Basic Med Surge Final Exam Review

When testing the visual acuity of a patient, what instructions should be give for this test?

"Stand 20 feet away from the wall chart."

The nurse is providing discharge teaching to a patient who has had a laparoscopic cholecystectomy at an ambulatory surgery center. Which statement, if made by the patient, indicates an understanding of the discharge instructions?

"I will have someone stay with me for 24 hours in case I feel dizzy." The nurse must assess understanding of discharge instructions and the ability of the patient and caregiver to provide for home care needs. A responsible adult caregiver must accompany the patient. The patient may not drive after receiving anesthetics or sedatives. The patient should understand how to manage pain, and pain medication should be taken before the pain becomes severe. The patient should understand symptoms to be reported, such as a fever.

After the RN taught therapeutic lifestyle changes in diet, which statement by a pt with CAD , needs further teaching?

"I will miss being able to eat peanut butter sandwiches."

Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching

"I will remove my contact lenses at bedtime."

The nurse is performing an admission assessment on a client with osteoarthritis. Which of the following clinical manifestations would the nurse expect to find? 1. Joint pain after exercise relieved by rest 2. Symmetrical swelling of the joints of both hands 3. Morning stiffness lasting longer than 30 minutes 4. Fever

1. Joint pain after exercise relieved by rest

The best prognosis is indicated in the patient with breast cancer when diagnostic studies reveal 1. Negative axillary lymph nodes 2. Aneuploid DNA tumor content 3. Cells with high S-phase fractions 4. An estrogen receptor - progesterone receptor-negative tumor

1. Negative axillary lymph nodes

What should the nurse teach the patient recovering from an episode of acute low back pain? 1. Perform daily exercise as a lifelong routine 2. Sit in a chair with the hips higher than the knees 3. Avoid occupations in which the use of the body is required 4. Sleep on the abdomen or on the back with the legs extended

1. Perform daily exercise as a lifelong routine

A nurse is planning to assess the structure of a family. Which question should the nurse ask? 1. Who lives with you in this home? 2. Who does the grocery shopping? 3. Who provides support in your family? 4. How old are the members of your family?

1. Who lives with you in this home?

A client is admitted with suspected malignant melanoma on his left shoulder. During the physical assessment, the nurse would anticipate observing: 1. A brown birthmark that has lightened in color 2. A brown or black mole with red, white, or blue areas 3. Petechiae 4. A red birthmark that has recently become darker

2. A brown or black mole with red, white, or blue areas

The most common type of skin cancer is: 1. Melanoma 2. Basal Cell Carcinoma (BBC) 3. Squamous Cell Carcinoma 4. Actinic Keratosis

2. Basal Cell Carcinoma (BBC)

A client with acute asthma is experiencing inspiratory and expiratory wheezes and a decreased forced expiratory volume. What is the priority intervention by the nurse? 1. Beta-adrenergic blockers 2. Bronchodilators 3. Inhaled steroids 4. Oral steroids

2. Bronchodilators

The nurse is admitting a client who is scheduled for a thyroidectomy. The initial serum laboratory tests indicate high levels of T3 and T4. The nurse expects to see which of the following related to levels of thyroid-stimulating hormone (TSH) for this client? 1. High 2. Low 3. Normal 4. Not important

2. Low

A nurse is caring for a client with COPD. Which nursing interventions are appropriate? Select all that apply? 1. Reduce fluid intake to less than 2,500 ml/day 2. Teach diaphragmatic, pursed lip breathing 3. Administer low-flow oxygen 4. Keep the client in a supine position as much as possible 5. Encourage alternating activity with rest periods 6. Teach the family use of postural drainage and chest physiotherapy

2. Teach diaphragmatic, pursed lip breathing 3. Administer low-flow oxygen 5. Encourage alternating activity with rest periods 6. Teach the family use of postural drainage and chest physiotherapy

