Advanced Med surg week 1 & 2 practice

a nurse is teaching a client about using a PCA device for postop pain management. Which of the following statements should the nurse make? "You will have control of administering your own pain medication." "The pain medication is delivered into your muscle." "A large dose of pain medication is administered with each injection." "Your partner can push the PCA button for you if you are asleep."

"You will have control of administering your own pain medication."

a nurse is caring for a client who develops PE. Which of the following interventions should the nurse implement first? Give morphine IV. Administer oxygen therapy. Start an IV infusion of lactated Ringer's. Initiate cardiac monitoring.

Administer oxygen therapy.

a nurse is caring for a client who is well-hydrated and who demonstrates no evidence of anemia. Which of the following lab values gives the nurses an assessment of the adequacy of the client's protein uptake and synthesis? Albumin Calcium Sodium Potassium

Albumin Albumin levels reflect the overall body protein status and is used to detect metabolic and liver dysfunction.

a nurse is caring for a client who is postop following knee arthroplasty and has a continuous passive motion (CPM) machine, which of the following actions should the nurse take? Store the CPM machine on the floor when not in use. Use a special pillow to rotate the affected knee internally. Set the CPM to fully flex the knee joint. Apply ice to the operative knee.

Apply ice to the operative knee. The nurse should apply ice to the client's operative knee to reduce edema postoperatively, which will decrease pain and bruising.

a nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports N/V. which of the following actions should the nurse take? Insert a nasogastric tube. Administer an antiemetic. Encourage use of the incentive spirometer. Auscultate bowel sounds.

Auscultate bowel sounds. Using the nursing process, assessing for the presence or absence of bowel sounds and the passage of flatus is an appropriate action at this time. Determining the cause of the nausea and reducing contributing factors should precede any treatment.

a nurse is planning care for a client who is to receive competitive neuromuscular blocking agent. Which of the following items should the nurse plan to have at the client's bedside? Bag-valve-mask device Temporary pacemaker Urinary catheter insertion tray Central venous catheterization tray

Bag-valve-mask device Competitive neuromuscular blocking agents prevent acetylcholine from activating receptors on the skeletal muscles and cause muscle relaxation. These agents can cause respiratory arrest due to relaxation of the respiratory muscles. The nurse should have a bag-valve-mask device, endobrachial intubation equipment, and oxygen at the bedside of a client who is receiving this medication to reduce the risk for respiratory arrest.

a nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia? Position the head of the client's bed in the flat position. Turn the client every 4 hr. Brush the client's teeth with a suction toothbrush every 12 hr. Provide humidity by maintaining moisture within the ventilator tubing.

Brush the client's teeth with a suction toothbrush every 12 hr.

a nurse is caring for a client is receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale from 0 to 10. Which of the following actions should the nurse take first? Administer a bolus of medication. Check the display on the PCA pump. Obtain an order for another pain medication for breakthrough pain. Encourage the client to administer a demand dose.

Check the display on the PCA pump.

a nurse in a provider's office is assessing an older adult client whose son reports that the client has been sick with resp illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client? Bradycardia Night sweats Confusion Narrowed pulse pressure

Confusion Confusion, weakness and anorexia are manifestations of pneumonia in an older adult client.

A nurse is assessing a client who has chronic kidney disease. Which of the following findings is a manifestation of hyperkalemia? Wheezing Hypoactive bowel sounds Cerebral edema Decreased deep tendon reflexes

Decreased deep tendon reflexes Hyperkalemia can cause decreased deep tendon reflexes, paralysis, and dysrhythmias.

a nurse is assessing a client who is 1 day postop following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention? Chest tube eyelets not visible Continuous bubbling in the suction control chamber Presence of tidal fluctuation in the water seal chamber Development of subcutaneous emphysema

Development of subcutaneous emphysema Subcutaneous emphysema is an indication that air is trapped in and under the skin, which be the result of a pneumothorax and should be reported to the provider.

a nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? Encourage the client to ambulate frequently. Encourage coughing and deep breathing. Encourage the client to increase fluid intake. Encourage regular use of the incentive spirometer.

