and avoid triggers of the allergic reaction Use cromolyn nasal spray prophylactically year-round Use antihistamines and decongestants during an attack 7. A nurse is completing the health history for a client who has been taking Echinacea for a common cold. The client asks: “Why is this not helping me feel better?” Which response by the nurse is most accurate? a. b. c. d. “There is limited information as to the effectiveness of herbal products.” “Antibiotics are the most effective way to treat a common cold.” “Your cold should be almost gone within the next thirty days.” “Combining herbal products with antiviral medicine is sure to help.” 8. Which is an expected outcome for a client recovering from an upper respiratory tract infection? a. b. c. d. 9. Maintain a fluid intake of 800 mL every 24 hrs. Experience chills only once in a 24 hr. period Cough productively without chest discomfort. Experience less nasal obstruction and drainage Pseudoephedrine has been prescribed as a nasal decongestant. What is a possible side effect of this drug? a. b. c. d. Constipation Bradycardia Dysphagia Restlessness 10. The nurse is teaching a client with bacterial sinusitis on care needed when at home. What is the most important information to emphasize during this teaching session? a. b. c. d. Using a humidifier to promote sinus drainage Completing the antibiotic prescription as ordered Sleeping with the head of bed elevated to 45 degrees Maintaining a liberal fluid intake to help liquefy secretions 11. The nurse knows that the physician is most likely to order which of the following laboratory tests to evaluate a client for hypoxemia and acid/base status? a. b. c. d. Red blood cells Neutrophil count Arterial blood gases Sputum culture 12. A client returns from having a bronchoscopy. The client is complaining of being hungry. What should the nurse do? a. b. c. d. Consult with the nutritionist about the best diet for the client Check for a gag reflex before giving the client food or liquids Administer medication for nausea before allowing the client to eat Obtain an oxygen saturation and administer oxygen if needed 13. During the admission assessment for a client admitted with COPD, the client tells the nurse that he has to sleep in a recliner because he gets short of breath when he lies down. The nurse documents this finding as which of the following: a. b. c. d. Tachypnea Rhinorrhea Orthopnea Fremitus 14. The nurse assesses a client who is on fluticasone (Flovent) inhaler for the treatment of asthma. The nurse observes lesions in the oral cavity. What is the nurse’s best action? a. b. c. d. Teach the client to rinse the mouth after using the inhaler Start the client on long-term antibiotic medication Document the findings as an expected result of taking Flovent Have the client gargle with mouthwash before using the inhaler 15. Which client diagnosed with pneumonia is most likely to have community-acquired pneumonia? a. b. c. d. A client newly admitted to a long term care facility A client who recently traveled on a cruise ship A client who has had multiple family visitors A client whose spouse recently passed away 16. During an annual health assessment of a 65-year old patient, the patient tells the nurse that he had the pneumonia vaccine when he was age 58. What should the nurse advise him about the best way to prevent pneumonia? a. b. c. d. Seek medical care and antibiotic therapy for all upper respiratory infections Obtain the pneumococcal vaccine this year with an annual influenza vaccine Make plans to get the pneumococcal vaccine if exposed to persons with pneumonia Get the influenza vaccine every year, but not the pneumococcal vaccine as you have immunity to pneumococcus 17. The nurse in a long-term care facility is planning the care for a client with a percutaneous endoscopic gastrostomy (PEG) feeding tube. Which intervention should the nurse include in the plan of care? a. b. c. d. Inspect the insertion line at the naris prior to instilling formula. Place the client in the Sims position following each feeding Elevate the head of the bed during and after feeding the client Change the dressing on the feeding tube every three (3) days 18. The nurse is caring for the client diagnosed with pneumonia. Which information should the nurse include in the teaching plan? (Select all that apply) a. b. c. d. e. Place the client on oxygen delivered by nasal cannula Plan for periods of rest during activities of daily living Place the client on fluid restrictions of 1,000 mL/day Restrict the client’s smoking to three cigarettes a day Monitor the client’s pulse oximetry every four hours 19. The nurse is reviewing the chart of a 58 year-old client with community acquired pneumonia. Which bacteria are the most likely causative microorganism? a. b. c. d. Haemophilus influenza Klebsiella pneumonia Streptococcus pneumonia Staphylococcus aureus 20. A client, hospitalized for severe pneumonia, asks the nurse why a sputum sample is necessary. The nurse should reply that the primary reason for the specimen is to a. b. c. d. Differentiate between atelectasis and pneumonia Remind the client of the importance of expectorating