MED SURG - Week 4
Vital signs for a patient reveal a high blood pressure of 187/100. Orders state to notify the health care provider for diastolic blood pressure greater than 90. What is the nurse's first action? A. Assess the patient for other symptoms or problems, and then notify the health care provider. B. Review the most recent lab results for the patient's potassium level. C. Follow the clinical protocol for a stroke. D. Administer an antihypertensive medication from the stock supply, and then notify the health care provider.
A. Assess the patient for other symptoms or problems, and then notify the health care provider.
A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. After analyzing these data, the nurse assigns which of the following nursing diagnoses? A. Adult failure to thrive B. Hypothermia C. Deficient fluid volume D. Nausea
C. Deficient fluid volume
A nurse using the problem-oriented approach to data collection will first A. Complete an observational overview. B. Disregard cues and complete the database questions in chronological order. C. Focus on the patient's presenting situation. D. Make accurate interpretations of the data.
C. Focus on the patient's presenting situation.
Which of the following are examples of subjective data? (Select all that apply.) A. Patient describing excitement about discharge. B. Patient's wound appearance. C. Patient's expression of fear regarding upcoming surgery. D. Patient pacing the floor while awaiting test results. E. Patient's temperature.
A & C A. Patient describing excitement about discharge. C. Patient's expression of fear regarding upcoming surgery.
Which interventions are appropriate for the nursing diagnosis Impaired tissue integrity related to poor wound healing secondary to diabetes? (Select all that apply.) A. Teach the patient about signs and symptoms of infection. B. Help the patient cope with changes in body image that result from the wound. C. Perform dressing changes twice a day as ordered. D. Administer medications to control the patient's blood sugar as ordered. E. Teach the family how to perform dressing changes.
A, C, D, & E A. Teach the patient about signs and symptoms of infection. C. Perform dressing changes twice a day as ordered. D. Administer medications to control the patient's blood sugar as ordered. E. Teach the family how to perform dressing changes.
The nurse is caring for a 23-year-old male client who is in the ICU with second and third degree burns over 40 percent of his body. One of the first symptoms that the client is having organ failure is that the urine output is less than: A. 30 mL/hour B. 40 mL/hour C. 50 mL/hour D. 60 mL/hour
A. 30 mL/hour
Subjective data include A. A patient's feelings, perceptions, and reported symptoms. B. A description of the patient's behavior. C. Observations of a patient's health status. D. Measurements of a patient's health status.
A. A patient's feelings, perceptions, and reported symptoms.
The nurse is assessing a client admitted with complaints related to chronic kidney dysfunction. The nurse recognizes that this client is most likely to present with which of the resulting symptoms? A. Anemia B. Hypotension C. Diabetes mellitus D. Clinical depression
A. Anemia Feedback: Clients with chronic alterations in kidney function cannot produce sufficient quantities of the hormone erythropoietin; therefore they are prone to anemia. Diabetes mellitus may be a cause of the renal dysfunction, and the client may or may not be depressed. Hypertension, not hypotension, is a typical outcome of kidney dysfunction.
The nurse is caring for a patient who requires a complex dressing change. While in the patient's room, the nurse decides to change the dressing. What does the nurse do just before changing the dressing? A. Assesses the patient's readiness for the procedure B. Gathers and organizes needed supplies C. Decides on goals and outcomes for the patient D. Calls for assistance from another nursing staff member
A. Assesses the patient's readiness for the procedure
A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing student then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The nursing nurse states she was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is re-checked and it has dropped even lower. The nurse first made an error in what phase of the nursing process? A. Assessment B. Diagnosis C. Planning D. Evaluation
A. Assessment
During the assessment phase of the nursing process ensures that the nurse A. Completes a comprehensive database. B. Identifies pertinent nursing diagnoses. C. Intervenes based on patient goals and priorities of care. D. Determines whether outcomes have been achieved.
A. Completes a comprehensive database.
Before implementing any intervention, the nurse uses critical thinking to A. Determine whether an intervention is correct and appropriate for the given situation. B. Evaluate the effectiveness of interventions. C. Establish goals for a particular patient without the need for reassessment. D. Read over the steps and perform a procedure despite lack of clinical competency.
A. Determine whether an intervention is correct and appropriate for the given situation.
Which of the following statements should the nurse use to instruct the nursing assistant caring for a client with an indwelling urinary catheter? A. Empty the drainage bag at least every 8 hours. B. Clean up the length of the catheter to the perineum. C. Use clean technique to obtain a specimen for culture and sensitivity. D. Place the drainage bag on the client's lap while transporting the client to testing.
