NCLEX REVIEW MED SURG

During a first aid class, a student asks what should be done if a person's clothes catch on fire. The nurse explains that after the flames are extinguished it is most important to perform this action. Which action did the nurse describe? Give the person sips of water. Assess the person's breathing. Cover the person with a warm blanket. Calculate the extent of the person's burns

A patent airway is most vital; if the person is not breathing, cardiopulmonary resuscitation (CPR) should be instituted. The person should be kept NPO because large burns decrease intestinal peristalsis and the person may vomit and aspirate. Covering the person with a warm blanket is not done; rather a light blanket or sheet can be used. Calculating the extent of the person's burns is not the priority; this assessment is done after transfer to a medical facility.

The nurse is caring for a client with a possible pulmonary embolism (PE). Which diagnostic test should the nurse initially anticipate will be prescribed for this client because it is the evidence-based gold standard for a PE diagnosis? Spiral (helical) computed tomographic angiography (CTA) D-dimer and arterial blood gas (ABG) laboratory tests Ventilation-perfusion (V/Q) scan Pulmonary angiography

A spiral (helical) computed tomographic angiography (CTA) is considered the gold standard for a pulmonary embolism (PE) medical diagnosis. The spiral CTA also has the added advantage of diagnosing other pulmonary abnormalities. A pulmonary angiography is still used as a PE diagnostic test, usually if the client also has coronary disease and invasive treatment (i.e., angioplasty) may become necessary; however, it is no longer the gold standard because it is expensive and invasive, and the spiral CTA has excellent accuracy and better accessibility. Ventilation/perfusion (V/Q) scans are currently used only in certain circumstances such as when the client has contrast dye allergy. D-dimer and arterial blood gas (ABG) laboratory tests are typically prescribed for a client with a possible PE; however, these tests are not specific or sensitive enough to be used alone to make the PE diagnosis. An ABG is used to evaluate the client's oxygenation status during medical dx and tx to determine if additional ER tx is needed, such as intubation and mechanical ventilation. A D-dimer simply reveals the presence or absence of fibrin split products which occur when a blood clot degrades or breaks down; however, about half of clients with a PE still test negative (a normal result) and several other conditions can produce a positive D-dimer result.

Which type of immunity will clients acquire through immunizations with live or killed vaccines? Natural active immunity Artificial active immunity Natural passive immunity Artificial passive immunity

Artificial active immunity is acquired through immunization with live or killed vaccines. Natural active immunity is acquired when there is natural contact with antigens through a clinical infection. Natural passive immunity is acquired through the transfer of colostrums from mother to child. Artificial passive immunity is acquired by injecting serum from an immune human.

A client is admitted with suspected atelectasis. Which clinical manifestation does the nurse expect to identify when assessing this client? Slow, deep respirations Normal oral temperature Dry, unproductive cough Diminished breath sounds

Because atelectasis involves collapsing of alveoli distal to the bronchioles, breath sounds are diminished in the lower lobes. The client will have rapid, shallow respirations to compensate for poor gas exchange. Atelectasis results in an elevated temperature. Atelectasis results in a loose, productive cough.

The clinical findings of a client with diabetes mellitus show decreased glucose tolerance. Which complication is anticipated in the client? Cystitis Thin and dry skin Decreased bone density Frequent yeast infections

Decreased glucose tolerance may cause frequent yeast infections, but it is not associated with the risk of cystitis, thin and dry skin, and decreased bone density. The risk of cystitis, thin and dry skin, and decreased bone density are due to decreased ovarian production of estrogen.

A client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain on the right side of the chest. The nurse suspects a pneumothorax. What breath sound is most likely to be present when the nurse assesses the client's right side? Crackling Wheezing Decreased sounds Adventitious sounds

Decreased sounds Because the affected lung will not expand, aeration of the lung is not complete, and breath sounds are diminished. Crackling sounds occur with pulmonary edema, not with a pneumothorax; with a pneumothorax there is no air in the alveoli to produce crackles. Wheezing sounds occur with asthma, not with a pneumothorax. "Adventitious sounds" is a broad term that includes all abnormal breath sounds; it is not specific to pneumothorax.