Which observation indicates to a nurse that a client understands his instructions on crutch walking? 1. The client's axillae rest on the crutches 2. The client's hands bear the body weight 3. Crutches are 12' (30.5cm) in front of the feet 4. The client uses long strides when walking

2. The client's hands bear the body weight

A client with hyperthyroidism develops a high fever, extreme tachycardia, and systolic hypertension. The nurse suspects which of the following? 1. Hepatic coma 2. Thyroid storm 3. Myxedema 4. Laryngeal spasm

2. Thyroid storm

A client exhibiting exophthalmos, weight loss, and tachycardia would be evaluated by checking the levels of which hormones? 1. Amylase, lipase, and trypsin 2. Triiodothyronine (T3), thyroxine (T4) and thyroid-stimulating hormone (TSH) 3. Glucocorticoids, mineralocorticoids, and androgens 4. Vasopressin and oxytocin

2. Triiodothyronine (T3), thyroxine (T4) and thyroid-stimulating hormone (TSH) The symptoms reflect a potential dysfunction of the thyroid gland. T3, T4 are secreted by the thyroid gland. TSH influences their excretion.

As part of the nursing process, cultural assessment is best accomplished by 1. Judging the patient's cultural values based on observations 2. Using a cultural assessment guide as part of the nursing process 3. Seeking guidance from a nurse from the patient's cultural background 4. Relying on the nurse's previous experience with patients from that cultural group

2. Using a cultural assessment guide as part of the nursing process

Confused patients should be

Assigned to a room near the nurse's station.

After surgical repair of the client's hip, which of the following positions would be best for this client 1. Prone 2. Adduction 3. Abduction 4. Subluxated

3. Abduction

Risk factors for breast cancer in women include all of the following except: 1. Family history 2. Environmental factors 3. Age 59 or younger 4. Early menarche and late menopause

3. Age 59 or younger

Which medication should a nurse withhold from a client 6 hours before a series of pulmonary function tests (PFTs)? 1. Azithromycin 2. Robitussin 3. Albuterol 4. Cefaclor

3. Albuterol

Complications of hip fractures include all the following except: 1. Venous thrombosis embolism (VTE) 2. Compartment syndrome 3. Diarrhea 4. Fat embolism

3. Diarrhea

Several days after being admitted with hyperglycemia, D.B's blood glucose drops to 56 mg/dL. D.B. remains alert and oriented. What are your priority nursing interventions? 1. Offer crackers and peanut butter 2. Administer 50% dextrose 20 to 50 mL IV push 3. Have D.B. drink 4 to 6 oz fruit juice (15 g of a simple carbohydrate) 4. Administer Glucagon 1 mg IM or subcutaneously

3. Have D.B. drink 4 to 6 oz fruit juice (15 g of a simple carbohydrate)

A client is diagnosed with uncomplicated rheumatoid arthritis. The nurse explains to the client that nonsteroidal anti-inflammatory drugs (NSAIDs) are used in the treatment plan. Which NSAID medication is used to treat rheumatoid arthritis? 1. Furosemide 2. Haloperidol 3. Ibuprofen 4. Methotrexate

3. Ibuprofen

The nurse is performing an assessment on a client with a suspected diagnosis of asthma. Which assessment finding supports the diagnosis? 1. Circumoral cyanosis 2. Increased forced expiratory volume 3. Inspiratory and expiratory wheezing 4. Normal breath sounds

3. Inspiratory and expiratory wheezing

The client is 8 hours status-post partial thyroidectomy for Graves' disease. What is the best documentation by the nurse of evaluation outcome criteria for the nursing diagnosis: risk for ineffective airway clearance? 1. Dressing is clean dry and intact, pain minimal and controlled, alert and oriented 2. Vital signs stable; client supports neck with hand during change of position 3. No tracheal stridor, speaks clearly and denies numbness or tingling 4. Balanced intake and output, vital signs stable and alert and oriented