secretions Assist the health care provider in selecting the appropriate antibiotic To be certain that the sputum sample does not contain cancer cells 21. The nurse is teaching a client with pneumonia ways to clear secretions. Which intervention is the most effective? a. b. c. d. Giving the client cough medicine Increasing fluids to 2L/day if tolerable Teaching diaphragmatic breathing Having the client deep breath hourly 22. The influenza vaccine is in short supply. Which group of clients would the public health nurse consider priority when administering the vaccine? a. b. c. d. Elderly and chronically ill clients Child care workers and children < four (4) years of age Hospital chaplains and health-care workers Schoolteachers and students living in a dormitory 23. The nurse is preparing to administer influenza vaccines to a group of elderly clients in a long-term care facility. Which client should the nurse question receiving the vaccine? a. b. c. d. The client diagnosed with congestive heart failure The client who had an anaphylactic reaction to penicillin The client with an elevated blood pressure and pulse The client with a documented history of an allergy to eggs 24. A nurse is working at a telephone health service. Which advice should the nurse give to a client who has had 3 days of symptoms that strongly suggest influenza? a. b. c. d. Return to work after another day of rest Rest and increase the intake of fluids Use over the counter antihistamines Make an appointment to get the flu shot 25. When obtaining a history from a patient suspected of having early tuberculosis (TB), what clinical signs or symptoms should the nurse question the patient about? a. b. c. d. Pleuritic chest pain, hemoptysis, and weight loss Cough with purulent sputum and fever with chills Fatigue, low grade fever in the evenings, and night sweats Nonproductive cough and cervical lymph node enlargement 26. The nurse is discussing the results of a tuberculosis skin test. Which explanation should the nurse provide the client? a. b. c. d. A red area is a positive reading that means the client has tuberculosis The skin test is the only procedure needed to diagnose tuberculosis Do not get another skin test for one year if the skin test is positive A positive reading means exposure to the tuberculosis bacilli 27. The nurse is preparing to enter the private, well-ventilated isolation room of a client with active tuberculosis. Which of the following actions is most important for the nurse to do prior to entering the room? a. b. c. d. Perform good handwashing with antimicrobial soap and water Wear a sterile gown and gloves with a protective eye shield Place a particulate filter respirator (HEPA/N95) mask over the mouth and nose Take in fresh linen and disposable masks for the client to wear in the room 28. The certified nursing assistant (CNA) informs the nurse that her spouse is diagnosed with tuberculosis. The CNA has a positive PPD but active disease has been ruled out. The CNA declines preventative treatment. Which response by the nurse is best? a. b. c. d. “Notify your health care provider if you have weight loss or decreased appetite.” “Why don’t you want to take the prophylactic (preventative) medicine?” “You will have to wear a mask while working with patients on the unit.” “You cannot work with patients so you will need to find another type of job.” 29. Which technique for administering the Mantoux (PPD) test is correct? a. b. c. d. Hold the needle and syringe almost parallel to the client’s skin Pinch up the skin while administering the medication Aspirate before injecting the medication into the client Massage the site after injecting the medication 30. A client had a Mantoux (PPD) test result of 8-mm duration. The test is considered positive when the client: a. b. c. d. Lives in a long term care facility Has no known risk factors Is immunocompromised Works as a nurse in a hospital 31. A nurse is teaching a client about the spread of tuberculosis (TB). Which statement, made by the client, would indicate that teaching has been effective? a. b. c. d. “I could get TB by walking by someone who has the disease.” “I could get TB if I inhale droplets when an infected individual coughs.” “I could get TB if I enter the home of someone infected with TB.” “I could get TB if I come in contact with blood from an infected person.” 32. A client diagnosed with tuberculosis has been placed on drug therapy. The medication regimen includes rifampin. Which instruction should the nurse give to the client about potential adverse effects of this drug? (Select all that apply) a. b. c. d. e. Have eye examinations every six months Maintain follow-up monitoring of liver enzymes Decrease protein intake in the diet Avoid drinking alcohol The urine may have an orange color 33. An older adult client has developed pneumonia. What initial assessment finding would most concern the nurse? a. b. c. d. Confusion or delirium High grade fever with chills Hemoptysis and dyspnea Pleuritic chest pain and cough 34. A client is exhibiting symptoms of pneumonia. Which diagnostic test would the nurse anticipate to confirm this diagnosis? a. b. c. d. ABG