A. Empty the drainage bag at least every 8 hours. Feedback: The urinary drainage bag should be emptied at least every 8 hours. If large outputs are noted, more frequent emptying will be required. The perineum should be cleansed and then down the catheter for a length of approximately 10 cm (4 inches). Only use sterile technique to collect specimens from a closed drainage system. Avoid raising the drainage bag above the level of the bladder. If it becomes necessary to raise the bag during transfer of the client to a bed or stretcher, clamp the tubing or empty the tubing contents to the drainage bag first. The drainage bag can be attached to the wheelchair below the level of the client's bladder for transport. It should not be placed on the client's lap.
Which of these outcomes would be most appropriate for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications? A. Patient will have one soft, formed bowel movement by end of shift. B. Patient will not take any pain medications this shift. C. Patient will walk unassisted to bathroom by the end of shift. D. Patient will not take laxatives or stool softeners this shift.
A. Patient will have one soft, formed bowel movement by end of shift.
The nurse is intervening for an identified nursing diagnosis of Risk for infection. Which direct care nursing intervention is most appropriate? A. Teaching the family proper handwashing technique B. Leaving side rails up at all times C. Teaching the patient how to use crutches D. Counseling the family on stress reduction techniques
A. Teaching the family proper handwashing technique
The nurse is evaluating whether patient goals and outcomes have been met. Which option below is an expected outcome for a patient with Impaired physical mobility? A. The patient is able to ambulate in the hallway with crutches for 15 minutes with no assistance. B. The patient's level of mobility will improve. C. The nurse provides assistance while the patient is walking in the hallways. D. The patient will deny pain while walking in the hallway.
A. The patient is able to ambulate in the hallway with crutches for 15 minutes with no assistance.
The following statements are on a patient's nursing care plan. Which of the following statements is written as an outcome? A. The patient will verbalize a decreased pain level to a tolerable level by the end of this shift. B. The patient will demonstrate increased mobility by the end of this shift. C. The patient will demonstrate increased tolerance to activity over the next month. D. The patient will understand needed dietary changes by discharge.
A. The patient will verbalize a decreased pain level to a tolerable level by the end of this shift.
When obtaining a sterile urine specimen from an indwelling urinary catheter the nurse should: A. Use a needle to withdraw urine from the catheter port B. Disconnect the catheter from the drainage tubing C. Open the drainage bag and removing urine D. Withdraw urine from a urinometer
A. Use a needle to withdraw urine from the catheter port A sterile specimen can be obtained through the special port found on the side of the indwelling catheter. The nurse clamps the tubing below the port, allowing fresh, uncontaminated urine to collect in the tube. After the nurse wipes the port with an antimicrobial swab, a sterile syringe needle is inserted, and at least 3 to 5 mL of urine is withdrawn. Using sterile technique, the nurse transfers the urine to a sterile container. The catheter should not be disconnected from the drainage tubing. The system should remain a closed system to prevent infection. A urinometer is a device used to determine the specific gravity of urine. It is not a sterile device and should not be used for obtaining a sterile urine specimen. Urine should not be obtained from a drainage bag for a specimen, because the urine would not be fresh and would be contaminated from microorganisms in the drainage bag.
Which of these questions would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea? A. "What types of foods do you think caused your upset stomach?" B. "How many bowel movements a day have you had?" C. "Are you able to get to the bathroom in time?" D. "What medications are you currently taking?"
B. "How many bowel movements a day have you had?"
The nurse is evaluating whether a patient's turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule? A. Staff documentation of turning the patient every 2 hours. B. Absence of skin breakdown. C. Presence of redness only on the heels of the patient. D. Patient's eating 100% of all meals.
B. Absence of skin breakdown.
Which diagnosis below is NANDA-I approved? A. Sleep disorder B. Acute pain C. Sore throat D. High blood pressure
B. Acute pain
While completing an admission database, the nurse is interviewing a patient who states that he is allergic to latex. The most appropriate nursing action is to first A. Leave the room and place the patient in isolation. B. Ask the patient to describe the type of reaction. C. Proceed to the termination phase of the interview. D. Document the latex allergy on the medication administration record.