3. No tracheal stridor, speaks clearly and denies numbness or tingling

A client asks the nurse, "What is the difference between rheumatoid arthritis and osteoarthritis?" What is the most appropriate response by the nurse? 1. Osteoarthritis is gender specific; rheumatoid arthritis is not 2. Osteoarthritis is a systemic disease; rheumatoid arthritis is localized 3. Osteoarthritis is a localized disease; rheumatoid arthritis is systemic 4. Osteoarthritis has dislocations and subluxations; rheumatoid arthritis does not

3. Osteoarthritis is a localized disease; rheumatoid arthritis is systemic

What method of oxygen administration is used for short-term therapy for patients needed higher 02 concentrations (60%-90% at 10-15 L/min)? 1. Venturi mask 2. Nasal cannula 3. Partial and non-rebreather mask 4. Simple face mask

3. Partial and non-rebreather mask

A nurse assesses her patient at beginning of the shift and observes the following: H.B. age 78 is hyperventilating, RR 36 breaths per minute, C/O dizziness, shortness of breath, tingling in hands and feet, weakness and is anxious. An ABG shows pH 7.48 and PaCO2 33 mm Hg. The nurse interprets these results as indicating which of the following: 1. Metabolic acidosis 2. Acute respiratory failure 3. Respiratory alkalosis 4. Anxiety reaction

3. Respiratory alkalosis

A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5 degree temperature, slight erythema at the incision margins, and 30 ml serosanguinous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusions would the nurse make? 1. The abdominal incision shows signs of an infection 2. The abdominal incision shows signs of impending dehiscence 3. The patient has a normal inflammatory response 4. The patient's health care provider must be notified about her condition

3. The patient has a normal inflammatory response

The home health nurse assesses four clients. The nurse determines that which client is at highest risk for impaired wound healing after surgery? 1. A 65-year-old client with hypertension 2. A 60-year-old client who's slightly overweight 3. A 78-year-old client in general good health 4. A 75-year-old client with poorly controlled diabetes mellitus

4. A 75-year-old client with poorly controlled diabetes mellitus

An 82-year-old woman is taking ibuprofen (Motrin) 3200 mg divided three times daily as treatment for arthritis. She has had no other health problems. What is the most important assessment for the nurse to monitor while the patient is on this therapy? 1. Blood sugar 2. Liver function studies 3. Assessment of hearing 4. Renal function studies

4. Renal function studies

Two hours after starting a continuous total enteral nutrition through a nasogastric tube, a client starts to have abdominal distention. Which action should the nurse take first? 1. Aspirate stomach contents 2. Reposition the tube 3. Place client in supine position 4. Stop the feeding

4. Stop the feeding

A client has cellulitis of the finger. Which organism or condition is the most likely cause of the infection? 1. Parainfluenza virus 2. Respiratory syncytial virus 3. Escherichia coli 4. Streptococcus

4. Streptococcus

Questions the nurse should ask when using the FICA tool for spiritual assessment include all the following except 1. What things do you believe in that give meaning to life? 2. Are you connected with a faith center in your community? 3. How has your illness affected your personal beliefs? 4. When was the last time you have been to church?

4. When was the last time you have been to church?

Which patient would be at highest risk for hypothermia after surgery?

A 75-yr-old patient with repair of a femoral neck fracture after a fall. Patients at highest risk for hypothermia are those who are older, debilitated, or intoxicated. Also, long surgical procedures and prolonged anesthetic administration increase the patient's risk for hypothermia.

A patient presents to the clinical after tripping on a curb and spraining the right ankle. Which initial care measures are appropriate? (Select all that apply.)

Administer antiinflammatory medication. Compress ankle using an elastic bandage. Rest and elevate the ankle above the heart. Appropriate care for a sprain is represented with the acronym RICE (rest, ice, compression, and elevation). Antiinflammatory medication should be used to decrease swelling if not contraindicated for the patient. After the injury, the ankle should be immobilized and rested. Prolonged immobilization is not required unless there is significant injury. Ice is indicated but will cause tissue damage if applied directly to the skin. Apply ice to sprains as soon as possible and leave in place for 20 to 30 minutes at a time. Moist heat may be applied 24 to 48 hours after the injury.

