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NURS 406: CAPSTONE MED
SURG ASSESSMENT Q & A
1. A nurse is providing discharge instructions to a client who has GERD. Which of
the following statements by the client demonstrates an understanding of the teaching? I will limit activities that require bending at the waist.
2. A nurse at a provide office is interviewing a client who has multiple sclerosis and has
been taking dantrolene for several months. Which of the following client statements should the nurse identify as an indication that the medication is effective? I don’t have muscle spasms as frequently
3. A nurse is assessing a client who reports a possible exposure to HIV. Which of the
following finding should the nurse identify as an early manifestation of HIV infection? Fatigue
4. A nurse is teaching a client who has type 1 diabetes mellitus about hypoglycemia
.which of the following statements by the client indicates an understanding of the teaching? I can drink 4 ounces of soda if my blood sugar is low
5. A nurse is providing discharge teaching to a client who has heart failure and a
prescription for furosemide 20 mg PO two times daily. Which of the following instructions should the nurse include in the teaching? Increase intake of high-potassium foods
6. 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.
7. 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.
8. 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
9. 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
10.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.
11.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.
16.A nurse is providing discharge teaching to a client following a heart transplant. Which
of the following information should the nurse include in the teaching? Shortness of breath might be an indication of transplant rejection
17.A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone
(SIADH) and is receiving 3 % sodium chloride via continuous IV. Which of the following laboratory finding should the nurse identify as an indication that the SIADH is resolving? Urine specific gravity 1.
18.A nurse is teaching a client about fecal occult blood testing (FOBT) for the screening
of colorectal cancer. Which of the following statements should the nurse include in the teaching? You should avoid taking corticosteroids prior to testing
19.A nurse is preparing a client for a colonoscopy. Which of the following
medications should the nurse anticipate the provider to prescribe as an anesthetic for the procedure? Propofol
20.A nurse is planning care for a client who has acute pancreatitis. Which of the
following interventions should the nurse include in the clients plan? Select all that apply. Monitor blood glucose levels Maintain NPO status until pain-free Manage acute pain
21.A nurse is teaching a client who has hypertension about dietary modifications to help
control blood pressure. Which of the following food choices should the nurse recommend as the client to include in their diet? 3 oz of chicken breast
22.A nurse is reviewing the medical record of a client who has unstable angina. Which of
the findings should the nurse report to the provider? Breath Sounds
23.A triage nurse nds a school-age child lying in the road following a school bus crash
with multiple casualties. The child has a respiratory rate of 8/min, is unresponsive to verbal commands, and groans to painful stimuli. The nurse should assign the client which of the following triage tags?
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.
Limit visitors to 1 hr. per day. Wear a lead apron during care
44.A nurse is assessing a client who is postoperative following a kidney transplant.
Which of the following findings indicates the client is experiencing a transplant rejection? Polyuria • Hypothermia Hypertension Hypovolemia
45.A nurse is providing teaching to a client who is scheduled for a bone marrow
biopsy taken from the iliac crest. Which of the following information should the nurse include? "Avoid taking warm baths following the procedure." • "You will lie on your back during the procedure." "You will receive general anesthesia for the procedure." "Take acetaminophen as prescribed for pain relief after the procedure."
46.A nurse is providing discharge instructions to a client who has a peptic ulcer. Which of
the following dietary medications should the nurse include? Provide a snack at bedtime.
Choose decatenated coee. Restrict intake of fried foods. Avoid drinking liquids with meals
47.A nurse is assessing a client following a hypophysectomy. Which of the following
findings indicates the client might be developing diabetes insipidus? Urine ketones Hyperglycemia • Halo or ring-shaped dressing drainage Low urine specic gravity
of the following instructions should the nurse include in the teaching?
"It is important to engage in a strenuous aerobic exercise program to build strength and endurance." "It is important with this disease to relax muscles in a hot tub or spa." "It is important to engage in social activity, and volunteering to read to schoolchildren will keep you active." "It is important to develop a daily schedule that reduces fatigue and conserves energy."
53.A nurse is caring for a client who is postoperative immediately following a
pheochromocytoma removal. Which of the following actions is the nurse's priority? Increase hydration. Monitor blood pressure. • Measure urine output. Provide a calm environment.
54.A nurse is teaching a client who has glaucoma and is to start taking timolol. Which of
the following information should the nurse include? "Notify the provider if you experience a stinging sensation following administration." Para mi "Watch for a decreased heart rate while using this medication." "You can expect to develop a harmless darkening of the iris." • "This medication can cause the lashes of the affected eye to lengthen."
