Med Surg/NEURO
A nurse is caring for a client who has ingested a toxic agent. Which of the following actions should the nurse plan to take? (Select all that apply.)
A. Induce vomiting.
B. Instill activated charcoal.
C. Perform a gastric lavage with aspiration.
D. Administer syrup of ipecac.
E. Infuse IV fluids.
ANSWER: B, C, E
A. Vomiting places the client at risk for aspiration.
B. CORRECT: activated charcoal adsorbs toxic substances, and the charcoal does not pass into the bloodstream.
C. CORRECT: gastric lavage with aspiration removes the toxic substance when the instilled fluid is suctioned from the gastrointestinal tract.
D. ipecac is not recommended because it induces vomiting, which increases the client’s risk for aspiration.
E. CORRECT: This is an appropriate action by the nurse because
intravenous fluids help dilute the toxic substances in the bloodstream
and promote elimination from the body through the kidneys.
A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect?
A. Fluctuations in blood pressure
B. Loss of cognitive function
C. Ineffective cough
D. Drooping eye lids
ANSWER: B
A. Fluctuations in blood pressure is a manifestation associated with amyotrophic lateral sclerosis.
B. CORRECT: Loss of cognitive function is a manifestation associated with MS.
C. Ineffective cough is a manifestation associated with amyotrophic lateral sclerosis.
D. Drooping eyelids is a manifestation associated with myasthenia gravis.
A nurse is providing discharge instructions to a female client who has a prescription for phenytoin. Which of the following information should the nurse include?
A. Consider taking oral contraceptives when on this medication.
B. Watch for receding gums when taking the medication.
C. Take the medication at the same time every day.
D. Provide a urine sample to determine therapeutic levels of the medication.
ANSWER: C
A. The nurse should not instruct the client to take oral contraceptives, because contraceptive effectiveness is decreased when taking phenytoin.
B. The nurse should instruct the client that phenytoin causes overgrowth of the gums.
C. CORRECT: The nurse should instruct the client to take phenytoin at the same time every day to enhance effectiveness.
D. The nurse should instruct the client to have periodic blood tests to determine the therapeutic level of phenytoin.
A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multimedication regimen. Which of the following instructions should the nurse give the client related to ethambutol?
A. “Your urine can turn a dark orange.”
B. “Watch for a change in the sclera of your eyes.”
C. “Watch for any changes in vision.”
D. “Take vitamin B6 daily.”
ANSWER: C
A. The client who is receiving rifampin should expect to see his urine turn a dark orange.
B. The client who is taking ethambutol does not have an adverse effect resulting in changes to the sclera of the eyes.
C. CORRECT: The client who is receiving ethambutol will need to watch for visual changes due to optic neuritis, which can result from taking this medication.
D. The client who is taking isoniazid should tak
A nurse is caring for a client who has suspected Ménière’s disease. Which of the following is an expected finding?
A. Presence of a purulent lesion in the external ear canal
B. Feeling of pressure in the ear
C. Bulging, red bilateral tympanic membranes
D. Unilateral hearing loss
ANSWER: D
A. Ménière’s disease is an inner ear disorder. A purulent lesion in the external ear canal is not an expected finding.
B. A feeling of pressure in the ear can occur with otitis media, but is not an expected finding in Ménière’s
C. Ménière’s disease is an inner ear disorder. Bulging, red bilateral tympanic membranes is a finding associated with a middle ear infection.
D. CORRECT: Unilateral sensorineural hearing lossis an expected finding in Ménière’s disease.
A nurse in a clinic is caring for a client who has frequent migraine headaches. The client asks about foods that can cause headaches. The nurse should recommend that the client avoid which of the following foods?
A. Baked salmon
B. Salted cashews
C. Frozen strawberries
D. Fresh asparagus
ANSWER: B
A. The client should avoid fish that is smoked because it contains tyramine. Baked salmon does not contain tyramine and is not a trigger for migraine headaches.
B. CORRECT: Nuts contain tyramine, which can trigger migraine headaches.
C. Fruits are not a source of tyramine.
D. Vegetables are not a source of tyramine.
A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following manifestations should the nurse expect? (Select all that apply.)
A. Eye pain
B. Floating spots
C. Blurred vision
D. White pupils
E. Bilateral red reflexes
ANSWER: C, D
A. Eye pain is manifestation associated with primary angle‑closure glaucoma.
B. Floating spots are a manifestation associated with retinal detachment.
C. CORRECT: Blurred vision is a manifestation associated with cataracts.
D. CORRECT: White pupils are a manifestation associated with cataracts.
E. Bilateral red reflexes are absent in a client who has cataracts.
A nurse is monitoring a client who is receiving opioid analgesia. Which of the following findings should the nurse identify as adverse effects of opioid analgesics? (Select all that apply.)
