Medsurg Final

The nurse is preparing to assist in the insertion of a peripherally inserted central catheter (PICC) line in a patient's left forearm. Which solution will be best for cleansing the skin prior to insertion?

0.5% chlorhexidine in alcohol (Hibistat)

The amount of effort needed to maintain a given level of ventilation is termed

work of breathing

A client with endocarditis is being discharged home. What statement indicates effectiveness of client teaching about preventing recurrence of the infection?

"I will ask for antibiotics whenever I have dental work done." Rationale: The patient should take antibiotics for dental procedures that involve manipulation of gingival tissue or the periapical area of the teeth or perforation of the oral mucosa. Exceptions include routine anesthetic injections through non-infected tissue, placement of orthodontic brackets, loss of deciduous teeth, bleeding from trauma to the lips or oral mucosa, dental x-rays, adjustment of orthodontic appliances, and placement of removable prosthodontic or orthodontic appliances.

The nurse is providing teaching about tissue repair and wound healing to a postoperative patient who has an abdominal wound. Which of the following statements by the patient indicates that teaching has been effective?

- "I'll make sure that the bandage is wrapped tightly." - "I'll eat plenty of fruits and vegetables." Rationale: Optimal nutritional status is important for wound healing; the patient should eat plenty of fruits and vegetables and not reduce protein intake. To avoid impeding circulation to the area, the bandage should be secure but not tight. If the patient's foot feels cold, circulation is impaired, which inhibits wound healing.

A client has a plural chest tube following removal of the lower lobe of the lung. Two days after surgery, the tube is accidentally pulled out of the chest wall. What should the nurse do first?

- Apply an occlusive dressing such as petroleum jelly gauze. - Auscultate the lung to determine whether it collapsed. Rationale: If the chest tube is accidentally pulled out (a rare occurrence), a petroleum jelly gauze and sterile 4×4 inch dressing should be applied over the chest wall insertion site immediately. The dressing should be covered with adhesive tape and be occlusive, and the surgeon should be notified. The lungs can be auscultated and vital signs can be taken after the dressing is in place and the surgeon has been called. Placing the tube in sterile water will not re-establish a seal to prevent air entering the insertion site of the chest tube.

Carcinogenic factors related to an increased risk of cancer include (Select all that apply):

- Smoked and salted meats with nitrates diet - Obesity - tobacco use

The nurse is caring for a client who is known to have a high risk for venous thromboembolism. What preventive actions should the nurse recommend? Select all that apply.

- Weight loss - Regular exercise - Smoking cessation Rationale: Clients at risk for VTE should be advised to make lifestyle changes, as appropriate, which may include weight loss, smoking cessation, and regular exercise. Increased protein intake and supplementation with vitamin D and calcium do not address the main risk factors for VTE.

A nurse practitioner has provided care for three different clients with chronic pharyngitis over the past several months. Which clients are at greatest risk for developing chronic pharyngitis?

A client who is a habitual user of alcohol and tobacco Rationale: Chronic pharyngitis is common in adults who live and work in dusty surroundings, use the voice to excess, suffer from chronic cough, and habitually use alcohol and tobacco. Caffeine and spicy foods have not been linked to chronic pharyngitis. GERD is not a noted risk factor.

An oncology nurse is contributing to the care of a client who has failed to respond appreciably to conventional cancer treatments. As a result, the care team is considering the possible use of biologic response modifiers (BRMs). The nurse should know that these achieve a therapeutic effect by what means?

Altering the immunologic relationship between the tumor and the client Rationale: BRMs alter the immunologic relationship between the tumor and the cancer client (host) to provide a therapeutic benefit. They do not necessarily increase white cell production or focus the immune system solely on the tumor. BRMs do not potentiate radiotherapy and chemotherapy.

A client with an occluded coronary artery is admitted and has an emergency percutaneous transluminal coronary angioplasty (PTCA). The client is admitted to the cardiac critical care unit after the PTCA. The complications for which the nurse should monitor the client include which of the following complications associated with the procedure?