55.A nurse is providing teaching to a client who has a new onset of genital herpes.
Which of the following statements should the nurse include in the teaching? "You are not contagious when lesions are healed." "This infection is spread through the air." "Stress can activate an outbreak." "Antiviral drugs will cure the infection."
56.A nurse is instructing a client's caregiver on how to position the client before
administering tube feedings in the home. Which of the following statements by the caregiver demonstrates an understanding of the teaching?
Tuck the top bedsheet tightly around the client's torso. Monitor for cerebrospinal fluid leakage
61.A nurse is caring for a client who is using a ventilator when the low- pressure ventilator
alarm sounds. Which of the following actions should the nurse take? Suction secretions from the endotracheal tube. Check the ventilator tubing connections. Administer intravenous sedation and analgesia. Reassure the client and instruct them not to bite on the tube.
62.A nurse is caring for a client who has renal calculi. Which of the following
prescriptions by the provider is the priority action for the nurse to take? Strain all urine. Schedule a retrograde pyelography. Monitor intake and output. Schedule a kidney ultrasound.
63.A nurse is providing discharge teaching to a client who is postoperative following a
total hip arthroplasty. Which of the following statements by the client indicates an understanding of the teaching? "When I'm exercising, I'll include bent-leg raises." "I'll use my reaching device to help me pick up objects I drop on the oor." "I can stop physical therapy when I quit using my walker." • "I'll sleep on my back with my knees close together."
64.A nurse is providing teaching for a client who has Parkinson's disease and a new
prescription for selegiline. Which of the following statements should the nurse include? "You might experience joint pain while taking this medication." "The medication cannot be combined with other antiparkinsonian agents." "Avoid eating aged cheeses or smoked meats while taking this medication." "It will take up to 2 weeks for the medication to work."
65.A nurse is caring for a client who has renal failure. Which of the following arterial
blood gas (ABG) results should the nurse expect? pH 7.25, HCO3 20 mEq/L, PaCO 35 mm Hg -2 pH 7.30, HCO3 22 mEq/L, PaCO 50 mm Hg - pH 7.50, HCO3 32 mEq/L, PaCO 45 mm Hg - pH 7.55, HCO3 28 mEq/L, PaCO 31 mm Hg
66.A nurse is reviewing a client's medical record prior to administering furosemide via
IV bolus to a client who has heart failure. For which of the following ndings should the nurse withhold the medication and notify the provider? Hypokalemia Hypernatremia Hypoglycemia Hypermagnesemia
67.A nurse is initiating a plan of care for a client who has COPD. Which of the following
interventions should the nurse include? Request a prescription for an antibiotic. Educate the client on pursed-lip breathing. Place the client in airborne precautions. Initiate a referral for gene therapy.
68.A nurse is receiving report on a group of clients. Which of the following clients
should the nurse assess first? A client who has a chest tube and reports a pain level of 6 on a scale of 0 to 10 A client who received parenteral cephalosporin and reports urticaria and edema A client who is being admitted with bilateral Stage 3 pressure injuries on both heels A client who has a systemic infection and an oral temperature of 39.1° C (102.4° F)
73.A nurse is creating a plan of care for a client who has meningitis. Which of the
following interventions should the nurse include? Initiate contact isolation precautions. Keep the client's environment dark and quiet. Restrict the client's fluid intake. Perform neurovascular assessments once a day.
74.A nurse is a caring for client who is postoperative following a below-the- knee
amputation. Which of the following actions should the nurse take? Maintain a loose bandage on the residual limb. Turn the client from side to side once every 4 hr. Request a soft mattress for the client. Place the client prone for 20 min every 3 hr.
75.A nurse is assessing a client who has meningitis. The nurse should identify which of
the following findings as a positive Kernig's sign? After stroking the lateral area of the foot, the client's toes contract and draw together. After hip exion, the client is unable to extend their leg completely without pain. Esta es la misma pregunta 17 The client's voluntary movement is not coordinated. The client reports pain and stiness when exing their neck
76.A nurse is caring for a client who has rheumatoid arthritis and has been taking
prednisone. Which of the following findings should the nurse identify as an adverse effect of this medication? Weight loss Hypoglycemia Hypertension Hyperkalemia
77.A nurse is caring for a client who has increased intracranial pressure (ICP). Which of
the following interventions should the nurse implement?
Place several pillows behind the client's head.
