Med-Surg 2

Question 1

The UAP removed the nasal cannula from the pt with COPD while ambulating to the bathroom. which action RN should do?
a) Praise the UAP because this prevents the pt from tripping the tubing
b) Place the oxygen back on the pt while sitting in the bathroom and say nothing
c) Explain to the UAP in front of the pt O2 must be left in place at all times

Answer 1

b
Pt needs the oxygen and the nurse should not correct UAP in front of the pt.
The nurse should first address the behavior with the person directly and then chain of command

Question 2

Which statement made by the pt indicates the nurse’s discharge teaching is effective for the pt with COPD?
a) I need to get a flu vaccine each year
b) I need to get a pneumonia vaccine each year
c) I need to restrict my drinking liquids to keep from having so much phlegm

Answer 2

a
b-every 5 years
c-should increase their fluid intake

Question 3

The nurse is monitoring the lab values of a pt on long-term steroid use. Which value would the nurse expect to be altered in the urine? SATA

a) Protein
b) Glucose
c) Ketones
d) RBCs
e) Uric acid

Answer 3

b,c
a-protein should never in urine, if so kidney disfunction

Question 4

What foods would be the best choice for a pt with a blood sugar of 60? SATA
a) Skim Milk
b) Apple juice
c) Milk chocolate bar
d) A handful of raisins

Answer 4

a,b,d

Question 5

A client newly diagnosed with fluid retention and heart failure. What should the nurse advise the client to avoid? SATA
1. Broiled, fresh fish
2. Effervescent soluble medications
3. Seasoning with lemon pepper
4. Chicken noodle soup
5. Deli-ham sandwiches

Answer 5

2,4,5
Effervescent soluble medications and canned/processed foods should be avoided because they all contain a lot of sodium

Question 6

A client diagnosed with Cushing’s disease. Which statement by the client would best indicate understanding of the teaching?

1. “The increased level of ADH will cause my potassium level to be too high.”
2. “I will be retaining sodium and water due to the increased amount of aldosterone.”
3. “I will be losing lots of fluid due to the hormonal imbalance I have.”
4. “I will feel jittery and nervous due to the elevated thyroxine levl

Answer 6

2

Question 7

A client with diabetes insipidus following a head injury. Which finding would the nurse anticipate in this client?

1. Low serum hematocrit
2. High serum glucose
3. High urine protein
4. Low urine specific

Answer 7

4
Results from decreased ADH production cause polyuria

Question 8

A client is severe burn. What changes related to fluid status would the nurse anticipate? SATA

1. Fluid volume excess
2. Hypovolemia
3. Third spacing
4. Increased urine output
5. Low CVP
6. Increased urine specific gravity

Answer 8

2,3,5,6
When the fluid volume becomes depleted, the urine output will decrease in an effort to hold on to the fluid (compensate) or the kidneys are not being perfused

CVP= Central venous pressure

Question 9

A client with chronic liver disease has ascites and is being treated with an albumin infusion. What should the nurse anticipate and monitor in this client?

1. Fluid volume excess
2. Cellular edema
3. Severe hypotension
4. Decreasing CVP

Answer 9

1
Albumin is a hypertonic solution. This type of solution will draw fluid from the cell into the vascular space. This builds up the volume in the vascular space

Question 10

A client is admitted with hypocalcemia. Which treatment would the nurse anticipate for this client? SATA

1. PO Calcium
2. Rapid IV Push Calcium
3. Vitamin D
4. Sevelamer hydrochloride
5. Phosphate supplements

Answer 10

1,3,4
sevelamer hydrochloride and how will this help hypocalcemia? Well, it is a phosphate binder. And remember that we said if you bind the phosphorus, the phosphorus levels go down.

ascites=fluid builds up in the abdomen

Question 11

The nurse is preparing to administer magnesium sulfate IV to a client. Prior to the initiation of IV magnesium, which assessment data would be important for the nurse to document? SATA

1. Liver function
2. Respiratory rate
3. Calcium levels
4. Deep Tendon Reflexes (DTRs)
5. Urinary output

Answer 11

2,4,5

Question 12

While performing wound care to a donor skin graft site, the nurse notes some scabbing around the edges and a dark collection of blood. What is the nurse’s next action?

1. Leave the scabbing area alone and apply extra ointment.
2. Notify the primary healthcare provider.
3. Gently remove the debris and re-dress the wound.
4. Apply skin softening lotion for 3 hours and then re-dress

Answer 12

3
What likes to live in the scabs and dried blood? Bacteria. That is why it is important to remove the debris to prevent infection.