A. Urinary incontinence
B. Diarrhea
C. Bradypnea
D. Orthostatic hypotension
E. Nausea
ANSWER: C, D & E
A. Urinary retention, not urinary incontinence, is a common adverse effect of opioid analgesia.
B. Constipation, not diarrhea, is a common adverse effect of opioid analgesia.
C. CORRECT: Respiratory depression, which causes respiratory rates to drop to dangerously low levels, is a common adverse effect of opioid analgesia.
D. CORRECT: Dizziness or lightheadedness when changing positions is a common adverse effect of opioid analgesia.
E. CORRECT: Nausea and vomiting are common adverse effects of opioid analgesia.
A nurse on a cardiac unit is caring for a client who is on telemetry. The nurse recognizes the client’s heart rate is 46/min and notifies the provider. The nurse should anticipate that which of the following management strategies will be used for this client?
A. Defibrillation
B. Pacemaker insertion
C. Synchronized cardioversion
D. Administration of IV lidocaine
ANSWER: B
A. Defibrillation is used when a client has ventricular fibrillation or pulseless ventricular tachycardia.
B. CORRECT: A client who has bradycardia is a candidate for a pacemaker to increase his heart rate.
C. Synchronized cardioversion is used when a client has a dysrhythmia such as atrial fibrillation, supraventricular tachycardia (SVT), or ventricular tachycardia with pulse.
D. The administration of IV lidocaine is used in clients who have a pulseless ventricular dysrhythmia to stimulate cardiac electrical function.
A nurse is caring for a client 2 hr after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medications should the nurse expect to administer?
A. Antibiotic
B. Beta‑blocker
C. Antiviral
D. Beta2 agonist
ANSWER: D
A. An antibiotic typically is given for a bacterial infection.
B. A beta‑blocker typically is given for dysrhythmias, heart disease, or hypertension.
C. An antiviral typically is given for a virus.
D. CORRECT: The nurse should administer a beta2 agonist, which causes dilation of the bronchioles to relieve symptoms.
A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse plan to take? (Select all that apply.)
A. Implement seizure precautions.
B. Perform neurological checks four times a day.
C. Administer morphine for the report of neck and generalized pain.
D. Turn off room lights and television.
E. Monitor for impaired extraocular movements.
F. Encourage the client to cough frequently.
ANSWER: A, D & E
A. CORRECT: The client is at risk for seizures due to possible increased ICP.
B. The nurse should perform neurological checks at least every 2 hr for a client who is at risk for increased ICP.
C. The nurse should avoid administering opioids to a client who is at risk for increased ICP. Opioids can mask changes in the client’s level of consciousness.
D. CORRECT: The nurse should turn off room lights and the television because they can increase neuron stimulation and cause a seizure when a client is at risk for increased ICP.
E. CORRECT: The nurse should monitor for impaired extraocular movements because this finding can indicate increased ICP.
F. The nurse should instruct the client to avoid coughing because this action can cause increased ICP.
A nurse is caring for a client who has Alzheimer’s disease. A family member of the client asks the nurse about risk factors for the disease. Which of the following should be included in the nurse’s response? (Select all that apply.)
A. Exposure to metal waste products
B. Long-term estrogen therapy
C. Sustained use of vitamin E
D. Previous head injury
E. History of herpes infection
ANSWER: A, D, E
A. Exposure to metal waste products
D. Previous Head inury
E. Hx of herpes infection
A nurse is reinforcing teaching with a client who has Parkinson’s disease and has a new prescription for bromocriptine. Which of the following instructions should the nurse include in the teaching?
A. Rise slowly when standing.
B. Expect urine to become dark‑colored.
C. Avoid foods containing tyramine.
D. Report any skin discoloration.
ANSWER: A
A. CORRECT: Orthostatic hypotension is a common adverse effect of bromocriptine, a dopamine receptor agonist. Therefore, rising slowly when standing up will decrease the risk of dizziness and lightheadedness.
B. The client should expect urine to turn dark when taking entacapone, a COMT inhibitor. Dark urine is not an expected finding when taking bromocriptine.
C. The client should avoid tyramine in the diet when taking selegiline, a monoamine type B inhibitor. However, bromocriptine does not interact with foods that contain tyramine.
