Med Surg exam 2 module review questions

The nurse has just admitted a client for cardiac surgery. The client tearfully describes feeling afraid of dying while undergoing the surgery. What is the nurse's best response? A. Explore the factors underlying the client's anxiety B. Teach the client guided imagery techniques C. Obtain an order for a PRN benzodiazepine D. Describe the procedure in greater detail

A. Explore the factors underlying the client's anxiety

A client in the ICU has had an endotracheal tube in place for 3 weeks. The health care provider has ordered that a tracheostomy tube be placed. The client's family wants to know why the endotracheal tube cannot be left in place. What would be the nurse's best response? A. "When an endotracheal tube is left in too long it can damage the lining of the windpipe." B. "The physician may feel that mechanical ventilation will have to be used long-term." C. "Long-term use of an endotracheal tube diminishes the normal breathing reflex." D. "It is much harder to breathe through an endotracheal tube than a tracheostomy."

A. "When an endotracheal tube is left in too long it can damage the lining of the windpipe."

The OR nurse is setting up a water-seal chest drainage system for a client who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? A. 20 cm H2O B. 15 cm H2O C. 10 cm H2O D. 5 cm H2O

A. 20 cm H2O

A client with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, the client reports a new onset of pain at the surgical site. What is the nurse's best action? A. Assess the surgical site and the affected extremity B. Reassure the client that pain is a direct result of increased activity C. Assess the client for signs and symptoms of systemic infection D. Administer pain medication as prescribed

A. Assess the surgical site and the affected extremity rationale: Worsening pain after a total hip replacement may indicate dislocation of the prosthesis. Assessment of pain should include evaluation of the wound and the affected extremity. Assuming he's anxious about discharge and administering pain medication do not address the cause of the pain. Sudden severe pain is not considered normal after hip replacement. Sudden pain is rarely indicative of a systemic infection.

A client has been discharged home after thoracic surgery. The home care nurse performs the initial visit and finds the client discouraged and saddened. The client states, "I am recovering so slowly. I really thought I would be better by now." What nursing action should the nurse prioritize? A. Provide emotional support to the client and family. B. Schedule a visit to the client's primary physician within 24 hours. C. Notify the physician that the client needs a referral to a psychiatrist. D. Place a referral for a social worker to visit the client.

A. Provide emotional support to the client and family

The nurse has admitted a client who is scheduled for a thoracic resection. The nurse is providing preoperative teaching and is discussing several diagnostic studies that will be required prior to surgery. Which study will be performed to determine whether the planned resection will leave sufficient functioning lung tissue? A. Pulmonary function studies B. Arterial blood gas volume C. Exercise tolerance tests D. Chest x-ray

A. Pulmonary function studies

A nurse is educating a client in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the client and the family that this drainage system is used for? A. Removing excess air and fluid B. Maintaining positive chest-wall pressure C. Monitoring pleural fluid osmolarity D. Providing positive intrathoracic pressure

A. Removing excess air and fluid

An elderly client's hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurse's priority assessment? A. Signs of neurovascular compromise B. The presence of internal or external rotation C. The presence of leg shortening D. The client's complaints of pain

A. Signs of neurovascular compromise rationale: Because impaired circulation can cause permanent damage, neurovascular assessment of the affected leg is always a priority assessment. Leg shortening and internal or external rotation are common findings with a fractured hip. Pain, especially on movement, is also common after a hip fracture.

A 91-year-old client is slated for orthopedic surgery and the nurse is integrated gerontologic considerations into the client's plan of care. What intervention is most justified in the care of this client? A. Use of a pressure-relieving mattress B. Administration of prophylactic antibiotics C. Total parenteral nutrition (TPN) D. Use of a Foley catheter until discharge

A. Use of a pressure-relieving mattress rationale: Older adults have a heightened risk of skin breakdown; use of a pressure-reducing mattress addresses this risk. Older adults do not necessarily need TPN and the Foley catheter should be discontinued as soon as possible to prevent urinary tract infections. Prophylactic antibiotics are not a standard infection prevention measure.