B. Ask the patient to describe the type of reaction.
A patient of Middle Eastern descent has lost 5 lbs during hospitalization and states that the food offered is not allowed in his diet owing to religious preferences. Based on this information, an appropriate nursing diagnostic statement is Imbalanced nutrition: less than body requirements related to A. Religious preferences. B. Decreased oral intake. C. Weight loss. D. Race and ethnicity.
B. Decreased oral intake.
One purpose of using standard formal nursing diagnoses in practice is to A. Form a language that can be encoded only by nurses. B. Distinguish the nurse's role from the physician's role. C. Allow for the communication of patient needs to assistive personnel. D. Help nurses focus on the scope of medical practice.
B. Distinguish the nurse's role from the physician's role.
The nurse defines a clinical guideline or protocol as a A. Guideline to follow that replaces the nursing care plan. B. Document that assists the clinician in making decisions and choosing interventions for specific health care problems or conditions. C. Hospital policy designating each nurse's duty according to standards of care and a code of ethics. D. Prescriptive order form that individualizes the plan of care.
B. Document that assists the clinician in making decisions and choosing interventions for specific health care problems or conditions.
The charge nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate to bathroom. The nurse needs to revise which part of the diagnostic statement? A. Nursing diagnosis B. Etiology C. Patient chief complaint D. Defining characteristic
B. Etiology
A nurse is getting ready to discharge to home a patient who has a nursing diagnosis of Impaired physical mobility. Before discontinuing the patient's plan of care, what does the nurse need to do? A. Determine whether the patient has transportation to get home. B. Evaluate whether patient goals and outcomes have been met. C. Establish whether the patient has a follow-up appointment scheduled. D. Ensure that the patient's prescriptions have been filled.
B. Evaluate whether patient goals and outcomes have been met.
After completing a thorough database and analyzing the data to identify any problems, the nurse should proceed to what step of the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation
B. Planning
The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800. At 1400, the nurse notices that the dressing is saturated with blood. What is the nurse's next action? A. Wait and change the dressing at 1800 as ordered. B. Revise the plan of care and change the dressing now. C. Reassess the dressing and the wound in 1 hour. D. Discontinue the plan of care.
B. Revise the plan of care and change the dressing now.
A nursing student is completing an assessment on an 80-year-old patient who is alert and oriented. The patient's daughter is present in the room. Which of the following actions made by the nursing student requires the nursing professor to intervene? A. The nursing student is making eye contact with the patient. B. The nursing student is speaking only to the patient's daughter. C. The nursing student nods periodically while the patient is speaking. D. The nursing student leans forward while talking with the patient.
B. The nursing student is speaking only to the patient's daughter.
When evaluating a plan of care, the nurse reviews the goals for the patient. Which goal statement is REALISTIC to assign to a patient with a pelvic fracture on bed rest? The patient will increase mobility by A. Ambulating in the hallway two times this shift. B. Turning side to back to side with assistance every 2 hours. C. Using the walker correctly to ambulate to the bathroom as needed. D. Using a sliding board correctly to transfer to the bedside commode as needed.
B. Turning side to back to side with assistance every 2 hours.
A nursing student asks her nursing instructor to describe the primary purpose of evaluation. Which of the following statements made by the nursing instructor is most accurate? A. "During evaluation, you determine whether all nursing interventions were completed." B. "During evaluation, you determine when to downsize staffing on nursing units." C. "Nurses use evaluation to determine the effectiveness of nursing care." D. "Evaluation eliminates unnecessary paperwork and care planning."
C. "Nurses use evaluation to determine the effectiveness of nursing care."
When calculating the daily intake and output, the nurse anticipates that the urinary output for an average adult should be: A. 800 to 1000 mL/day B. 1000 to 1200 mL/day C. 1500 to 1600 mL/day D. 2000 to 2300 mL/day
C. 1500 to 1600 mL/day
When planning patient care, a goal can be described as A. A statement describing the patient's accomplishments without a time restriction. B. A realistic statement predicting any negative responses to treatments. C. A broad statement describing a desired change in patient behavior. D. An identified long-term nursing diagnosis.
C. A broad statement describing a desired change in patient behavior.
The standing orders for a patient include acetaminophen (Tylenol) 650 mg every 4 hours prn for headache. After assessing the patient, identifying the need for headache relief, and determining that the patient has not had Tylenol in the past 4 hours, the nurse A. Notifies the health care provider to obtain a verbal order. B. Directs the nursing assistant to give the Tylenol. C. Administers the Tylenol. D. Performs a pain assessment only after administering the Tylenol.