Encourage the client to increase fluid intake. Increasing fluid intake to1,500 to 2,500 mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the client's ability to cough and remove the secretions.

a nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions? Intracranial pressure Spinal cord perfusion Renal function Hemodynamic status

Hemodynamic status A pulmonary artery catheter is inserted into the pulmonary artery and monitors a client's hemodynamic status by measuring pulmonary artery pressures and cardiac output.

a nurse is teaching a group of newly licensed nurses about the progressive nature of Alzheimer's disease. which of the following should the nurse include in the teaching as a manifestations seen in the moderate stage of alzheimer's disease? SATA Inability to find commonly used items Inability to perform common tasks Difficulty with talking or reading Difficulty remembering how to swallow Inability to recognize family members

Inability to perform common tasks Difficulty with talking or reading

a nurse is caring for a confused client who has Alzheimer's disease. Which of the following actions should the nurse take? Turn the television on at all times. Hang abstract pictures on the walls. Keep familiar personal items at the bedside. Encourage bright glaring lighting in the room.

Keep familiar personal items at the bedside.

a nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider? Movement of the trachea toward the unaffected side Bubbling of the water in the water seal chamber with exhalation Crepitus in the area above and surrounding the insertion site Eyelets are not visible

Movement of the trachea toward the unaffected side A chest tube inserted for a spontaneous pneumothorax may result in the development of a tension pneumothorax, a medical emergency. This results from air in the pleural space compressing the blood vessels of the thorax and limiting blood return to the heart. An assessment of tracheal deviation, or movement of the trachea toward the unaffected side, is indicative of tension pneumothorax and should be reported to the provider immediately.

A nurse is caring for a client who is placed on supplemental oxygen for hypoxia. The nurse should identify that which of the following findings indicate the intervention was effective? Respiratory rate 28/min Pink mucous membranes Restlessness Heart rate 110/min

Pink mucous membranes

a nurse is planning care for a client who has acute resp distress syndrome (ARDS). which of the following interventions should the nurse include in the plan? Administer low-flow oxygen continuously via nasal cannula. Encourage oral intake of at least 3,000 mL of fluids per day. Offer high-protein and high-carbohydrate foods frequently. Place in a prone position.

Place in a prone position. Oxygenation in clients who have ARDS is improved when placed in the prone position. Frequent and consistent turning of the client is also beneficial and can be accomplished by the use of specialty beds.

a nurse is reviewing the lab data on a client who has a new prescription for heparin for treatment of a pulmonary embolism. Which of the following data should the nurse report to the provider? Hematocrit 45% Partial thromboplastin time (PTT) 65 seconds White blood cell count 8,000/mm3 Platelets 74,000/mm3

Platelets 74,000/mm3

a nurse is caring for a client who has ARDS, and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes? Decrease chest wall compliance Suppress respiratory effort Induce sedation Decrease respiratory secretions

Suppress respiratory effort Neuromuscular blocking agents, such as pancuronium, induce paralysis and suppress the client's respiratory efforts to the point of apnea, allowing the mechanical ventilator to take over the work of breathing for the client. This therapy is especially helpful for a client who has ARDS and poor lung compliance.

a nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect? Bradypnea Somnolence Pallor Tachycardia

Tachycardia

A nurse is reviewing the client's medical record. Which of the following prescriptions should the nurse anticipate for a client who has a pneumothorax? For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

anticipated - Obtain ABGs. Prepare for insertion of a chest tube. Obtain intravenous access. nonessential - Computed tomography (CT) of the chest. Pulmonary Function Tests (PFTs). contraindicated - Thoracentesis

a nurse is reviewing the ABG results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? pH below 7.35 HCO3 above 26 mEq/L PaO2 below 70 mm Hg PaCO2 above 45 mm Hg

pH below 7.35

a nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5L/min via nasal cannula. Which of the following actions should the nurse take? Attach a humidifier bottle to the base of the flow meter. Remove the nasal cannula while the client eats. Secure the oxygen tubing to the bed sheet near the client's head. Apply petroleum jelly to the nares as needed to soothe mucous membranes.