analysis Chest X-ray Blood cultures Sputum C &S 35. The nurse is caring for a client in the immediate post-operative period. The nurse’s priority would be to prevent a. b. c. d. Atelectasis Bronchitis Pneumothorax Tuberculosis 36. A nurse is preparing a plan of care for a post-operative client. What is the most appropriate nursing intervention to prevent the development of atelectasis? a. b. c. d. Chest physiotherapy Mechanical ventilation Reducing oxygen requirements Use of an incentive spirometer 37. A client’s ABG results are as follows: pH 7.29, PaCO2 56, HCO3 24. Based on these values the client is showing signs of a. b. c. d. Metabolic acidosis Respiratory alkalosis Metabolic alkalosis Respiratory acidosis 38. The nurse is obtaining a client’s pulse oximetry reading. The nurse understands that pulse oximetry measures a. b. c. d. Carbon dioxide levels in the blood Saturation of venous oxygen levels The percentage of blood oxygen saturation Respiratory rate and rhythm 39. An 89 year-old client is being discharged following treatment for pneumonia. What information should the nurse review regarding activities of daily living? a. b. c. d. Increase activities gradually Exercise at least once a week Walk daily until fatigued Begin walking using a treadmill 40. A client with COPD is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as prescribed. Which statement is true concerning the oxygen administration to a client with COPD? a. b. c. d. High oxygen concentrations will cause coughing and dyspnea. High oxygen concentrations may inhibit the hypoxic stimulus to breathe. Increased oxygen use will cause the client to become dependent on oxygen. Administration of oxygen is contraindicated in clients who are using bronchodilators. 41. The nurse is performing a Mantoux (PPD) test on a client being screened for tuberculosis. The client reports have negative results in the past. The nurse instructs the client to return to have the results interpreted a. b. c. d. In 2 hours after performing the test 24 hours after performing the test 48 hours after performing the test One week after performing the test 42. The influenza vaccine is in short supply. Which group of clients would the public health nurse consider priority when administering the vaccine? a. b. c. d. Elderly and chronically ill clients Child care workers and children under 4 years School teachers and students living in a dormitory Hospital chaplains and health care workers 43. The nurse is preparing to administer influenza vaccines to a group of elderly clients in a long term care facility. Which client should the nurse question receiving the vaccine? a. b. c. d. The client diagnosed with congestive heart failure The client who had an anaphylactic reaction to penicillin The client with a documented history of an allergy to eggs The client with high blood pressure and elevated heart rate 44. A client is admitted to the hospital for dyspnea. The health care provider orders blood to be drawn for a hemoglobin and hematocrit. The client wants to know why blood needs to be drawn when he only having trouble breathing. The nurse’s best response is a. “We are checking baseline labs. Hemoglobin does not affect oxygen.” b. “We want to see if your hemoglobin is too high as it can affect your respiration rate.” c. “If your hemoglobin is low, it tells us that you have reduced oxygen carrying capacity.” d. “If your hemoglobin is high, your oxygen carrying capacity in the blood low.” 45. A client in a long term care facility is receiving continuous tube feedings. The nurse is aware the tube feedings place the client at risk for a. b. c. d. Bilateral atelectasis Chronic bronchitis Aspiration pneumonia Pulmonary embolism 46. A client received a Mantoux skin test for tuberculosis in the right forearm. After 2 days, the site is reddened with an induration about 3 mm. The nurse interprets this result as a. b. c. d. Indeterminate Invalid and needs repeated Negative result Positive result 47. A client is admitted with possible tuberculosis. In order to obtain a definitive diagnosis, the nurse anticipates thayat the health care provider will order which test? a. b. c. d. Chest X-ray Tuberculin skin test Sputum for acid fast bacilli (AFB) Magnetic resonance imaging (MRI) of the chest 48. What priority instruction should the nurse give a client taking medication for active tuberculosis (TB)? a. b. c. d. “It is alright to miss a dose every day or two.” “You must comply with the medication regimen to treat TB.” “Only take the medicine until you feel like you are better.” “If side effects occur, stop taking the medicine.” 49. A client diagnosed with active tuberculosis (TB), asks the nurse if he will be admitted to the hospital. The nurse responds that hospitalization would most likely occur to a. b. c. d. Evaluated his condition Determine his compliance Prevent the spread of disease Administer antibiotic therapy 50. A nurse is caring for a client following a bronchoscopy. Which of the following findings should the nurse report to the health care provider? a. b. c. d. Blood-tinged sputum Dry, nonproductive cough Complaints of a sore throat Bronchospasms