C. Administers the Tylenol.
After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the student nurse. With this in mind, what clinical decision should the nurse make? A. Administer scheduled medications assuming she would have been informed if the vital signs were abnormal. B. Have the patient transported to the radiology department for a scheduled x-ray, and review vital signs upon return. C. Ask the student nurse to record the patient's vital signs before administering medications. D. Omit the vital signs because the patient is presently in no distress.
C. Ask the student nurse to record the patient's vital signs before administering medications.
Which of the following actions by the nurse would indicate the need for remedial education in the removal of an indwelling catheter? A. Draping the female client between the thighs B. Obtaining a specimen before removal C. Cutting the catheter to deflate the balloon D. Checking the client's output for 24 hours after removal
C. Cutting the catheter to deflate the balloon Feedback: The nurse should not cut the catheter to deflate the balloon. The nurse inserts an empty, sterile syringe into the injection port. The nurse slowly withdraws all of the solution to deflate the balloon totally. The nurse then pulls the catheter out smoothly and slowly. The nurse positions the client in the same position as during catheterization. The nurse places a towel between a female client's thighs or over a male client's thighs. Some institutions recommend collecting a sterile urine specimen before removal of the catheter or sending the catheter tip for culture and sensitivity tests. The nurse should assess the client's urinary function by noting the first voiding after catheter removal and documenting the time.
Which nursing diagnostic statement is accurately written for a patient with a medical diagnosis of pneumonia? A. Risk for infection related to lower lobe infiltrate B. Risk for deficient fluid volume related to dehydration C. Impaired gas exchange related to alveolar-capillary membrane changes D. Ineffective breathing pattern related to pneumonia
C. Impaired gas exchange related to alveolar-capillary membrane changes
In which step of the nursing process does the nurse provide nursing care interventions to patients? A. Assessment B. Planning C. Implementation D. Evaluation
C. Implementation
Which of the following methods of data collection is utilized to establish a nursing assessment? A. Reviewing the current literature to determine evidence-based nursing actions. B. Orders for diagnostic and laboratory tests. C. Physical examination. D. Anticipated medications to be ordered.
C. Physical examination.
Which of the following is a nursing intervention? A. The patient will ambulate in the hallway twice this shift using crutches. B. Impaired physical mobility related to inability to bear weight on right leg C. Provide assistance while the patient walks in the hallway twice this shift with crutches. D. The patient is unable to bear weight on right lower extremity.
C. Provide assistance while the patient walks in the hallway twice this shift with crutches.
After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen (Tylenol) for the patient's headache. What is the nurse's next priority action for this patient? A. Eliminate Acute pain from the nursing care plan. B. Direct the nursing assistant to ask if the patient's headache is relieved. C. Reassess the patient's pain level in 30 minutes. D. Revise the plan of care.
C. Reassess the patient's pain level in 30 minutes.
What is the first intervention included on any patient's plan of care? A. Determine patient outcomes and goals. B. Prioritize the patient's nursing diagnoses. C. Reassess the patient. D. Assess for a patent airway.
C. Reassess the patient.
The nurse is caring for seven patients this shift. After completing their assessments, the nurse states that he doesn't know where to begin in developing care plans for these patients. Which of the following is an appropriate suggestion by another nurse? A. "Choose all the interventions and perform them in order of time needed for each one." B. "Make sure you identify the scientific rationale for each intervention first." C. "Decide on goals and outcomes you have chosen for the patients." D. "Begin with the highest priority diagnoses, then select appropriate interventions."
D. "Begin with the highest priority diagnoses, then select appropriate interventions."
A patient presents to the emergency department following a motor vehicle crash and suffers from a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and complains only of moderate discomfort. What is the most pertinent nursing diagnosis to be included in the plan of care based on the assessment data provided? A. Posttrauma syndrome B. Constipation C. Urinary retention D. Acute pain
D. Acute pain
A patient recovering from a leg fracture after a fall states that he has dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. What is the priority nursing intervention for this patient? A. Assist the patient to walk in the room with crutches. B. Obtain a walker for the patient. C. Consult physical therapy. D. Administer pain medication.
D. Administer pain medication.
A new graduate nurse is not sure what the heart sound is that she is listening to on a patient. To avoid diagnostic error, what should the nurse do? A. Assign the nursing diagnosis of Decreased cardiac output. B. Ask the patient if he has a history of cardiac problems before assigning the diagnosis of Decisional conflict. C. Check the previous shift's assessment and document what was noted on the last shift. D. Ask a more experienced nurse to listen also.
