WorksheetsReview Med/Surg
Total questions: 38
Worksheet time: 19mins
The emergency nurse is admitting a client experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation?
cool, clammy skin
hyperactive bowel sounds
increased urine output
decreased heart rate
decreased blood pressure
The nurse is caring for a client who is exhibiting signs and symptoms of hypovolemic shock following injuries from a motor vehicle accident. In addition to normal saline, which crystalloid fluid should the nurse prepare to administer?
lactated ringers
albumin
D5 1/2 Normal Saline
.45 Normal Saline
A client who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurse’s care planning during the administration of a vasoactive drug?
The drug should be discontinued immediately after blood pressure increases.
The drug dose should be tapered down once vital signs improve.
The client should have arterial blood gases drawn every 10 minutes during treatment.
The infusion rate should be titrated according the client's subjective sensation of adequate perfusion.
The nurse is caring for a client in the early stages of sepsis. The client is not responding well to fluid resuscitation measures and has a worsening hemodynamic status. Which nursing intervention is most appropriate for the nurse to implement?
Administer norepinephrine as prescribed.
Initiate enteral feedings as prescribed.
Begin a continuous IV infusion of insulin per protocol.
Administer recombinant human activated protein C (rhAPC) as prescribed.
The nurse is writing a plan of care for a client with a cardiac dysrhythmia. What would be the priority goal for the client?
Maintain a resting heart rate below 70 bpm.
Maintain adequate control of chest pain.
Maintain adequate cardiac output.
Maintain normal cardiac structure.
A nurse is caring for a client who is exhibiting ventricular tachycardia (VT). Because the client is pulseless, the nurse should prepare for what intervention?
angioplasty
ECG monitoring
implantation of a cardioverter defibrillator
Defibrillation
Which assessment finding would put a patient at risk for hemorrhagic stroke?
blood glucose of 480
right sided carotid bruit
BP of 220/105
small cell lung cancer
A patient with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the ICU nurse implement
encourage patient to cough each hour
administer a stool softener
maintain the dopamine drip to keep BP at 160/90
Monitor neurological status every shift
Your patient is experiencing status epilepticus which collaborative intervention should you anticipate
Assess Neuro status every hour
monitor the client's heart rhythm via telemetry
Administer Solumedrol IV
Administer IV push anticonvulsants
You see the following rhythm on the monitor what is your first intervention
Defibrillation
Assess the patient to see if they are symptomatic
Administer Atropine
Initiate Transcutaneous Pacing
The nurse is caring for clients on an oncology floor. Which neutropenia precautions should be implemented
hold all venipuncture cites for at least 5 minutes
limit fresh fruits and flowers
place all clients in reverse isolation
have clients use a soft-bristle toothbrush
Which signs and symptoms should the nurse expect to assess in the client with Hemophilia A?
Epistaxis
Petechiae
Subcutaneous emphysema
intermittent claudication
the client diagnosed with ARDS is transferred to your critical care unit and is on the ventilator. Which intervention should you implement first?
Confirm the ventilator settings are correct
Verify the ventilator alarms are functioning
Assess respiratory status and pulse oximeter reading
Monitor the ABG results
Which assessment finding would indicate that the client diagnosed with ARDS has experienced a complication secondary to the ventilator?
Urine output is 150 mls in 3 hours
pulse oximeter shows an 0 sat of 95%
the client has asymmetrical chest expansion
Telemetry show sinus tachycardia
Which signs and symptoms would you expect to see in a patient diagnosed with ulcerative colitis?
oral temperature of 102.4
20 bloody stools per day
hard, rigid abdomen
urinary stress incontinence
The client has end stage liver failure secondary to alcoholic cirrhosis, which finding below puts the patient at risk for developing hepatic encephalopathy
splenomegaly
low albumin
high ammonia
low sodium
Which type of hepatitis is transmitted through fecal oral route?
Hepatitis A
Hepatis B
Hepatitis C
None of the above
Your client is admitted to with abdominal pain and they are trying to r/o pancreatitis. Which lab value should you monitor to help confirm the diagnosis?