Question 13

What sign/symptom would indicate to the nurse that a client has had an inhalation injury? SATA
1. Stridor
2. Swallowing difficulty
3. Singed nasal hair
4. Blisters to upper arms
5. Wheezing

Answer 13

1,2,3,5

Question 14

A client with deep partial thickness burns to is admitted to the burn unit. The nurse knows elevated results are most likely to be? SATA

Answer 14

1,3,4
Hematocrit increases as the fluid from the vascular spaces leaks into the interstitial tissues.
Because of lysis of cells, potassium is released into the circulation
The kidneys are impacted by the decreased cardiac output as well as the myoglobin released by the lysed cells

Question 15

A client sustains a high-voltage electrical injury while at work. Which interventions should the occupational health nurse initiate? SATA

1. Assess entry and exit wound.
2. Monitor vital signs.
3. Place on a spine board.
4. Connect to cardiac monitor.
5. Perform the rule of nines.
6. Apply cervical collar to neck.

Answer 15

1,2,3,4,6
Why place the client on a spine board and put a c-collar on? Contact with electricity can cause muscle contractions strong enough to fracture bones.

Question 16

A client being admitted in diabetic ketoacidosis (DKA). Which arterial blood gas value would be expected? SATA
1. pH 7.32
2. PaCO2 32
3. HCO3 25
4. PaO2 78
5. SaO2 82

Answer 16

1,2
2-The client in DKA is kussmauling to blow off the CO2 (acid), so the PaCO2 will either be normal or low.
4-Normal PaO2 is 80-100
5-The client in DKA is kussmauling to blow off the CO2 (acid), so the oxygen saturation of blood will be high

Question 17

A client who had a CVA is now having Cheyne-Stokes respirations ranging from 12-30 breaths/minute. BP 158/108, HR 46. Which acid/base imbalance does the nurse anticipate that this client will develop?
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis

Answer 17

1
The respiratory center in the brain is impaired and affects oxygenation.
Cheyne-Stokes respirations are characterized by progressively deeper and sometimes faster respirations followed by periods of apnea. This leads to acidosis and often times respiratory arrest.

Question 18

Which initial arterial blood gas (ABG) results would the nurse likely see in a client who has overdosed on acetylsalicylic acid (ASA)?
1. pH 7.50, PaCO2 42, PaO2 63, SaO2 91, HCO3 28
2. pH 7.32, PaCO2 36, PaO2 83, SaO2 95, HCO3 19
3. pH 7.28, PaCO2 28, PaO2 72, SaO2 90, HCO3 16
4. pH 7.48, PaCO2 30, PaO2 88, SaO2 92, HCO3 24

Answer 18

4. acetylsalicylic acid stimulates the respiratory center and causes an increase in respiratory rate and depth. This causes respiratory alkalosis by blowing off CO2 and causing the pH to increase. Losing CO2 (acid) makes the client more alkalotic, which is reflected with an increased pH, decreased PaCO​2 and normal HCO​3.

Question 19

A client who has been given steroids for a prolonged period to treat asthma, reports dizziness, tingling of the fingers, and muscle weakness. What action should the nurse take first?

1. Determine current blood pressure
2. Connect client to a cardiac monitor
3. Administer oxygen
4. Obtain arterial blood gases

Answer 19

2.
These symptoms are indicative of hypokalemia and metabolic alkalosis.
What do steroids do to the body? Steroids make you retain sodium and excrete potassium. So, you could become hypokalemic.

Question 20

When explaining the mnemonic of cancer C-A-U-T-I-O-N”, the nurse explains the ‘N’ stands for what sign/symptom?
1. Nausea
2. Nipple drainage
3. Nagging cough
4. Nose bleeds

Answer 20

3
C: Change in bowel or bladder habits
A: A sore that doesn’t heal
U: Unusual bleeding or discharge
T: Thickening or lump in the breast or elsewhere
I: Indigestion or difficulty swallowing
O: Obvious changes in warts or moles
N: Nagging cough or hoarseness

Question 21

A client is to begin external beam radiation for Ewing’s sarcoma. What symptoms would the nurse teach the client to expect during radiation treatments?