D. Skin discoloration is an adverse effect of amantadine, an anti‑viral medication. However it is not an adverse effect of bromocriptine.
A nurse is caring for a group of clients. Which of the following clients are at risk for a pulmonary embolism? (Select all that apply.)
A. A client who has a BMI of 30
B. A female client who is postmenopausal
C. A client who has a fractured femur
D. A client who is a marathon runner
E. A client who has chronic atrial fibrillation
ANSWER: A, C, E
A. CORRECT: The client who has a BMI of 30 is considered obese and is at increased risk for a blood clot.
B. A woman who is postmenopausal has decreased estrogen levels and is not at risk for developing a pulmonary embolism.
C. CORRECT: The client who has a fractured bone, particularly in a long bone such as the femur, increases the risk of fat emboli.
D. The client who is a marathon runner has increased blood flow and circulation of his body, which decreases the risk for developing a pulmonary embolism.
E. CORRECT: The client who has turbulent blood flow in the heart, such as with atrial defibrillation, is also at increased risk of a blood clot.
A nurse in the emergency department is caring for a client who had an allergic reaction related to a bee sting. The client is experiencing wheezing and swelling of the tongue. Which of the following medications should the nurse anticipate administering first?
A. Methylprednisolone IV bolus
B. Diphenhydramine subcutaneously
C. Epinephrine IV
D. Albuterol inhaler
ANSWER: C
A. The nurse should administer methylprednisolone to treat the inflammatory response to the bee sting. However, the nurse should administer another medication first.
B. The nurse should administer diphenhydramine to treat the client’s itching related to the bee sting. However, the nurse should administer another medication first.
C. CORRECT: When using the airway, breathing, circulation approach to client care, the nurse should place the priority on administering epinephrine to the client. This is a rapid‑acting medication that promotes effective oxygenation and is used to treat anaphylactic shock.
D. The nurse should administer albuterol to assist with the client’s breathing. However, the nurse should administer another medication first.
A nurse is assessing a client for manifestations of Parkinson’s disease. Which of the following are expected findings? (Select all that apply.)
A. Decreased vision
B. Pill‑rolling tremor of the fingers
C. Shuffling gait
D. Drooling
E. Bilateral ankle edema
F. Lack of facial expression
ANSWER: B, C, D, F
A. Decreased vision is not an expected finding in PD
B. CORRECT: The client who has PD can manifest pill‑rolling tremors of the fingers due to overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult.
C. CORRECT: The client who has PD can manifest shuffling gait because of overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult.
D. CORRECT: The client who has PD can manifest drooling because of overstimulation of the basal ganglia by acetylcholine, making the controlled movement of swallowing secretions difficult.
E. Bilateral ankle edema is not an expected finding in a client who has PD, but can be an adverse effect of certain medications used for treatment.
F. CORRECT: The client who has PD can manifest a lack of facial expressions due to overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult.
A nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.)
A. Persistent cough
B. Weight gain
C. Fatigue
D. Night sweats
E. Purulent sputum
ANSWER: A, C, D, E
A. CORRECT: The nurse should include in the teaching that a persistent cough is a manifestation of tuberculosis.
B. The nurse should include in the teaching that weight loss is a manifestation of tuberculosis.
C. CORRECT: The nurse should include in the teaching that fatigue is a manifestation of tuberculosis.
D. CORRECT: The nurse should include in the teaching that night sweats is a manifestation of tuberculosis.
E. CORRECT: The nurse should include in the teaching that purulent sputum is a manifestation of tuberculosis.
A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor?
A. Hyperglycemia
B. Hyponatremia
C. Hypervolemia
D. Oliguria
ANSWER: B
A. Hyperglycemia is not an adverse effect of mannitol.
B. CORRECT: Mannitol is a powerful osmotic diuretic. Adverse effects include electrolyte imbalances, such as hyponatremia.
C. Hypovolemia NOT HYPER-volemia is an adverse effect of mannitol
D. Polyuria NOT OLIGURIA is an adverse effect of mannitol
A nurse is assessing a client who has a pulmonary embolism. Which of the following manifestations should the nurse expect to find? (Select all that apply.)
A. Bradypnea
B. Pleural friction rub
C. Hypertension
D. Petechiae
E. Tachycardia
ANSWER: B, D, E
A. The nurse should expect the client to have tachypnea, which is a manifestation associated with a pulmonary embolism.
B. CORRECT: The nurse should expect the client to have a pleural friction rub, which is a manifestation associated with a pulmonary embolism.