BUN and Creatnine
Troponin and CK
Amylase and lipase
bilirubin and calcium
The nurse is planning care for a patient with Addison's disease, which intervention should be included
Administer steroids medications
place patient on fluid restriction
provide frequent stimulation
consult PT for gain training
The client is admitted to rule out Cushing's disease,. Which lab tests should the nurse anticipate being ordered?
drug levels of digoxin and hydralazine
ACTH and cortisol
check urine for WBCs
24-hour urine test
Your client has been diagnosed with SIADH, care should focus on?
assessing for dehydration and monitor blood glucose levels
assess for nausea and vomiting and weigh patient daily
monitor K levels and encourage fluid intake
administer vasopressin IV and conduct a fluid deprivation test
Which statement made by the patient makes you suspect the patient has hyperthyroidism?
I don't have any appetite any more
I have a bowel movement every 3 to 4 days
My skin is really becoming dry and course
I have noticed all of my heart beating faster over the past month
A client is admitted to the hospital with pernicious anemia. The nurse should prepare to administer which of the following medications?
Folic acid
Vitamin B12
magnesium sulfate
Lactulose
A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the priority medical treatment to include which of the following?
Cholesterol-lowering drugs
Carotid endarterectomy
Monthly prothrombin levels
Anticoagulant medication
A client the nurse is caring for experiences a seizure. What would be a priority nursing action?
Suction the mouth during the convulsion.
Insert a tongue blade in the mouth
Protect the patient from injury
Restrain the client during the seizure.
The recovery room nurse is caring for a patient with a VKA which intervention should the nurse implement?
Asses the surgical dressing every hour
Do not allow the client to see the residual limb
keep a large tourniquet at the patient's bedside
Explain to patient that pain medications are not needed for phantom pain
The client with a long arm cast is complaining of unrelenting pain and feeling as if there fingers are asleep, Which complication should the nurse suspect the client is experiencing?
Fat Embolism
Compartment syndrome
Pressure ulcer under the cast
Surgical incision infection
The client is diagnosed with neurogenic shock. Which symptom should you assess the client for?
cool, moist skin
bradycardia
wheezing
absent bowel sounds
The client with septic shock has the following orders, which one has the highest priority?
Provide clear liquid diet
initiate IV antibiotic therapy
attain a chest X-ray
Perform hourly glucose checks
What is the primary goal of the ED nurse in caring for a client who has ingested poison?
Remove or inactivate the poison to limit absorption
Provide long-term supportive care to prevent organ damage
administer an antidote to increase the effects of the poison
implement treatment prolonging the elimination of the poison
What is your first priority with this rhythm
Defibrillation
Cardioversion
Initiate CPR
check a pulse
All of the following are appropriate interventions for the following rhythm except for?
Initiate CPR
IV Amiodarone
Defibrillation
IV Adenosine
Your client presents with complaints of palpitations, when you connect her to the monitor you see the following arrythmia, which of the following is an appropriate intervention?
Administer Atropine
Defibrillation
Administer Adenosine
Start CPR
The client has GERD, which order would you question?
Elevate the head of the bed with blocks
Administer (Protonix) Pantoprazole three times daily
Avoid citrus and spicy foods
Activity as tolerated and sit upright when eating meals
The client has Chrohns disease with assessment data would warrant immediate attention
The WBC count is 10,000
the serum amylase is 100
The potassium is 3.1
The blood glucose after breakfast is 148
Which signs and symptoms should the nurse expect to assess in the client diagnosed with Addison's disease?
hypotension and bronze skin pigmentation
water retention and osteoporosis
Hirsutism and abdominal straie
Truncal obesity and thin, waster extremities
The client diagnosed with chronic renal failure is receiving peritoneal dialysis. Which assessment finding would require immediate intervention?
The dialysate return is cloudy
there is greater dialysate return than input
the client complains of abdominal fullness
the client voided 50 mls in the last hour
When assessing the patient who has a lower urinary tract infection the nurse will initially ask about?
flank pain
pain with urination
poor urine output
nausea
