Med Surg III - Final Study
The nurse is planning care for a patient with acute severe pancreatitis. What is the highest priority patient outcome?
Maintaining normal respiratory function
What should the nurse teach a patient with chronic pancreatitis is the time to take the prescribed pancrelipase (Viokase)?
Mealtime
Which assessment finding is of most concern for a patient with acute pancreatitis?
Palpable abdominal mass
The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient?
"Call the doctor if you experience pain or develop herpes lesions near the ear."
A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with morbid thoughts about dying." Which response by the nurse is appropriate?
"Can you tell me more about the thoughts that you are having?"
Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best for this situation?
"The monitoring system helps show whether blood flow to the brain is adequate."
A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ count of less than 200 cells/L. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct?
"The patient has developed acquired immunodeficiency syndrome (AIDS)."
The following male patients recently arrived in the emergency department. Which one should the nurse assess first?
A 19-yr-old patient who is reporting severe scrotal pain
Several patients call the urology clinic requesting appointments with the health care provider as soon as possible. Which patient will the nurse schedule to be seen first?
A 22-yr-old patient who has noticed a firm, nontender lump on his scrotum
Which laboratory test result will the nurse monitor to evaluate the effects of therapy for a patient who has acute pancreatitis?
Lipase
A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take?
Administer the spironolactone
A construction worker arrives at an urgent care center with a deep puncture wound from a rusty nail. The patient reports having had a tetanus booster 6 years ago. What intervention should the nurse anticipate?
Administration of the tetanus-diphtheria (Td) booster
What risk factor will the nurse specifically ask about when a patient is being admitted with acute pancreatitis?
Alcohol use
An unconscious patient is admitted to the emergency department (ED) with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment. What action is best for the nurse to take?
Allow the family to stay with the patient and briefly explain all procedures to them
A patient with a history of T3 spinal cord injury is admitted with dermal ulcers. The patient tells the nurse, "I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first?
Assess the blood pressure (BP)
A female patient who had a stroke 24 hours ago has expressive aphasia. What is an appropriate nursing intervention to help the patient communicate?
Ask questions that the patient can answer with "yes" or "no."
How should the nurse prepare a patient with ascites for paracentesis?
Ask the patient to empty the bladder
Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy?
Ask the patient to extend both arms forward
When administering the Mini-Cog exam to a patient with possible Alzheimer's disease, which action will the nurse take?
Ask the patient to indicate a specific time on a clock drawing
A 20-yr-old patient who sustained a T2 spinal cord injury 10 days ago tells the nurse, "I want to be transferred to a hospital where the nurses know what they are doing." Which action should the nurse appropriately take?
Ask the patient to provide input for the plan of care
A patient with a history of hypertension was prescribed ACE inhibitor, upon arrival to the ER, the patient reported massive headache, nausea and blood pressure is 200/110, what should you ask the patient?
Ask when last they took the medication
A patient born in 1955 had hepatitis A infection 1 year ago. According to Centers for Disease Control and Prevention (CDC) guidelines, which action should the nurse include in care when the patient is seen for a routine annual physical examination?
Ask whether the patient has been screened for hepatitis C
Which action should the nurse recognize has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?
Assessment of respiratory rate and effort
Which intervention will the nurse include in the plan of care for a patient with moderate dementia who is admitted for other health problems?
Assign unlicensed assistive personnel (UAP) to stay with and reorient the patient
Several weeks after a stroke, a 50-yr-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program?
Assist the patient onto the bedside commode every 2 hours
A client with hypertension and they have been prescribed propranolol, you look at the medical history in the chart, what would you notice in their history that you need to notify the provider about before giving the propranolol?
Asthma
After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider?
Bilateral crackles
Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse?
Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min
Which action should the nurse in the emergency department take first for a new patient who is vomiting blood?
Check blood pressure and heart rate
When taking the blood pressure (BP) on the right arm of a patient who has severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next?
Check the calcium level in the chart
A 20-yr-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take?
Check the drainage for glucose content
What should the nurse explain to the patient who has a T2 spinal cord transection injury?
Function of both arms should be maintained
A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 mm Hg, and heart rate is 132 beats/min. Based on this information, which patient problem is the priority?
Decreased cardiac output
The nurse is monitoring a client with hypertension who is taking propranolol. Which assessment finding indicates a potential adverse complication associated with this medication?
Development of expiratory wheezes
What should the nurse include when teaching an adult patient to prevent the recurrence of kidney stones?