SATA
1. Nausea and Vomiting
2. Skin shedding
3. Erythema with pain
4. Pancytopenia
5. Exhaustion

Answer 21

2,3,4,5
2-even blistering may occur
damage affects even healthy tissue like bone marrow. The client may eventually develop pancytopenia: a lack of all blood components, including red cells, white cells and platelets. As the body struggles with cancer and the effects of radiation, the client may experience severe or overwhelming fatigue which needs reported to the primary healthcare provider.

Question 22

What does the nurse need to remember when caring for clients on the oncology unit who have a radiation implant?
SATA
1. Nursing assignments should be rotated weekly.
2. The nurse should care for no more than 3 clients with a radiation implant per shift.
3. Limit visitors to 60 minutes per day.
4. Wear film badge throughout assigned shift.
5. Educate visitors to stay at least 6 feet from the client.

Answer 22

4,5
1-should be rotated daily, so that the nurse is not continuously exposed
2-should only care for one client with a radiation implant in a given shift

Question 23

The nurse is preparing discharge teaching for a client post right radical mastectomy with reconstruction. What instruction should the nurse include?
SATA
1. Squeeze tennis ball with right hand every 2-4 hours while awake.
2. No blood pressure readings in right arm for one year.
3. Wear gloves when gardening.
4. Wear your watch on the left wrist.
5. Brush your hair with your left hand until pain free.

Answer 23

1,3,4
5-We want the client to use the affected arm when brushing hair. This will help promote new circulation and will help prevent frozen shoulder.

Question 24

Following chemotherapy for acute lymphocytic leukemia (ALL), the client’s lab results indicate a white blood count of 1000 cells mm3. What measures should the nurse institute immediately?
SATA
1. Request to change IM antiemetic medication to oral pill.
2. Have client increase fresh fruits and vegetables in diet.
3. Obtain client’s temperature at least every two hours.
4. Move client into isolation with a negative flow room.
5. Remove fresh flowers and limit visits from children.

Answer 24

1,3,5
1- Reducing invasive procedures
3-Fever is generally an early sign of infection, so taking the client’s temperature frequently may alert staff

Question 25

A client has returned to the room post stem cell transplant. What early signs of rejection should the nurse monitor for in the client? SATA 1. Abdominal pain 2. Straw colored urine 3. Jaundice 4. Pruritus 5. Diarrhea

Answer 25

1,3,4,5 Pruritus=itching

Question 26

The nurse is planning care for a client admitted for chemotherapy. What interventions should the nurse initiate to prevent infection? SATA 1. Change IV tubing every 48 hours. 2. Place supplies for client in room. 3. Limit nursing personnel in room. 4. Bathe perineum once daily. 5. Place in protective isolation.

Answer 26

2,3 2-They need their own BP cuff etc... they need their own everything. 1-should be changed daily 4-Moist areas are a great place for bacteria to grow, so take every other day 5-A private room is acceptable at this time.

Question 27

A client is placed on neutropenic precautions. What interventions should the nurse initiate? SATA 1. Use antimicrobial soap for handwashing. 2. Post neutropenic precautions sign on door. 3. Administer acetaminophen for fever greater than 101 degree F (38.3 degrees C). 4. Administer platelets as prescribed. 5. Vital signs at least every 4 hours.

Answer 27

1,2,5 3- Don't administer acetamenophen. It can be toxic to the liver 4- Platelets are not needed for a low white count.

Question 28

What action by the nurse, who is administering platelets to a client, would require the charge nurse to intervene? 1. Verifies prescription for platelet transfusion. 2. Confirm client has provided informed consent. 3. Hangs platelets immediately upon arrival from blood bank refrigerator. 4. Infuse platelets with normal saline solution.

Answer 28

3 **NEVER** infuse cold platelets, because the spleen will reject them if they are cold and not absorb them

Question 29

What should the nurse do after administering a chemotherapeutic drug intravenously (IV) to a client in the outpatient infusion unit? 1. Hang a 250 mL normal saline (NS) bag to flush the IV line. 2. Wear shoe covers during disposal of the drug. 3. Place the IV bag and tubing into a chemotherapy waste container. 4. Disposal of personal protective equipment (PPE) in a biohazardous container.

Answer 29

3

Question 30

Vanillylmandelic acid test

Answer 30

Test measures the amount of VMA in a urine sample over a 24-hour period. VMA is a metabolite of epinephrine and norepinephrine, hormones in the catecholamine group, so the test measures excess levels of these hormones.