A client who is post-thoracotomy is retaining secretions. What is the nurse's initial intervention? A. Perform chest physiotherapy B. Perform nasotracheal suctioning C. Encourage the client to cough D. Perform postural drainage

C. Encourage the client to cough

In preparation for cardiac surgery, a client was taught about measures to prevent venous thromboembolism. What statement indicates that the client clearly understood this education? A. "I'll try to stay in bed for the first few days to allow myself to heal." B. "I'll make sure that I don't cross my legs when I'm resting in bed." C. "I'll keep pillows under my knees to help my blood circulate better." D. "I'll put on those compression stockings if I get pain in my calves."

B. "I'll make sure that I don't cross my legs when I'm resting in bed."

A nurse is caring for an older adult client who is preparing for discharge following recovery from a total hip replacement. What outcome must be met prior to discharge? A. Client is able to weight-bear equally on both legs. B. Client is able to perform transfers safely. C. Client is able to demonstrate full ROM of the affected hip. D. Client is able to perform ADLs independently.

B. Client is able to perform transfers safely. rationale: The client must be able to perform transfers and to use mobility aids safely. Each of the other listed goals is unrealistic for the client who has undergone recent hip replacement.

The nurse is caring for a client who underwent a total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis? A. Keep the affected leg in a position of adduction B. Protect the affected leg from internal rotation C. Have the client reposition himself independently D. Keep the hip flexed by placing pillows under the client's knee

B. Protect the affected leg from internal rotation rationale: Abduction of the hip helps to prevent dislocation of a new hip joint. Rotation and adduction should be avoided. While the hip may be flexed slightly, it shouldn't exceed 90 degrees and maintenance of flexion isn't necessary. The client may not be capable of safe independent repositioning at this early stage of recovery.

A client is recovering in the hospital from cardiac surgery. The nurse has identified the diagnosis of risk for ineffective airway clearance related to pulmonary secretions. What intervention best addresses this risk? A. Administration of bronchodilators by nebulizer B. Administration of inhaled corticosteroids by metered dose inhaler (MDI) C. Client's consistent performance of deep-breathing and coughing exercises D. Client's active participation in the cardiac rehabilitation program

C. Client's consistent performance of deep-breathing and coughing exercises

A client who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurse's most appropriate action? A. Document the client's low urine output and monitor closely for the next several hours. B. Contact the dietitian and suggest the need for increased oral fluid intake. C. Contact the client's health care provider and suggest assessment of fluid balance and renal function. D. Increase the infusion rate of the client's IV fluid to prompt an increase in renal function

C. Contact the client's health care provider and suggest assessment of fluid balance and renal function.

The nurse is assessing a client who was admitted to the critical care unit 3 hours ago following cardiac surgery. The nurse's most recent assessment reveals that the client's left pedal pulses are not palpable and that the right pedal pulses are rated at +2. What is the nurse's best action? A. Document this expected assessment finding during the initial postoperative period. B. Reposition the client with his left leg in a dependent position. C. Inform the client's health care provider of this assessment finding. D. Administer an ordered dose of subcutaneous heparin

C. Inform the client's health care provider of this assessment finding.

A nurse is caring for a client who is postoperative day 1 right hip replacement. How should the nurse position the client? A. Keep hips flexed at no less than 90 degrees B. Elevate the head of the bed to high Fowler's C. Keep the client's hips in abduction at all times D. Seat the client in a low chair as soon as possible

C. Keep the client's hips in abduction at all times rationale: The hips should be kept in abduction by an abductor pillow. Hips should not be flexed more than 90 degrees, and the head of bed should not be elevated more than 60 degrees. The client's hips should be higher than the knees; as such, high seat chairs should be used.

While assessing the client, the nurse observes constant bubbling in the water-seal chamber of the client's closed chest-drainage system. What should the nurse conclude? A. The system is functioning normally. B. The client has a pneumothorax. C. The system has an air leak. D. The chest tube is obstructed.

C. The system has an air leak.

A client is being prepared for a total hip arthroplasty, and the nurse is providing relevant education. The client is concerned about being on bed rest for several days after the surgery. The nurse should explain what expectation for activity following hip replacement? A. "For the first 2 weeks after the surgery, you can use a wheelchair to meet your mobility needs." B. "Actually, clients are only on bed rest for 2 to 3 days before they begin walking with assistance." C. "Our goal will actually be to have you walking normally within 5 days of your surgery." D. "The physical therapist will likely help you get up using a walker the day after your surgery."