In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, the nurse recognizes which action will best enable the patient to achieve the desired outcomes?

Administering adequate analgesics to promote relief or control of pain Even when a patient understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate with the activities.

A patient is admitted to the postanesthesia care unit (PACU) after abdominal surgery. Which assessment, if made by the nurse, is the best indicator of respiratory depression?

Increased carbon dioxide pressure

When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. What is the priority action by the nurse?

Assess the patient's blood pressure and heart rate. The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.

In caring for the postoperative patient on the clinical unit after transfer from the postanesthesia care unit (PACU), which care can the nurse delegate to the unlicensed assistive personnel (UAP)?

Assist the patient to take deep breaths and cough. The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report pain to the nurse caring for the patient. The RN should do the admission vital signs for the patient transferring to the clinical unit from the postanesthesia care unit (PACU). The RN will monitor and treat the patient's pain and change the dressings.

The nurse determines a postoperative patient has a bronchial obstruction from retained secretions and an oxygen saturation of 87%. What condition does the nurse suspect is occurring?

Atelectasis The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.

Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is termed

Breakthrough

An older adult patient who had surgery has signs of delirium. What priority action would benefit this patient?

Check the preoperative assessment for previous delirium or dementia. If the patient's ABCs are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications and pain will be assessed as these can all contribute to delirium.

A pt with Meniere's disease has vertigo, nausea, & vomiting. Which nursing intervention will be included in the care

Dim the lights in the patient's room

A patient has a plaster cast applied to the right arm for a Colles' fracture. Which nursing action is most appropriate?

Elevate the right arm on 2 pillows for 24 hours. The casted extremity should be elevated at or above heart level for 24 hours to reduce swelling or inflammation. The cast should be supported on pillows during the drying period to prevent denting and flattening of the cast. Ice (not heat) should be applied for the first 24 to 36 hours to reduce swelling or inflammation. Active movement of the thumb and fingers should be encouraged to reduce edema and increase venous return. A sling may be used to support and protect the extremity after the cast is completely dry, but the patient should perform active movements of the shoulder to prevent stiffness or contracture.

When developing a teaching plan for an elderly pt with coronary artery disease, what should the RN focus on

Elevated low-density lipoprotein (LDL) levels

The nurse determines that an older adult patient recovering from left total knee arthroplasty has impaired physical mobility from decreased muscle strength. What nursing intervention is appropriate?

Encourage isometric quadriceps-setting exercises at least 4 times a day. Emphasis is placed on postoperative exercise of the affected leg, with isometric quadriceps setting beginning on the first day after surgery. Vitamin C and calcium do not improve muscle strength, but they will facilitate healing. The patient should be able to perform active range of motion to all joints. Keeping the leg in one position (extension and abduction) may contribute to contractures.

A diet low in fiber and low in fats and red meat is recommended to prevent diverticulitis.

False

A patient with a possible stroke should be given Aspirin

False

Assault is intentional offensive touching without consent or lawful justification.

False

Battery is an intentional threat toward another person that gives that person a reasonable fear of harmful contact

False

Nebulizers are used to give aerosol meds. A mist is seen when the med is aerosolized, & continues when the med is done

False

Resting with the head elevated and knees flat will reduce the strain on the back and decrease muscle spasms.

False

Ringing in the ear is a common side effect of the drug niacin?

False

Veracity is keeping promises and Fidelity is telling the truth.

False

The etiology of coronary artery disease associated with cholesterol and other lipids moving into the intima is

Fibrous plaque

The nurse is caring for a Native American patient 2 days after a thoracotomy for a tumor resection. What would be the most appropriate action if the patient does not report any pain?