Bleeding at insertion site Rationale: Complications of PTCA may include bleeding at the insertion site, abrupt closure of the artery, arterial thrombosis, and perforation of the artery. Complications do not include left ventricular hypertrophy because this problem takes an extended time to develop and is not emergent. Bleeding is a more likely and more serious complication than edema.

Identify the medical term that refers to a common finding in oncology patients, characterized by weight loss, muscle atrophy, and generalized weakness:

Cachexia Rationale: Oncology patients often experience weight loss, loss of muscle, and generalized weakness. They may experience cachexia since cancer cells are parasitic and compete with normal cells for their nutrition. Anorexia as a symptom may also occur, but this term does not fully describe the effects on a patient.

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?

Contact the client's health care provider and continue to assess fluid balance and renal function. Rationale: Nursing management includes accurate measurement of urine output. An output of less than 30 mL per hour could be associated with an altered renal function.

A client presents to the clinic complaining of intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the client that angina is most often attributable to what cause?

Coronary arteriosclerosis Rationale: In most cases, angina pectoris is due to arteriosclerosis. The disease is not a result of impaired cardiac output or contractility. Infarction may result from untreated angina, but it is not a cause of the disease.

When discussing angina pectoris secondary to atherosclerotic disease with a client, the client asks why he tends to experience chest pain when he exerts himself. The nurse should describe which of the following phenomena?

Exercise increases the heart's oxygen demands. Rationale: Physical exertion increases the myocardial oxygen demand. If the client has arteriosclerosis of the coronary arteries, then blood supply is diminished to the myocardium. Exercise does not cause vasoconstriction or interfere with drug metabolism. Exercise does not shunt blood flow away from the heart.

A client visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage, the nurse should instruct the client to perform what action?

Increase fluid intake Rationale: For a client diagnosed with acute sinusitis, the nurse should instruct the client that hot packs, increasing fluid intake, and elevating the head of the bed can promote drainage. Applying heat will not promote sinus drainage. Postural drainage is used to remove bronchial secretions.

Which discharge instruction for self-care should the nurse provide to a client who has undergone a percutaneous transluminal coronary angioplasty (PTCA) procedure?

Monitor the site for bleeding or hematoma Rationale: The nurse provides certain discharge instructions for self-care, such as monitoring the site for bleeding or the development of a hard mass indicative of hematoma. A nurse does not advise the client to clean the site with disinfectants or refrain from sexual activity for 1 month.

Ten minutes after receiving the ordered preoperative opioid (narcotic) analgesic medication by intravenous (IV) injection, the patient asks to get up to go to the bathroom to urinate. The most appropriate action by the nurse is to

Offer a urinal or bedpan and position the patient in bed.

For the care of a patient who is experiencing the side effects of radiation therapy, which task would be most appropriate to delegate to the unlicensed assistive personnel (UAP)?

Reporting the amount and type of a meal taken by the patient. Rationale: LaCharity question on delegation to an unlicensed assistive personnel (UAP). UAPs can assist in the nursing process by collecting assessment data and reporting back to the RN.

The nurse notes that there are initial changes in the electrocardiogram (ECG) during Acute Coronary Syndrome (ACS). The nurse recognizes that a change on the ECG that may indicate myocardial ischemia is:

ST elevation

The nurse is analyzing a rhythm strip. What component of the ECG corresponds to the resting state of the client's heart?

T wave Rationale: The T wave specifically represents ventricular muscle depolarization, also referred to as the resting state. Ventricular muscle depolarization does not result in the P wave, U wave, or QRS complex.

Which of the following should be considerations in the teaching as the nurse plans to instruct the COPD patient on how to perform pursed lip breathing?

Take a deep breath in through your nose Rationale: While placing the hand on the stomach is useful in practicing diaphragmatic or abdominal breathing, breathing in through the nose is helpful in practicing pursed lip breathing. the client should not puff out cheeks, as this could interfere with the release of carbon dioxide.

The nurse is caring for a client with a diagnosis of pleurisy. The client begins reporting right-sided chest pain that gets worse when he coughs or breathes deeply. Vital signs are within normal limits. What is the nurse's best action?

