NURS 455 MED Surg Questions

A nurse is reviewing the laboratory results of a client who has acute leukemia and received an aggressive chemotherapy treatment 10 days ago. Which of the following hematologic laboratory values should the nurse NOT expect? A. Decreased leukocyte count B. Decreased platelet count C. Decreased erythrocyte count D.​Increased hemoglobin count

D.​Increased hemoglobin count Feedback: The nurse should expect to see a decreased hemoglobin count due to bone marrow suppression from the chemotherapy treatment

A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the rule of nines to determine the total body surface area of the burn injury. What percentage of body surface area should the nurse estimate the client has burned?

54% Feedback: First, determine the burned areas:1) Entire right and left leg2) Entire rear torsoNext, refer to the Rule of Nines for estimating body surface area Rule of NinesHead: 9%Torso: 36% total (front 18% & back 18%)Arm 9% eachLeg 18% eachPerineum 1%Apply the Rule of Nines to this client:Left leg = 18%Right leg = 18%Rear torso = 18%Then total all the burned areas:18 x 3 = 54%InCorrect Answer Rationale:First, determine the burned areas:1) Entire right and left leg2) Entire rear torsoNext, refer to the Rule of Nines for estimating body surface areaRule of NinesHead: 9%Torso: 36% total (front 18% & back 18%)Arm 9% eachLeg 18% eachPerineum 1%Apply the Rule of Nines to this client:Left leg = 18%Right leg = 18%Rear torso = 18%Then total all the burned areas:18 x 3 = 54%

A nurse is talking with a client who has cholelithiasis and is about to undergo an oral cholangiogram. Which of the following client statements indicates to the nurse understanding of the procedure? A. "They are going to examine my gallbladder and ducts." B. "Soon those shock waves will get rid of my gallstones." C. "I'll have a camera put down my throat so they can see my gallbladder." D. "They'll put medication into my gallbladder to dissolve the stones."

A. "They are going to examine my gallbladder and ducts." Feedback: With oral cholangiography, the client receives an iodide-containing contrast agent 10 to 12 hr before the procedure. Then, the examiner can evaluate the gallbladder for filling, contracting, and emptying and can also see the gallstones on the x-rays.

A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history? A. Gallstones B. Hypolipidemia C. COPD D. Diabetes mellitus

A. Gallstones Feedback: The client's history might reveal biliary obstruction from a gallstone causing bile to inflame the pancreas.

A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention? A. Daily weight B. Sodium level C. Tissue turgor D. Intake and output

A. Daily weight Feedback: Obtaining a client's daily weight and comparing it to previous weights is a reliable method for measuring a client's fluid volume over time.

A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect? A. Fatty stools B. Straw-colored urine C. Tenderness in the left upper abdomen D. Ecchymosis of the extremities

A. Fatty stools Feedback: Chronic cholecystitis occurs following several bouts of acute cholecystitis. The repeated episodes of inflammation result in a fibrotic and contracted gallbladder. Because of inflammation in the gallbladder, bile needed to absorb fat and fat-soluble vitamins is unable to enter the bowel, resulting in steatorrhea (fatty stools).

A nurse is caring for a client who has polycystic kidney disease (PKD). Which of the following findings should the nurse expect? A. Flank pain B. Hypotension C. Confusion D. Urinary retention

A. Flank pain Feedback: Flank pain is a finding associated with PKD.

A nurse is teaching a client who has chronic kidney disease and a new prescription for epoetin alfa. The nurse should instruct the client to increase dietary intake of which of the following substances? A. Iron B. Protein C. Potassium D. Sodium

A. Iron Feedback: Epoetin alfa is a synthetic form of erythropoietin, a substance produced by the kidneys that stimulates the bone marrow to produce red blood cells. Increased iron is needed for the production of hemoglobin and red blood cells by the bone marrow.

A nurse is caring for a client who has cirrhosis and a prothrombin time of 30 seconds. Which of the following medications should the nurse plan to administer? A. Vitamin K B. Vitamin B C. Heparin D. Warfarin

A. Vitamin K Feedback: A prothrombin time of 30 seconds indicates the clotting time is prolonged and bleeding could occur. Vitamin K injection increases the synthesis of prothrombin by the liver; therefore, the nurse should plan to administer vitamin k.

