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Capstone Med Surg Assessment Exam Grade A+ latest June 2023.docx
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Manage acute pain
14.A nurse is caring for a client who has burn injuries covering their upper body and is concerned about their altered appearance .Which of the following statements should the nurse make? It could be helpful for you to attend a support group for people who have burn injuries. 15.A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine .Which of the following interventions should the nurse include in the plan? Monitor the client skin under the halo vest. 16.A nurse is caring for a client who has a traumatic brain injury. Which of the following finding should indicate to the nurse the need for immediate intervention? Respiratory rate 30/min 17.A nurse is assessing a client who has meningitis. The nurse should identify which of the following finding as a positive Kerning s sign? After stroking the lateral area of the foot, the client’s toes contract and draw together. After hip flexion, the client is unable to extend their leg completely without pain 18.A nurse is teaching a group of assistive personnel (AP) about caring for client who have Alzheimer’s disease. Which of the following information should the nurse include in the teaching? Provide supervision to prevent a client from becoming injured or lost. 19.A home health nurse is providing teaching to the family of a client who has a seizure disorder. Which of the following interventions should the nurse include in the teaching? Keep a padded tongue blade near the bedside. Place a pillow under the client's head while in bed during a seizure.
Administer diazepam orally at the onset of seizures.
nurse should assign the client which of the following triage tags?
Red Yellow Green Black 24.A nurse is teaching a client who has a new diagnosis of polycystic kidney disease. Which of the following statements should the nurse include in the teaching? "Take aspirin as needed to reduce your pain." "Reduce your dietary beer intake." "Apply dry heat to your abdomen when needed." "Check your weight once per week." 25.A nurse is assessing a client who has right lower lobe pneumonia. Which of the following findings should the nurse expect? Dull percussion sounds Increased anterior posterior chest diameter Distended neck veins Pitting edema 26.A nurse is providing teaching to the caregivers of a client who has Alzheimer's disease. Which of the following instructions should the nurse give? (Select all that apply.) Install safety locks and alarm systems. Place nightlights throughout the home. Replace carpeted flooring with tile. Establish a predictable daily routine for the client. Remind the client of scheduled activities 1 day in advance. 27.A nurse is caring for a client who is hyperventilating and has the following
should recognize that the client has which of the following acid-base imbalances? 2 3 – Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis 28.A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include? Eat three large meals daily. Consume high-calorie foods. Limit caffeinated drinks to two per day. Drink fluids during mealtime 29.A nurse is caring for a client who has a right-sided pneumothorax. Following chest tube insertion, which of the following findings indicates that the chest drainage system is functioning correctly? Gentle bubbling in the suction chamber Crepitus around the insertion site Constant bubbling in the water seal chamber Absence of breath sounds on the right side 30.A nurse is caring for client who has a new diagnosis of tuberculosis. Which of the following precautions should the nurse initiate to present transmission of the disease? Contact precautions Airborne precautions Droplet precautions Protective environment
31.A nurse is planning care for a client who has Ménière's disease and is experiencing episodes of vertigo. Which of the following interventions should the nurse include in the plan? Maintain strict bed rest. Restrict uid intake to the morning hours. Administer aspirin. Provide a low-sodium diet. 32.A nurse reviewing laboratory reports for client who is taking NSAISs for rheumatoid arthritis. Which of the following results should the nurse recognize as a possible adverse effect of NSAID therapy? Increased erythrocyte sedimentation rate Elevated creatinine clearance Increased serum potassium Positive fecal occult blood test 33.A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates the client might be experiencing a hemolytic transfusion reaction. Hypertension Report of urticarial Distended neck veins Report of chest pain 34.A nurse is caring for a client who had surgery 2 days ago and reports incisional pain. Which of the following actions should the nurse take first? Determine the time the last dose of pain medication was administered. Reposition the client to assist with reduction of pain. Ask the client to describe the pain and rate it on a scale of 0 to 10. Para mi Check the client's medical record for type of PRN pain medication.
39.A nurse is preparing to administer epoetin to a client who has anemia due to chemotherapy. Which of the following actions should the nurse plan to take? Review the client's Hgb level prior to administration. Use the Z-tract method when administering the medication. Shake the vial for 30 seconds prior to withdrawing the medication. Ensure the client is not taking iron supplements while on this medication. 40.A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse report to the provider immediately? Decreasing leg strength Decreasing voice volume Decreased deep tendon reflexes Decreased sensation in the arm 41.A nurse is assessing a client who has Addison's disease. Which of the following manifestations should indicate to the nurse that the client is experiencing an Addisonian crisis? Hypothermia Increased deep tendon reflexes Hypotension Erythema of the neck and chest 42.A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is the nurse's priority? Provide assistance with ambulation. Facilitate retention of facts by repeating instructions. Place the client in a darkened room. Speak slowly and clearly. 43.A nurse is providing teaching to a newly licensed nurse about caring for a client who is receiving a ealed radioactive implant. Which of the following information should the nurse include in the teaching? Place soiled linens in a lead container. •
Allow children who are over 10 years old to visit.
48.A nurse is assessing a client who has a history of migraine headaches with aura and reports feeling "a migraine coming on." The nurse should expect the client to report which of the following manifestations? Visual disturbances
the teaching?
statements by the caregiver demonstrates an understanding of the teaching?
"I will allow him to assume a position of comfort." "I will elevate the head of the bed 10 degrees." "I will place him in a left side-lying position." "I will sit him up in bed." 57.A nurse is teaching a client who has asthma about using a peak ow meter. When a yellow zone meter reading appears, the nurse should instruct the client to take which of the following actions? Take another peak ow meter reading in 15 min. Take prescribed relief medication. Call for emergency transport to a hospital. Inhale through pursed lips. 58.A nurse is caring for a client who is postoperative and reports frequent leakage of small amounts of urine. The nurse notes that the client's bladder is palpable upon examination. The nurse should identify these findings as which of the following forms of incontinence? Stress Urge Functional Overow 59.A nurse is assessing a client who has tuberculosis and is taking rifampin. Which of the following findings should the nurse report as an adverse effect of the medication? Alopecia Yellowing of the sclera Report of constipation Report of insomnia 60.A nurse is caring for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse include in the plan of care to prevent autonomic dyslexia? Monitor bowel movement regularity.