D. Ask a more experienced nurse to listen also.
The unit manager is evaluating the care of a new nursing staff member. Which of the following is an appropriate technique for the nurse to implement in order to obtain a clean-voided urine specimen? A. Apply sterile gloves for the procedure B. Restrict fluids before the specimen collection C. Place the specimen in a clean urinalysis container. D. Collect the specimen after the initial stream of urine has passed.
D. Collect the specimen after the initial stream of urine has passed. Feedback: To collect a clean-voided specimen, the nurse should collect the specimen (30 to 60 mL) after the initial stream of urine has passed. Nonsterile gloves are adequate. Fluids are encouraged so the client will be more likely to be able to void. The specimen should be collected in a sterile container and then placed into a plastic specimen bag.
A registered nurse administers pain medication to a patient suffering from fractured ribs. What type of nursing intervention is this nurse implementing? A. Collaborative B. Independent C. Interdependent D. Dependent
D. Dependent
In which step of the nursing process does the nurse determine if the patient's condition has improved and whether the patient has met expected outcomes? A. Assessment B. Planning C. Implementation D. Evaluation
D. Evaluation
A patient's son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do? A. Individualize the care plan only according to the patient's needs. B. Request that the son leave at bedtime, so the patient can rest. C. Suggest that a female member of the family stay with the patient. D. Involve the son in the plan of care as much as possible.
D. Involve the son in the plan of care as much as possible.
A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which of the following is an appropriate evaluative measure demonstrating progress toward this goal? A. Nonproductive cough present in 4 days. B. Scattered rhonchi throughout all lung fields in 2 days. C. Respirations 30/minute in 1 day. D. Lungs clear to auscultation following use of inhaler.
D. Lungs clear to auscultation following use of inhaler.
Urinary elimination may be altered with different pathophysiological conditions. For the client with diabetes mellitus, the nurse anticipates that an initial urinary sign or symptom will be: A. Urgency B. Dysuria C. Hematuria D. Polyuria
D. Polyuria Feedback: An initial urinary symptom of diabetes mellitus is polyuria. Urgency is not a symptom of diabetes mellitus. Urgency may be caused by a full bladder, bladder irritation from infection, incompetent urethral sphincter, or psychological stress. Dysuria is not a symptom of diabetes mellitus. Dysuria may be caused by bladder inflammation, trauma, or inflammation of the urethral sphincter. Hematuria is not a symptom of diabetes mellitus. Hematuria may be a symptom of neoplasms of the bladder or kidney, glomerular disease, infection of the kidney or bladder, trauma to urinary structures, calculi, or bleeding disorders.
The nurse is reviewing the report of a client's routine urinalysis. Which value should the nurse consider abnormal? A. Specific gravity of 1.03 B. Urine pH of 5.0 C. Absence of protein D. Presence of glucose
D. Presence of glucose Feedback: Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal. Urine specific gravity normally ranges from 1.002 to 1.035, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, its color ranging from pale yellow to deep amber.
The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). The nurse is performing what type of assessment approach in this situation? A. Comprehensive assessment. B. General to specific assessment. C. Activity-exercise pattern assessment D. Problem-oriented assessment.
D. Problem-oriented assessment.
A newly admitted patient who is morbidly obese asks the nurse to assist her to the bathroom for the first time. What should the nurse do first? A. Ask for at least two other assistive personnel to come to the room. B. Medicate the patient to alleviate discomfort while ambulating. C. Offer the patient a walker. D. Review the patient's activity orders.
D. Review the patient's activity orders.
The nurse recognizes that a client recovering from anesthesia required for surgical repair of a fractured ulna is likely to experience difficulty urinating primarily because of: A. The length of time the client was under the effects of general anesthesia required for the surgical procedure B. The impaired cognitive state the client will experience as the effects of the anesthesia wear off C. The decreased volume of orally ingested fluids before, during, and after the surgical procedure D. The effects of the anesthetic on the nerves and muscles controlling the relaxation of the urinary bladder
D. The effects of the anesthetic on the nerves and muscles controlling the relaxation of the urinary bladder Feedback: Medications, including anesthesia, interfere with both the production and the characteristics of urine and affect the act of urination. The remaining options may affect urination but not to the extent of the anesthetic effects.