A nurse is preparing to administer a dose of lactulose to a client who has cirrhosis. The client states, "I don't need this medication. I am not constipated." The nurse should explain that in clients who have cirrhosis, lactulose is used to decrease levels of which of the following components in the bloodstream? A. Glucose B. Ammonia C. Potassium D. Bicarbonate

B. Ammonia Feedback:Lactulose, a disaccharide, is a sugar that works as an osmotic diuretic. It prevents absorption of ammonia in the colon. Accumulation of ammonia in the bloodstream, which occurs in pathologic conditions of the liver, such as cirrhosis, may affect the central nervous system, causing hepatic encephalopathy or coma

A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? A. BP B. Heart rate C. Urine output D. Weight

B. Heart rateFeedback: When a client's circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore, the nurse should identify a decrease in heart rate as in indication of adequate fluid replacement.

A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see? A. Decreased WBC B. Increased serum amylase C. Decreased serum lipase D. Increased serum calcium

B. Increased serum amylase Feedback: With acute pancreatitis, serum amylase rises within 24 hr of the start of the client's symptoms.

A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take? A. Insert an indwelling urinary catheter. B. Inspect the mouth for signs of inhalation injuries. C. Administer intravenous pain medication. D. Draw blood for a complete blood cell (CBC) count.

B. Inspect the mouth for signs of inhalation injuries. Feedback: Since the client sustained burns to the chest and face, there is a possibility that flames and smoke from the client's burning clothes could have caused an inhalation injury. The nurse should inspect the mouth and throat for soot and swelling. Using the airway, breathing, circulation (ABC) priority-setting framework, is the priority concern at this time.

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis? A. Hyperactive bowel sounds B. Nausea and vomiting C. Bradycardia D. Increased urinary output

B. Nausea and vomiting Feedback: Peritonitis is an inflammation of the peritoneum and is a potential complication of peritoneal dialysis. The nurse should monitor the client for manifestations such as abdominal tenderness or pain, anorexia, nausea, vomiting, restlessness, and confusion.

A nurse is teaching a client who has a history of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse identify as a contributing factor to the development of the anemia? A. Dietary iron restrictions B. Intestinal malabsorption syndrome C. Chronic blood loss D. Intestinal parasites

C. Chronic blood loss Feedback: A client with long-standing ulcerative colitis is most likely anemic due to chronic blood loss in small amounts that occurs over time, although the colitis may result in erosion of the intestine and hemorrhage. These clients often report bloody stools and are therefore at increased risk for developing anemia.

A nurse is caring for a client who is postoperative following an open cholecystectomy. Which of the following actions should the nurse take when caring for the client's Jackson-Pratt (JP) drain? A. Measure the drainage every hour for the first 8 hr postoperative. B. Secure the drain to the client's bed sheet. C. Expel the air from the JP bulb after emptying to re-establish suction. D. Remove the JP drain when the drainage has ceased, covering the opening with sterile gauze.

C. Expel the air from the JP bulb after emptying to re-establish suction. Feedback:With the drainage and the air removed and the bulb tightly closed, the system works to exert gentle negative pressure, facilitating the removal of accumulated fluid from the surgical area.

A nurse is caring for a young female adult client who reports weakness, fatigue, and heavy menstrual periods. The client has a hemoglobin level of 8 g/dL and a hematocrit level of 28 g/dL. The nurse suspect which of the following types of anemia? A. Folic acid deficiency anemia B. Pernicious anemia C. Iron-deficiency anemia D. Sickle cell anemia

C. Iron-deficiency anemia Feedback: Iron-deficiency anemia results from poor gastrointestinal absorption of iron, a diet that is deficient in iron, or blood loss. The nurse should expect a client who has iron-deficiency anemia to have weakness, pallor, fatigue, reduced tolerance for activity, and cheilosis (ulcerations of the corners of the mouth).

A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection? A. Temperature 36.1° C (97.0° F) B. Insomnia C. Oliguria D. Weight loss

C. Oliguria Feedback: The nurse should identify little to no urine output as possible manifestations of kidney rejection.

A nurse is teaching a client who has acute kidney injury about the oliguric phase. Which of the following information should the nurse include in the teaching? A. Renal function is reestablished. B. BUN and creatinine levels decrease. C. Urine output is less than 400 mL per 24 hr. D. The glomerular filtration rate (GFR) recovers.