Identify possible reasons for denying pain. Encourage older adults to report pain, especially those who are reluctant to discuss pain or deny pain when it is likely present, such as after surgery. Older patients may be hesitant to request pain medication, believe pain is an inevitable consequence of surgery, and may not understand how to use patient-controlled machines. Some cultures discourage the expression of pain. The nurse should encourage the use of analgesics, explaining to the patient that untreated pain has a negative effect on recovery. Assessment of pain and administration of medications are within the scope of practice of a nurse. An older patient may have decreased renal and liver function that may lead to drug toxicity. However, this would not be a reason for denial of pain. Administration of pain medication must be based on the patient assessment.

The nurse is repositioning a patient after a surgical procedure. What is the best position unless contraindicated, for this patient to be placed in to prevent respiratory complications?

Lateral Unless contraindicated by the surgical procedure, an unconscious patient is positioned in a lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated.

A nurse is caring for an unconscious patient who has just been admitted to the postanesthesia care unit (PACU) after an abdominal hysterectomy. How should the nurse position the patient?

Left lateral position with head supported on a pillow An unconscious patient should be placed in the lateral "recovery" position to keep the airway open and reduce the risk of aspiration. When conscious, the patient is usually returned to a supine position with the head of the bed elevated to maximize expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm.

The home care nurse visits a 74-yr-old man diagnosed with Parkinson's disease who fell while walking this morning. What observation is of most concern to the nurse?

Left leg externally rotated and shorter than the right leg Manifestations of hip fracture include external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness in the region of the fracture site. Expected clinical manifestations of Parkinson's disease include a stooped posture, shuffling gait, and slow movements. An abrasion is a soft tissue injury. Mild pain and minimal swelling may occur with a sprain or strain.

A patient is having elective facial cosmetic surgery and will be staying in the facility for 24 hours after surgery. What is the nurse's postoperative priority for this patient?

Manage oxygenation status. The nurse's priority is to manage the patient's oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise her ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase her risk for upper airway edema causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority.

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival?

Obtain the patient's vital signs. The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient's vital signs. The other actions can then take place in rapid sequence.

After a myocardial infarction, which complication may occur

Pericarditis

The priority problem for a patient experiencing an acute attack with Meniere's disease?

Risk for falls

What is not included in General adaptation syndrome (GAS)?

Short term response

These symptoms reflect a potential dysfunction of the thyroid gland - Hyperthyroidism

Tachycardia, weight loss, & exophthalmos

To relieve chest pain, how should you advise taking sublingual nitroglycerin tablets

Take 3 sublingual nitroglycerin tabs 5 min apart, Call an ambulance if unrelieved

Another name for Sterile field

Surgical Asepsis

What information about the pt who had a subarachnoid hemorrhage is most important to communicate to the doctor?

The patient's blood pressure (BP) is 94/50 mm Hg.

Which action demonstrates correct use of crutches by a patient following a left leg injury?

The pt moves the crutches approximately 12 inches forward with each step.

Aspirin is ordered to prevent strokes in patients who have experienced TIAs

True

Beneficence refers to helping others, Autonomy is the right to personal freedom

True

Increased chest pain may indicate thrombolytic therapy is not working & other actions such as PCI is needed

True

LPN/VN education and scope of practice include reinforcing education that has previously been done by the RN.

True

Right-sided paralysis indicates a left-brain stroke, this will lead to difficulty with comprehension and use of language

True

Teenagers are at risk for hearing loss as they age due to exposure to loud music

True

If a pt has otitis media, What part of the ear is affected?

Tympanum, ossicles & middle ear

A patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge? (Select all that apply.)

Vital signs baseline or stable Minimal nausea and vomiting Responsible adult taking patient home Ambulatory surgery discharge criteria include meeting phase I PACU discharge criteria that includes vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria include a responsible adult driving patient, no IV opioid drugs for the past 30 minutes, able to void, able to ambulate if not contraindicated, and received written discharge instruction with patient understanding confirmed.

Small emboli can occur during carotid artery angioplasty & stenting, if the PT becomes aphasic

a possible stroke occurred during the procedure

Which description of the mole is consistent with cancer and requires Surgical excision

lesion that is 6 mm in diameter