Question 31

Which selection by the client indicates to the nurse that the client understands food allowed during a vanillylmandelic acid (VMA) test? 1. Milk 2. Caffeine 3. Citrus fruit 4. Chicken 5. Vanilla ice cream

Answer 31

1,4

Question 32

A client diagnosed with diabetic ketoacidosis (DKA)? Which prescription from the PHP would the nurse question? SATA 1. Arterial blood gases 2. 500 ml D5W at 100 mL per hour 3. Serum glucose levels every hour 4. Hourly adjustment of Regular insulin IV according to serum glucose level protocol 5. 100 mL O.45% sodium chloride (NaCL) with potassium chloride KCL 10mEq IV

Answer 32

2,5 2- Prescribing D5W will increase the client’s serum glucose level,should give normal saline **D5W=Dextrose 5% in water,contains sugar** 5-Initially the potassium is normal or high and can decrease when treatment begins. This prescription should be questioned.

Question 33

A client with a possible diagnosis hyperparathyroidism. Which serum laboratory value would validate this diagnosis?SATA 1. BUN 12 mg/dL (4.28 mmol/L) 2. Calcium 12 mg/dL (3 mmol/L) 3. Sodium 140 mg/dL (140 mmol/L) 4. Phosphate 2.8 mg/dL (0.9 mmol/L) 5. Potassium 3.5 mEq/L (3.5 mmol/L)

Answer 33

2,4 Normal calcium range is 9.0 -10.5 mg/dl normal range for phosphate is 3.0 – 4.5 mg

Question 34

A a client who states, "I feel really sick and my heart is beating so fast." What s/s would indicate that the client's cardiac output is inadequate? SATA 1. CVP 5 mm Hg. 2. Moist skin. 3. Urinary output 150 mL over 4 hours. 4. Weak radial pulses. 5. BP 90/50, HR 200, RR 22. 6. Mild chest discomfort.

Answer 34

2,4,5,6 6-Chest pain means oxygenated blood is not reaching the heart muscles. 1-Normal CVP is 2-6 mmHg

Question 35

A group of clients newly diagnosed with chronic stable angina. What points should the nurse include? SATA 1. Wait 1/2-1 hour after eating to exercise. 2. Attend classes such as guided imagery to reduce stress. 3. Temperature extremes can precipitate an angina attack. 4. Gradually increase weightlifting training to improve cardiac output. 5. Eat a low fat, low fiber diet to lose weight. 6. Medications prescribed to prevent angina work by increasing the workload of the heart.

Answer 35

2,3 **They need decrease the workload of the heart** 2-Stress can increase the workload on the heart 1-should wait at least 2 hours after eating to exercise 5-maintain a low fat, high fiber diet

Question 36

A client post cardiac catheterization that was performed via the right femoral artery. What assessment finding in the right lower extremity would be of concern to the nurse? 1. Right pedal pulse 2+/4+. 2. Capillary refill 2 seconds. 3. Erythema. 4. Slight oozing of blood.

Answer 36

4 ozzing=to flow slowly out of something 1-2-4+ is a normal pulse amplitude. We worry about 1+

Question 37

A client reports dizziness and weakness while walking down the hall. The nurse notes the client’s cardiac rhythm displayed on the telemetry monitor. What actions should the nurse take? SATA 1. Assist client in ambulating back to bed. 2. Obtain client’s blood pressure. 3. Auscultate lung sounds. 4. Prepare for cardioversion. 5. Initiate 100% oxygen per nonrebreather mask.

Answer 37

2,3 This client is at risk for **falling**, so think safety and get the client back in bed. Use a wheelchair to accomplish this. Then obtain the client’s BP. It may be low, indicating poor tissue perfusion to the vital organs.

Question 38

A client one hour post CABG. ncreasingly more difficult to arouse. Skin cool/damp. Distended neck veins. Lungs clear bilaterally. Heart sounds distant. CVP 8 mm Hg. BP 90/60. Based on the assessment data, what action should the nurse take? 1. Administer stat dose of clopidogrel. 2. Notify cath lab to prepare for angioplasty. 3. Set up for a central catheter line. 4. Prepare for immediate pericardiocentesis.

Answer 38

4 This findings point to **cardiac tamponade**, which is an emergency situation. Did you pick up on the classic s/s of this? Dec LOC,evidence of poor perfusion from decreased cardiac output, distended neck veins from the backward pressure, muffled heart sounds from the fluid collection around the heart, increasing CVP, and the narrowing pulse pressure as the heart is being compressed. Treatment involves a pericardiocentesis to remove blood that has formed around the heart.