C. Urine output is less than 400 mL per 24 hr. Feedback: Inadequate urinary output is associated with the oliguric phase of acute kidney injury. The minimum amount of urine needed to rid the body of metabolic waste products is 400 mL. Therefore, a client who is producing less than 400 mL of output in 24 hr is manifesting acute kidney injury.

A nurse is reviewing the medication record for a client who has chronic kidney disease. Which of the following medications should the nurse identify as having the potential to cause nephrotoxicity? A. Diphenhydramine B. Ondansetron C. Vancomycin D. Mannitol

C. Vancomycin Feedback: The nurse should identify that vancomycin, an antibiotic, to be associated with nephrotoxic adverse effects.

A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching? A. Aplastic anemia is associated with a decreased intake of iron. B. Aplastic anemia results in an increased rate of RBC destruction. C. Aplastic anemia results in an inability to absorb vitamin B12. D. Aplastic anemia results from decreased bone marrow production of RBCs.

D. Aplastic anemia results from decreased bone marrow production of RBCs. Feedback: Aplastic anemia is a hypoproliferative anemia resulting from decreased production of RBC within the bone marrow.

A nurse is preparing a client for a kidney biopsy. Which of the following client conditions should the nurse identify as a contraindication for this diagnostic test? A. Elevated creatinine level B. Flank pain C. Urinary retention D. Bleeding tendencies

D. Bleeding tendencies Feedback: One of the risks of a kidney biopsy is bleeding from the biopsy site. Therefore, a history of bleeding tendencies or coagulation disorders is a contraindication for a kidney biopsy.

A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. His blood urea nitrogen (BUN) is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following nursing interventions is appropriate? A. Collect a urine specimen for culture and sensitivity. B. Continue routine care because the results are within the expected reference range. C. Decrease the IV fluid infusion rate and limit oral fluid intake. D. Evaluate urine for amount and for specific gravity.

D. Evaluate urine for amount and for specific gravity. Feedback: These results indicate that the client is dehydrated. Specific gravity and urine output measurements can support the laboratory findings. The higher the specific gravity, the more dehydrated the client.

A nurse is caring for a client who the provider suspects might have pernicious anemia. The nurse should expect the provider to prescribe which of the following diagnostic tests? A. Sweat test B. Haptoglobin C. Antinuclear antibodies D. Schilling test

D. Schilling test Feedback: The Schilling test helps determine the cause of vitamin B12 deficiency, which leads to pernicious anemia.

A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hr following a burn injury? A. Dextrose 5% in water B. Dextrose 5% in 0.9% sodium chloride C. 0.9% sodium chloride D. Lactated Ringer's

D. Lactated Ringer's Feedback: Lactated Ringer's is used in the first 24 hr following a burn injury because it is a crystalloid solution whose composition and osmolality most closely resembles plasma.

A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system? A. Auscultate cuff blood pressure. B. Palpate pulse pressure. C. Obtain a central venous pressure. D. Monitor the pulmonary artery pressure

D. Monitor the pulmonary artery pressure Feedback: Clients who have a large percentage of burned body surface area require critical care and accurate monitoring. The pulmonary artery pressure provides an accurate assessment of the cardiovascular system by detecting changes in both right and left heart pressure which can indicate possible development of pulmonary edema, as well monitor overall fluid status.

A nurse is caring for a client who is undergoing initial peritoneal dialysis. Which of the following should the nurse report immediately to the provider? A. Report of discomfort during dialysate inflow B. Blood-tinged dialysate outflow C. Dialysate leakage during inflow D. Purulent dialysate outflow

D. Purulent dialysate outflow Feedback: Peritonitis is an inflammation of the peritoneum and a major complication of peritoneal dialysis. Manifestations of peritonitis include cloudy dialysate outflow, fever, nausea, and vomiting. If untreated, the client can become severely ill, progressing to bacterial septicemia and hypovolemic shock. Peritonitis can be prevented with meticulous site care. The nurse and client should wear a mask when accessing the catheter. Strict aseptic technique should be used when connecting and disconnecting the catheter.

A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention? A. Auscultate the client's lungs. B. Assist the client to a side-lying position. C. Provide oral hygiene. D. Withhold oral fluids and food.

D. Withhold oral fluids and food. Feedback: To rest the pancreas and reduce secretion of pancreatic enzymes, NPO status must be initiated and maintained during the acute phase of pancreatitis. This is the priority intervention to address after the client's pain has been treated.