C. The nurse should expect the client to have hypotension, which is a manifestation associated with a pulmonary embolism.
D. CORRECT: The nurse should expect the client to have petechiae, which is a manifestation associated with a pulmonary embolism.
E. CORRECT: The nurse should expect the client to have tachycardia, which is a manifestation associated with a pulmonary embolism.
A nurse is caring for a client who experienced defibrillation. Which of the following should be included in the documentation of this procedure? (Select all that apply.)
A. Follow‑up ECG
B. Energy settings used
C. IV fluid intake
D. Urinary output
E. Skin condition under electrodes
ANSWER: A, B, E
A. CORRECT: The client’s ECG rhythm is documented following the procedure.
B. CORRECT: Energy settings used during the procedure are documented.
C. IV fluid intake is not documented during defibrillation.
D. Urinary output is not documented during defibrillation.
E. CORRECT: The condition of the client’s skin where electrodes were placed is documented.
A nurse is beginning a physical assessment of a client who has a new diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? (Select all that apply.)
A. Areas of paresthesia
B. Involuntary eye movements
C. Alopecia
D. Increased salivation
E. Ataxia
ANSWER: A, B, E
A. CORRECT: Areas of loss of skin sensation are a finding in a client who has MS.
B. CORRECT: Nystagmus is a finding in a client who has MS.
C. Hair loss is not a finding in a client who has MS.
D. Dysphagia, swallowing difficulty, is a finding in a client who has MS.
E. CORRECT: Ataxia occurs in the client who has MS as muscle weakness develops and there is loss of coordination.
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply.)
A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling in the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration
D. Exposed sutures without dressing
E. Drainage system upright at chest level
ANSWER: B, C
A. Continuous bubbling in the water seal chamber indicates an air leak.
B. CORRECT: Gentle bubbling in the suction control chamber is an expected finding as air is being removed.
C. CORRECT: A rise and fall of the fluid level in the water seal chamber upon inspiration and expiration indicates that the drainage system is functioning properly.
D. The nurse should cover the sutures at the insertion site with an airtight dressing.
E. The drainage system should be maintained in an upright position below the level of the client’s chest.
A nurse is preparing to administer a dose of a new prescription of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects of this medication? (Select all that apply.)
A. Hypokalemia
B. Tachycardia
C. Fluid retention
D. Nausea
E. Black, tarry stools
ANSWER: A, C, E
A. CORRECT: The nurse should observe for hypokalemia. This is an adverse effect of prednisone.
B. Tachycardia is an adverse effect of a bronchodilator.
C. CORRECT: The nurse should observe for fluid retention. This is an adverse effect of prednisone.
D. Nausea is an adverse effect of a bronchodilator.
E. CORRECT: The nurse should monitor for black, tarry stools. This is an adverse effect of prednisone.
A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states she is anxious and is unable to get enough air. Vital signs are heart rate 117/min, respirations 38/min, temperature 38.4° C (101.2° F), and blood pressure 100/54 mm Hg. Which of the following nursing actions is the priority?
A. Notify the provider.
B. Administer heparin via IV infusion.
C. Administer oxygen therapy.
D. Obtain a spiral CT scan.
ANSWER: C
A. The nurse should notify the provider about the condition. However, another action is the priority.
B. The nurse should administer IV heparin as a treatment to prevent growth of the existing clot and to prevent additional clots from forming. However, another action is the priority.
C. CORRECT: When using the airway, breathing, circulation (ABC) priority approach to care, the nurse determines that the priority finding is related to the respiratory status. Meeting oxygenation needs by administering oxygen therapy is the priority action.
D. The nurse should obtain a spiral CT scan to detect the presence and location of the blood clot. However, another action is the priority
A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increases the effort of the client’s respiratory muscles should the nurse include in the plan of care? (Select all that apply.)
A. Assist‑control
B. Synchronized intermittent mandatory ventilation
C. Continuous positive airway pressure
D. Pressure support ventilation
E. Independent lung ventilation
ANSWER: B, C, D
A. Assist‑control mode takes over the work of breathing.
B. CORRECT: Synchronized intermittent mandatory ventilation requires that the client generate force to take spontaneous breaths.
C. CORRECT: Continuous positive airway pressure requires that the client generate force to take spontaneous breaths.
D. CORRECT: Pressure support ventilation requires that the client generate force to take spontaneous breaths.
E. Independent lung ventilation mode is used for unilateral lung disease to ventilate the lung individually.