Drinking 3000 mL of fluid each day
The nurse is caring for a patient with pelvic inflammatory disease (PID) requiring hospitalization. Which nursing intervention will be included in the plan of care?
Elevate the head of the bed at least 30 degrees
A patient who was admitted to the emergency department with severe abdominal pain is diagnosed with an ectopic pregnancy. The patient begins to cry and asks the nurse to leave her alone to grieve. Which action should the nurse take next?
Explain the reason for taking vital signs every 15 to 30 minutes
A patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function?
Glomerular filtration rate (GFR)
A patient is considering the use of combined estrogen-progesterone hormone replacement therapy (HRT) during menopause. Which information will the nurse include during their discussion?
HRT decreases osteoporosis risk and increases the risk for cardiovascular disease and breast cancer
Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia?
Having the patient's family member administer the medication
The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which finding on the nursing assessment is congruent with neurogenic shock?
Hypotension and warm extremities
When assessing a patient who has a right frontal lobe tumor, what finding should the nurse expect?
Impaired judgment
What topic should the nurse plan to teach a female patient who has genital warts?
Importance of regular Pap tests
The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question?
Insert nasogastric tube to low suction
Which patient assessment would help the nurse identify potential complications of trigeminal neuralgia?
Inspect the oral mucosa and teeth
A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action should the nurse include in the plan of care?
Instruct the patient how to self-catheterize
The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness?
Intracranial pressure
What is most important for the nurse to teach a patient recently diagnosed with polycystic ovary syndrome?
Methods to maintain a healthy weight
A patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care?
Monitor the patient for shortness of breath
A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient?
Most infants born to HIV-positive mothers are not infected with the virus
Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient who has acute pancreatitis?
Muscle twitching and finger numbness
Which information about a patient receiving thrombolytic therapy for an acute myocardial infarction is most important for the nurse to communicate to the health care provider?
No change in the patient's reported level of chest pain
A patient is hospitalized with new onset of Guillain-Barré syndrome. What should the nurse recognize as the most essential assessment to complete?
Observing respiratory rate and effort
Which admission order written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever would be a priority for the nurse to implement?
Order blood cultures from two sites
A patient is being evaluated for a possible spinal cord tumor. Which finding should the nurse recognize as requiring the most immediate action?
Patient with botulism who is drooling and experiencing difficulty swallowing
Which hospitalized patient will the nurse assign to the room closest to the nurses' station?
Patient with new-onset confusion, restlessness, and irritability after surgery
A patient with chronic hepatitis B infection has several medications prescribed. Which medication order requires clarification with the health care provider before administration?
Pegylated-interferon (Pegasys) orally once daily
Which intervention should the nurse include in the plan of care for a patient with new right-sided homonymous hemianopsia after a stroke?
Place needed objects on the patient's left side
A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which action should the nurse include in the plan of care?
Positioning the patient's left leg when turning the patient
Which nursing action should be included in the plan of care for a patient returning to the surgical unit after a left modified radical mastectomy with dissection of axillary lymph nodes?
Post a sign at the bedside warning against venipunctures or blood pressures in the left arm
What should the nurse include in a rehabilitation plan as an appropriate goal for a 30-yr-old patient with a C6 spinal cord injury?
Propel a manual wheelchair on a flat surface
Which topic will the nurse include in the preoperative teaching for a patient admitted for an abdominal hysterectomy?
Purpose of ambulation and leg exercises
The nurse notes bilateral enlargement of the breasts during examination of a 62-yr-old male patient. Which action should the nurse take first?
Question the patient about current medications
The nurse is providing preoperative teaching about the transverse rectus abdominis musculocutaneous (TRAM) procedure to a patient. Which information will the nurse include?
Recovery from the TRAM surgery takes at least 6 to 8 weeks
Which intervention will the nurse include in the plan of care for a patient with moderate dementia who is admitted for other health problems?
Remind the patient frequently about being in the hospital
Which assessment finding in a patient who is admitted with infective endocarditis (IE) is most important to communicate to the health care provider?
Right flank pain
A 31-yr-old patient who has been diagnosed with human papillomavirus (HPV) infection gives a health history that includes smoking tobacco, taking oral contraceptives, and having been treated twice for vaginal candidiasis. Which topic will the nurse include in patient teaching?
Risk factors for cervical cancer
A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question?
Start a labetalol drip to keep BP less than 140/90 mm Hg
A patient who has cirrhosis and esophageal varices is being treated with propranolol (Inderal). Which finding is the best indicator to the nurse that the medication has been effective?