Question 39

A client newly diagnosed with chronic stable angina about Nitroglycerin SL. What points should the nurse include? SATA 1. Nitroglycerin increased blood flow to the heart. 2. Take one nitroglycerin every five minutes until pain stops. 3. Sit or lie down when taking nitroglycerin. 4. The most common side effect is a headache. 5. Keep nitroglycerin in a clear, plastic bottle.

Answer 39

1, 3,4 Nitroglycerin dilates the coronary arteries to allow more oxygen BP will drop. So they could faint. The most common side effect is that the client will get a headache. It is not life threatening, but advise the client that this will occur.

Question 40

Which would be the appropriate pt criteria for activating a rapid response? SATA a) GCS score of 9 throughout shift b) HR remaining at 58 for more than 1 hour c) Postoperative pain 10 d) RR maintains an increase to 30 e) Sustained change in LOC for 10 min

Answer 40

d,e HR less than 40 or greater than130 Systolic BP <90 O2 Satu <90 Urine output<50mL/4hr Dec LOC a-GCS is abnormal but is stable in the abnormality

Question 41

A pt with CAD and HF. Which of the findings would require immediate follow-up? a) Bruises easily on the arms b) Report Chronic fatigue c) Muscle cramps in the legs d) Reports feeling drepressed

Answer 41

c Hypokalemia is a common ADR, since they may take diuretics

Question 42

Which actions by the nurse indicate that more education is needed? SATA a) Reinforcing a torn peripherally inserted central catheter line dressing with tape b) Scrubbing the port with alcohol for 5 sec before use

Answer 42

a,b a-dressing that no longer occlude the insertion site must be changed immediately b-should scrub **the hub**

Question 43

The nurse is monitoring a pt who has been on clopidogrel therapy, Which assessments are essential? SATA a) Assess for brushing b) Assess for tarry stools c) Monitor I&O d) Monitor liver function tests e) Monitor platelets

Answer 43

1,2,5 Clopidogrel may cause thrombotic thrombocytopenic purpura, so check platlets

Question 44

What medications are used for antiplatelet therapy? What is Antiplatelet therapy?

Answer 44

Aspirin, clopidogrel, prasugrel, ticagrelor For prevent blood clots(for MI, stroke etc) Side effects is increase bleeding risk

Question 45

An 8-year-old with mild cognitive impairment who is hospitalized for diagnostic testing. Which of the following interventions are appropriate? SATA a) consistently assign the same nurse and UAP b) Give direct procedural education to the parents rather than the pt c) Reinforce parental limit-setting measures for preventing self-injurious behavior d) use picture board to facilitate communication and promote understanding of procedures

Answer 45

a,c,d b-the nurse should make the client involved too

Question 46

A pt is receiving methotrexate for RA. Which statement by the pt is most concerning? a) I am Nauseated and vomited 3/day b) I drink four large cups of coffee every day c) I have small, purple sports all over my skin d) I plan to stop taking birth control today

Answer 46

c ARDs are bone marrow suppression, hepatotoxicity, GI irritation a-vomiting is the most common side effect

Question 47

Which pt the nurse should see first? a) A pt who reports a flash-like vaginal odor for the past month b) A pt with intrauterine device who reports heavy bleeding with menses c) A pt who reports bloating and pelvic pressure for the past 2 months

Answer 47

c This is s/s of ovarian cancer, often not discovered until an advanced stage.

Question 48

A pt at 36 wks who experienced an intrauterine fetal demise and is scheduled for induction of labor. Which of the following actions would be a priority for the nurse to take? a) Initiate an oxytocin infusion to begin the induction of labor b) Apply a tocodynamoteter to evaluate the current contraction pattern c) Obtain blood specimens to check coagulation studies and platelet count

Answer 48

c Intrauterine fetal demise cause Disseminated intravascular coagulation(DIC), is a life-threatening Abnormal clot formation and hemorrhage is the risk

Question 49

Blood transfusion A can give? receives? B can give? receives? O can give? receives? AB can give? receives? Rh positive(most common)

Answer 49

A can give, A and AB but get only from A or O B can give B and AB but get only from B or O O can give to all but only get from O AB can give to AB but get from all Rh positive can give only +, but can receives + and -