D. "The physical therapist will likely help you get up using a walker the day after your surgery." rationale: Clients post-THA begin ambulation with the assistance of a walker or crutches within a day after surgery. Wheelchairs are not normally utilized. Baseline levels of mobility are not normally achieved until several weeks after surgery, however.

A client is scheduled for a total hip replacement and the surgeon has explained the risks of blood loss associated with orthopedic surgery. The risk of blood loss is the indication for which of the following actions? A. Use of a cardiopulmonary bypass machine B. Prophylactic blood transfusion C. Postoperative blood salvage D. Autologous blood donation

D. Autologous blood donation rationale: Many clients donate their own blood during the weeks preceding their surgery. Autologous blood donations are cost-effective and eliminate many of the risks of transfusion therapy. Orthopedic surgery does not necessitate cardiopulmonary bypass and blood is not salvaged postoperatively. Transfusions are not given prophylactically.

The OR nurse is explaining to a client that cardiac surgery requires the absence of blood from the surgical field. At the same time, it is imperative to maintain perfusion of body organs and tissues. What technique for achieving these simultaneous goals should the nurse describe? A. Coronary artery bypass graft (CABG) B. Percutaneous transluminal coronary angioplasty (PTCA) C. Atherectomy D. Cardiopulmonary bypass

D. Cardiopulmonary bypass

The nurse is assessing a client who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the client's respirations. How should the nurse best respond to this assessment finding? A. Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes. B. Inform the physician promptly that there is in imminent leak in the drainage system. C. Encourage the client to do deep breathing and coughing exercises. D. Document that the chest drainage system is operating as it is intended.

D. Document that the chest drainage system is operating as it is intended.

An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows that out of the following the vessels, the vessel most commonly used as source for a CABG is what? A. Brachial artery B. Brachial vein C. Femoral artery D. Greater saphenous vein

D. Greater saphenous vein

A nurse is planning the care of a client who has undergone orthopedic surgery. What main goal should guide the nurse's choice of interventions? A. Helping the client come to terms with limitations B. Improving the client's adherence to treatment C. Administering medications safely D. Improving the client's level of function

D. Improving the client's level of function rationale: Improving function is the overarching goal after orthopedic surgery. Some clients may need to come to terms with limitations, but this is not true of every client. Safe medication administration is imperative, but this is not a goal that guides other aspects of care. Similarly, adherence to treatment is important, but this is motivated by the need to improve functional status.

The nurse is caring for a client who will have coronary artery revascularization. When explaining the pre- and postoperative regimens, the nurse should address which subject? A. Symptoms of hypovolemia B. Symptoms of low blood pressure C. Complications requiring graft removal D. Intubation and mechanical ventilation

D. Intubation and mechanical ventilation

While assessing a client who has had knee replacement surgery, the nurse notes that the client has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this client? A. Unilateral Neglect Related to Hematoma B. Disturbed Kinesthetic Sensory Perception C. Risk for Infection D. Risk for Ineffective Peripheral Tissue Perfusion

D. Risk for Ineffective Peripheral Tissue Perfusion rationale: The hematoma may cause an interruption of tissue perfusion. There is also an associated risk for infection because of the hematoma, but impaired perfusion is a more acute threat. Unilateral neglect and impaired sensation are lower priorities than tissue perfusion.

A nurse assesses a patient who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.) a. Tracheal deviation b. Production of pink sputum c. Sudden onset of shortness of breath d. Pain at insertion site e. Drainage greater than 70 mL/hr f. Disconnection at Y site

a. Tracheal deviation c. Sudden onset of shortness of breath e. Drainage greater than 70 mL/hr f. Disconnection at Y site rationale: Immediate intervention is warranted if the patient has tracheal deviation because this could indicate a tension pneumothorax. Sudden shortness of breath could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax. Drainage greater than 70 mL/hr could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing. Production of pink sputum, oxygen saturation less than 95%, and pain at the insertion site are not signs/symptoms that would require immediate intervention.