Stools test negative for occult blood
What topic should the nurse anticipate teaching a patient who is diagnosed with lobular carcinoma in situ (LCIS)?
Tamoxifen
When the nurse is working in the women's health care clinic, which action is appropriate to take?
Teach a 34-yr-old patient with a BRCA-1 mutation about magnetic resonance imaging (MRI)
A patient with a left-brain stroke suddenly bursts into tears when family members visit. How should the nurse respond?
Teach the family that emotional outbursts are common after strokes
Which action should the nurse take when a 35-yr-old patient whose repeat cervical Pap test was abnormal?
Teach the patient about colposcopy
Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago?
Temperature 100.8° F (38.2° C)
Which action by the unlicensed assistive personnel (UAP) who are assisting with the care of male patients with reproductive problems indicates that the nurse should provide more teaching?
The UAP leave the foreskin pulled back after cleaning the glans of a patient who has a retention catheter
Which response by the nurse best explains the purpose of ranitidine (Zantac) for a patient who was admitted with bleeding esophageal varices?
The medication will prevent irritation of the enlarged veins
Which assessment information collected by the nurse may present a contraindication to a testosterone replacement therapy (TRT)?
The patient has had a gradual decrease in the force of his urinary stream
A patient is being evaluated for a possible spinal cord tumor. Which finding should the nurse recognize as requiring the most immediate action?
The patient has new-onset weakness of both legs
Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis?
The patient is alert and oriented
The nurse is caring for a patient with breast cancer who is receiving chemotherapy with doxorubicin and cyclophosphamide. Which assessment finding is most important to communicate to the health care provider?
The patient's apical pulse is irregular
Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider?
The patient's blood pressure (BP) is 90/50 mm Hg
Which assessment information will be most important for the nurse to report to the health care provider about a patient who has acute cholecystitis?
The patient's stools are tan colored
A patient diagnosed with breast cancer asks the nurse what "triple negative" means. What should an accurate response from the nurse about triple-negative breast cancer include?
The tumor is not likely to be responsive to hormone therapy
A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Health records show a history of several transient ischemic attacks (TIAs). What should the nurse anticipate for this patient?
Tissue plasminogen activator (tPa) infusion
Which collaborative and nursing actions should the nurse include in the plan of care for a patient who experienced a T2 spinal cord transection 24 hours ago? (Select all that apply.)
Urinary catheter care Continuous cardiac monitoring Administration of H2 receptor blockers Maintenance of a warm room temperature
A patient is on the surgical unit after a total abdominal hysterectomy. Which finding requires contacting the health care provider?
Urine output of 125 mL in the first 8 hours after surgery
Which action will help the nurse determine whether a new patient's confusion is caused by dementia or delirium?
Use the Confusion Assessment Method tool
You have 4 patients with moderate to high blood pressure, who will you see first?
a. A patient with chest pain
A patient in hypertensive crisis and receiving sodium nitroprusside, what can you delegate to an LPN?
taking blood pressure
Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit?
A 45-yr-old patient receiving IV antibiotics for meningococcal meningitis
After the emergency department nurse has received a status report on the following patients with head injuries, which patient should the nurse assess first?
A 50-yr-old patient whose right pupil is 10 mm and unresponsive to light
The outpatient clinic receives telephone messages from four patients. Which patient should the nurse call back first?
A 50-yr-old patient with stage 2 breast cancer who is receiving doxorubicin and has ankle swelling and fatigue
During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first?
A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C)
After receiving change-of-shift report about the following four patients on the cardiac care unit, which patient should the nurse assess first?
A 59-year-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI)
Which assessment finding in a 36-yr-old patient is most indicative of a need for further evaluation?
A breast nodule that is 1 cm in size, nontender, and fixed
What topic should the nurse plan to discuss with a patient who has been diagnosed with 0 cervical cancer?
Conization
A young patient who is trying to become pregnant asks the nurse how to determine when she is most likely to conceive. What information should the nurse provide?
Ovulation prediction kits can provide accurate information about ovulation
The nurse is caring for a patient with aortic stenosis. Which assessment data would be most important to report to the health care provider?
The patient reports chest pressure when ambulating
What will the nurse teach a patient with metastatic breast cancer who has a new prescription for trastuzumab (Herceptin)?
The patient should call if she notices ankle swelling
A patient had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to:
turn, cough, and deep breathe every 2 hours