Teach the client to splint the rib cage when coughing Rationale: Because the client has pain on inspiration, the nurse educates the client to use the hands or a pillow to splint the rib cage while coughing. Deep breathing and coughing would cause more pain, and pursed lip breathing would provide relief. The client is not in obvious respiratory distress, so there is no immediate need to contact the respiratory therapist.

The nurse has just finished assisting the health care provider with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is important to report to the health care provider (HCP)?

The patient reports sharp, stabbing chest pain with every deep breath.

While caring for a patient who had abdominal surgery on the second postoperative day, the nurse recognizes the differences between symptoms which are expected postoperatively and those which are not. Which information about the patient is most important to communicate promptly to the surgeon?

The right calf is swollen, warm, and painful.

A patient diagnosed with severe anemia is prescribed to receive a transfusion of packed red blood cells (RBCs). The patient begins to complain of shortness of breath, chills, and dizziness. The patient's skin is flushed and the patient feels a fever coming on. The nurse anticipates that this constellation of findings represent which type of hypersensitivity?

Type II Rationale: An incompatible blood transfusion occurs when an individual receives blood from someone with an incompatible blood group type. Recipient antibodies attach to the donor's red blood cell (RBC) antigens, resulting in a Type II Hypersensitivity reaction, during which the immune system attacks the donated blood cells, causing them to burst.

A student nurse completing a preceptorship is reviewing the use of standard precautions. Which of the following practices is most consistent with standard precautions?

Washing hands immediately after removing gloves Rationale: Standard precautions are used to prevent contamination from blood and body fluids. Gloves are worn whenever exposure is possible, and hands should be washed after removing gloves. Needles are never recapped after use because this increases the risk of accidental needlesticks. Under ordinary circumstances, masks and gowns are not necessary for starting an IV line. Double-gloving is not a recognized component of standard precautions.

Your patient has just returned from the postanesthetic care unit (PACU) following left tibia open reduction internal fixation (ORIF). The patient is complaining of pain, and you are preparing to administer the patient's first scheduled dose of hydromorphone(Dilaudid). Prior to administering the drug, you would prioritize which of the following patient assessments?

allergy status Rationale: Before administering medications such as narcotics for the first time, the nurse should assess for any previous allergic reactions. Electrolyte values, blood pressure, and hydration status are not what you need to assess prior to giving a first dose of narcotics.

Prior to the administration of preoperative medications, the nurse is preparing to witness the patient signing the operative consent form as the surgeon exits the room. When the patient says, "I do not really understand what the surgeon just said." Which action is best for the nurse to take?

notify the surgeon that the patient does not understand the procedure

The nurse is teaching a client who will be undergoing a lung resection. The client is told that a chest tube will be placed during surgery. When the nurse is evaluating the effectiveness of the tube placed lowest in the pleural cavity, what is the purpose of this chest tube?

removing fluid Rationale: Fluid accumulates in the base of the pleura postoperatively. The lower chest tube, called the posterior or lower tube, will drain serous and serosanguineous fluid that accumulates as a result of the surgical procedure. A larger-diameter tube is usually used for the lower tube to ensure drainage of clots. Air rises, and the anterior or upper tube is used to remove air from the pleural space. The practice of "milking" the tubes to prevent clots is becoming less common; the surgeon's prescriptions must be followed regarding this procedure.

As you review the telemetry waveforms for your unit, the attached tracing is recorded for the patient in bed 4. You recognize this tracing as:

ventricular paced rhythm

The nurse is caring for a client with influenza. The most effective way to decrease the spread of microorganisms is:

washing the hands frequently. Rationale: The hands spread disease-causing organisms. Frequent handwashing is essential to decrease the spread of microorganisms. Having separate personal care items for each client does not eliminate the potential for contamination of these items. When practical, using disposable equipment is preferable to sterilization, but it does not override frequent, thorough handwashing for control of infection. Isolating people known to be harboring disease-causing organisms is a cornerstone of infection control, but health care personnel must still wash their hands to avoid spreading disease.