A nurse cares for a patient who has a chest tube. When would this patient be at highest risk for developing a pneumothorax? a. When the tube becomes disconnected from the drainage system b. When the patient experiences pain at the insertion site c. When the tube drainage decreases and becomes sanguineous d. When the insertion site becomes red and warm to the touch

a. When the tube becomes disconnected from the drainage system rationale: Intrathoracic pressures are less than atmospheric pressures; therefore, if the chest tube becomes disconnected from the drainage system, air can be sucked into the pleural space and cause a pneumothorax. A red, warm, and painful insertion site does not increase the patient's risk for a pneumothorax. Tube drainage would decrease and become serous as the patient heals. Sanguineous drainage is a sign of bleeding but does not increase the patient's risk for a pneumothorax.

A nurse cares for a patient who is scheduled for a total laryngectomy. What action would the nurse take prior to surgery? a. Administer prescribed intravenous pain medication. b. Assist the patient to choose a communication method. c. Assess airway patency, breathing, and circulation. d. Ambulate the patient in the hallway to assess gait.

b. Assist the patient to choose a communication method. rationale: The patient will not be able to speak after surgery. The nurse would assist the patient to choose a communication method that he or she would like to use after surgery. Assessing the patient's airway and administering IV pain medication are done after the procedure. Although ambulation promotes health and decreases the complications of any surgery, this patient's gait would not be impacted by a total laryngectomy and therefore is not a priority.

A nurse cares for a patient who has a pleural chest tube. What action would the nurse take to ensure safe use of this equipment? a. Strip the tubing to minimize clot formation and ensure patency. b. Keep padded clamps at the bedside for use if the drainage system is interrupted. c. Secure tubing junctions with clamps to prevent accidental disconnections. d. Connect the chest tube to wall suction at the level prescribed by the provider.

b. Keep padded clamps at the bedside for use if the drainage system is interrupted. rationale: Padded clamps would be kept at the bedside for use if the drainage system becomes dislodged or is interrupted. The nurse would never strip the tubing. Tubing junctions would be taped, not clamped. Wall suction would be set at the level indicated by the device's manufacturer, not the provider.

A nurse teaches a patient to use a room humidifier after a laryngectomy. Which statement would the nurse include in this patient's teaching? a. "Use the humidifier when you sleep, even during daytime naps." b. "Add peppermint oil to the humidifier to relax the airway." c. "Make sure you clean the humidifier to prevent infection." d. "Keep the humidifier filled with water at all times."

c. "Make sure you clean the humidifier to prevent infection." rationale: Priority teaching related to the use of a room humidifier focuses on infection control. Patients would be taught to meticulously clean the humidifier to prevent the spread of mold or other sources of infection. Peppermint oil would not be added to a humidifier. The humidifier would be refilled with water as needed and would be used while awake and asleep.

A nurse cares for a patient who had a partial laryngectomy 10 days ago. The patient states that all food tastes bland. How would the nurse respond? a. "I will consult the speech therapist to ensure you are swallowing properly." b. "I will ask the dietitian to change the consistency of the food in your diet." c. "This is normal after surgery. What types of food do you like to eat?" d. "Replacement of protein, calories, and water is very important after surgery."

c. "This is normal after surgery. What types of food do you like to eat?" rationale: Many patients experience changes in taste after surgery. The nurse would identify foods that the patient wants to eat to ensure that the patient maintains necessary nutrition. Although the nurse would collaborate with the speech therapist and dietitian to ensure appropriate replacement of protein, calories, and water, the other responses do not address the patient's concerns.

While assessing a patient who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action by the nurse is best? a. Reinsert the tube using sterile technique. b. Contact the provider and obtain a suture kit. c. Assess for drainage from the site. d. Cover the insertion site with sterile gauze.

d. Cover the insertion site with sterile gauze. rationale: Immediately covering the insertion site helps prevent air from entering the pleural space and causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering the chest. The nurse would not leave the patient to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax. The site would only be assessed after the insertion site is covered. The provider would be called to reinsert the chest tube or prescribe other treatment options.