A nurse is collecting data from a client with varicose veins who is to have sclerotherapy. What should the nurse expect the client to report? Feeling of heaviness in both legs Intermittent claudication of the legs Calf pain on dorsiflexion of the foot Hematomas of the lower extremities

FEELING OF HEAVINESS IN BOTH LEGS Impaired venous return causes increased pressure, with symptoms of fatigue and heaviness. Pain when walking relieved by rest (intermittent claudication) is a symptom related to hypoxia. Symptoms of hypoxia are related to impaired arterial, rather than venous, circulation. Calf pain on dorsiflexion of the foot is Homans sign, which is suggestive of thrombophlebitis. Ecchymoses may occur in some individuals, but bleeding into tissue is insufficient to cause hematomas.

Which pulmonary function test provides a more sensitive index of obstruction in smaller airways? Forced vital capacity Functional residual capacity Forced expiratory volume in 1 second Forced expiratory flow over the 25% to 75% volume of the forced vital capacity

Forced expiratory flow over the 25% to 75% volume of the forced vital capacity is the measure that provides a more sensitive index of obstruction in smaller airways. Forced vital capacity indicates respiratory muscle strength and ventilator reserve. Functional residual capacity is normal or decreased in restrictive pulmonary diseases and increased in obstructive pulmonary diseases. Forced expiratory volume in 1 second is reduced in certain obstructive and restrictive disorders.

Which mechanism of action does norepinephrine promote to manage anaphylaxis? Blocks the effects of histamine Inhibits mast cell degranulation Increases blood pressure and cardiac output Stimulates muscarinic and nicotinic receptors

Increases blood pressure and cardiac output. Norepinephrine is a sympathomimetic vasopressor that elevates the blood pressure and cardiac output in clients with hypotension from anaphylaxis by stimulating alpha- and beta-adrenergic receptors. Diphenhydramine blocks the effects of histamine on various organs. Corticosteroids such as dexamethasone prevent mast cell degranulation. Acetylcholinesterase inhibitors such as neostigmine stimulate the muscarinic and nicotinic receptors for the reversal of neuromuscular blockade agents

Which diagnostic test may be used to distinguish vascular from nonvascular structures? Chest X-ray Pulmonary angiogram Computed tomography Magnetic resonance imaging

MRI is used for distinguishing vascular from nonvascular structures. An X-ray is useful to screen, diagnose, and evaluate changes in the respiratory system. A pulmonary angiogram is used to visualize pulmonary vasculature and locate obstruction of pathologic conditions. CT is performed for diagnosis of lesions difficult to assess by conventional X-ray studies.

After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus? Pink Clear Green Yellow

PINK! With a pulmonary embolus, there is partial or complete occlusion of pulmonary blood flow; when infarcted areas or areas of atelectasis produce alveolar damage, red blood cells move into the alveoli, resulting in hemoptysis. Clear sputum is associated with a viral infection. Green and yellow sputum are associated with a bacterial infection.

A client is admitted to the hospital from the emergency department with a diagnosis of urolithiasis. The nurse reviews the client's clinical record and performs an admission assessment. Which is the priority nursing action? Strain the client's urine. Place the client in the high-Fowler position. Administer the prescribed morphine. Collect a urine specimen for culture and sensitivity

Pain relief is the priority. Clients report that ureteral colic is excruciatingly painful. Once pain is under control and the client is comfortable, other medical and nursing interventions can be implemented. Although straining all urine is required, pain relief is the priority. Once the client is medicated for pain, the urine that was set aside can be strained. The high-Fowler position is not necessary. The client can be assisted to assume a position of comfort. The urine was sent for a culture and sensitivity in the emergency department.

What must the nurse do to determine a client's pulse pressure?

Pulse pressure is obtained by subtracting the diastolic from the systolic reading after the blood pressure has been recorded

The healthcare provider prescribes theophylline to be given intravenously for the client experiencing an acute asthma attack. What does the nurse teach the client is the function of this medication? Antibiotic Antihistamine Bronchodilator Expectorant

Theophylline is a bronchodilator. It relaxes the smooth muscles in the bronchial airway and relieves bronchospasms. This in turn improves air exchange. An antibiotic is used to treat a bacterial infection. An antihistamine blocks the action of histamine. An expectorant is used to loosen mucus in the lungs. An antibiotic, an antihistamine, or an expectorant will not relax the smooth muscles in the bronchial airway for clients experiencing an acute episode.