Medsurg Quiz 4

A patient presents to the emergency department with the complaint of vomiting and diarrhea for the past 48 hours. The nurse anticipates which fluid therapy initially? a) 0.9% sodium chloride b) Dextrose 10% in water c) Dextrose 5% in water d) 0.45% sodium chloride

ANS: A

The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care? a. Avoid intramuscular injections. b. Encourage increased oral fluids. c. Check temperature every 4 hours. d. Increase intake of iron-rich foods.

ANS: A

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake? a. "Increase fluids if your mouth feels dry. b. "More fluids are needed if you feel thirsty." c. "Drink more fluids in the late evening hours." d. "If you feel lethargic or confused, you need more to drink."

ANS: A

A postoperative patient who has been receiving nasogastric suction for 3 days has a serum sodium level of 125 mEq/L (125 mmol/L). Which of these prescribed therapies that the patient has been receiving should the nurse question? a. Infuse 5% dextrose in water at 125 ml/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d. Administer 3% saline if serum sodium drops to less than 128 mEq/L.

ANS: A Infuse 5% dextrose in water at 125 ml/hr. Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.

The nurse working on a medical unit recognizes that which of the following individuals are a risk for hyponatremia? Select all that apply. a. A 19-year-old drowning victim rescued from a nearby lake. b. A 52-year-old with congestive heart failure taking diuretics who is NPO for a cardiac catheterization. c. A 68-year-old with bowel obstruction receiving nasogastric suction d. A 92-year-old who is receiving total parenteral nutrition e. A 55-year-old who takes calcium supplements for osteoporosis f. A 42-year-old with chronic renal failure.

ANS: A, B, C, D

A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first? a. Obtain the baseline weight. b. Check the patient's blood pressure. c. Draw blood for serum electrolyte levels. d. Ask about any extremity numbness or tingling.

ANS: B Because the patient's history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. The other actions are also appropriate, but are not as essential as determining the patient's perfusion status

1. A patient who has been NPO during treatment for nausea and vomiting caused by gastric irritation is to start oral intake. Which of these should the nurse offer to the patient? a. A glass of orange juice b. A dish of lemon gelatin c. A cup of coffee with cream d. A bowl of hot chicken broth

ANS: B Clear liquids are usually the first foods started after a patient has been nauseated. Acidic foods such as orange juice, very hot foods, and coffee are poorly tolerated when patients have been nauseated.

Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura (ITP)? a. Assign the patient to a private room. b. Avoid intramuscular (IM) injections. c. Use rinses rather than a soft toothbrush for oral care. d. Restrict activity to passive and active range of motion.

ANS: B IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room.

When caring for an alert and oriented elderly patient with a history of dehydration, the home health nurse will teach the patient to increase fluid intake a. in the late evening hours. b. if the oral mucosa feels dry. c. when the patient feels thirsty. d. as soon as changes in level of consciousness (LOC) occur.

ANS: B if the oral mucosa feels dry.

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. Reported weight gain b. Serum hematocrit of 42% c. Serum sodium level of 120 mg/dL d. Total urinary output of 280 mL during past 8 hours

ANS: C Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value likely needs to be treated.

1. The nurse is assessing a patient with gastroesophageal reflux disease (GERD) who is experiencing increasing discomfort. Which patient statement indicates that additional patient education about GERD is needed? a. "I take antacids between meals and at bedtime each night." b. "I sleep with the head of the bed elevated on 4-inch blocks." c. "I quit smoking several years ago, but I still chew a lot of gum." d. "I eat small meals throughout the day and have a bedtime snack."

ANS: D GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD.

Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)? a. Prothrombin time b. Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time

ANS: D Platelet aggregation in HIT causes neutralization of heparin, so that the activated partial thromboplastin time will be shorter and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.

The nurse has administered 3% saline to a patient with hyponatremia. Which one of these assessment data will require the most rapid response by the nurse? a. The patient's radial pulse is 105 beats/minute. b. There is sediment and blood in the patient's urine. c. The blood pressure increases from 120/80 to 142/94. d. There are crackles audible throughout both lung fields.

ANS: D There are crackles audible throughout both lung fields. Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine also should be reported, but they are not as dangerous as the presence of fluid in the alveoli.

When caring for a patient with thrombocytopenia, the nurse instructs the patient to a. dab his or her nose instead of blowing. b. be careful when shaving with a safety razor. c. continue with physical activities to stimulate thrombopoiesis. d. avoid aspirin because it may mask the fever that occurs with thrombocytopenia.

ANS: a

1. A patient is seeking emergency care after choking on a piece of steak. The nursing assessment reveals a history of alcoholism, cigarette smoking, and hemoptysis. Which diagnostic study is most likely to be performed on this patient? a Barium swallow b Endoscopic biopsy c Capsule endoscopy d Endoscopic ultrasonography

ans: b Because of this patient's history of excessive alcohol intake, smoking, and hemoptysis and the current choking episode, cancer may be present. A biopsy is necessary to make a definitive diagnosis of carcinoma, so an endoscope will be used to obtain a biopsy and observe other abnormalities as well. A barium swallow may show narrowing of the esophagus, but it is more diagnostic for achalasia.

During care for patient with thrombocytopenia, the nurse a. takes frequent temperatures to assess for fever b. maintains the patient on strict bed rest to prevent injury c. monitors patient for headaches, vertigo, or confusion d. removes oral crusting and scabs with firm friction every two hours

ans: c Rationale: the major complication of thrombocytopenia is hemorrhage, and it may occur in any area of the body. cerebral hemorrhage may be fatal and evaluation of mental status for cns alteration to id cns bleeding is very important. fever is not a common finding in thrombocytopenia. protection from injury to prevent bleeding is an important nursing intervention, but strict bed rest is not indicated. oral care is performed very gently with minimum friction and soft swabs

Following a splenetomy for treatment of immune thrombocytopenic purpura, the nurse would expect the patients lab results to reveal a. decreased rbc b. decreased wbc c. increased platelets d. increased immunoglobulin's

ans: c. increased platelets splenectomy may be indicated for treatment of itp, and when spleen is removed platelet counts increase significantly in most patients in any of the disorders in which spleen removes excessive blood cells, splenectomy will most often increase peripheral rbc, wbc, and platelet counts

A patient has a platelet count of 50,000 and is diagnosied with immune thrombocytopenic purpura. the nurse would expect initial treatment to include a. splenectomy b. corticosteroids c. administration of platelets d immunosyppressive therapy

answer b. corticosteroids They suppress phagocytic response of splenic macrophages, decreasing platelet function they also depress autoimmune antibody formation and reduce capillary fragility and bleeding time.

During assessment of a patient with thrombocytopenia, the nurse would expet to find? a. sternal tenderness b. petechial and purpura c. jaundiced sclera and skin d. tender enlarged lymph nodes.

answer: b. petachiae and purpura rationale: petechiae are small, flat, red, or red brown pinpoint microhemorrhages that occur ont eh skin when platelet levels are low and when they are numerous, they group causing reddish bruises known as purpura. jaundice occurs when anemias are of a hemolytic origin, resulting in accumulation of bile pigments from rbc, enlarged lymph nodes are associated with infection, sternal tendernesss w leukemias