Attach a humidifier bottle to the base of the flow meter.

a nurse is caring for a client who is unconscious and has a breathing patter characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations? Kussmaul respirations Apneustic respirations Cheyne-Stokes respirations Stridor

Cheyne-Stokes respirations Cheyne-Stokes respirations (CSR) are characterized by a rhythmic increase (to the point of hyperventilation) and decrease (to the point of apnea) in the rate and depth of respiration. CSR are common respiratory alterations seen in clients who are unconscious, comatose, or moribund (approaching death).

the nurse is caring for a postop client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly? Fluctuation of the fluid level within the water seal chamber Absence of fluid in the drainage tubing Continuous bubbling within the water seal chamber Equal amounts of fluid drainage in each collection chamber

Fluctuation of the fluid level within the water seal chamber

a nurse is caring for a client who has just developed a PE. Which of the following medications should the nurse anticipate administering? Furosemide Dexamethasone Heparin Atropine

Heparin

a nurse is evaluating the Central Venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make? Fluid overload Left ventricular failure Intracardiac shunt Hypovolemia

Hypovolemia A low CVP indicates reduced right ventricular preload, which can be seen in clients who are experiencing hypovolemia, excessive blood loss, or overdiuresis.

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take? Clamp the chest tube prior to transferring the client to a wheelchair. Disconnect the chest tube from the drainage system during transport. Keep the drainage system below the level of the client's chest at all times. Empty the collection chamber prior to transport.

Keep the drainage system below the level of the client's chest at all times. During transport, the drainage system should be kept below the level of the client's chest to prevent air and drainage fluid from re-entering the thoracic cavity.

A nurse is assessing a client who has diarrhea. Which of the following findings is a manifestation of hypokalemia? Hypertension Hyperactive bowel sounds Muscle weakness Cerebral edema

Muscle weakness Hypokalemia can cause muscle weakness, hypotension, and dysrhythmias. hypoactive bowel sounds and constipation.

a nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded? Oxygen saturation of 95% No fluctuations in the water seal chamber No reports of pleuritic chest pain Occasional bubbling in the water-seal chamber

No fluctuations in the water seal chamber Fluctuation stops when the lung has re-expanded, but the nurse should check for other indications of re-expansion, such as equal breath sounds bilaterally, because fluctuation can also stop when the tubing is obstructed, a dependent loop hangs below the rest of the tubing, or the suction source is not functioning.

a nurse is caring for an antepartum client who has iron deficiency anemia. When teaching the client about nutrition, the nurse should emphasize the need for an increased intake of which of the following foods? Milk and cheese Red meat and organ meat Fresh fruits Whole grain breads

Red meat and organ meat

a nurse is caring for a client who has an acute resp failure (ARF). the nurse should monitor the client for which of the following manifestations of this condition? SATA. Severe dyspnea Nausea Decreased level of consciousness Headache Hypotension

Severe dyspnea Decreased level of consciousness Headache Hypotension

a nurse is assessing a client who is receiving dopamine IV to treat left ventricular failure. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect? Systolic blood pressure is increased Cardiac output is reduced Apical heart rate is increased Urine output is reduced

Systolic blood pressure is increased When dopamine has a therapeutic effect, it causes vasoconstriction peripherally and increases systolic blood pressure.

a nurse is assessing a client who has hypokalemia as a result of N/V, and diarrhea. Which of the following findings should the nurse expect? Hyperactive reflexes Extreme thirst Weak, irregular pulse Hyperactive bowel sounds

Weak, irregular pulse Common manifestations of potassium depletion include a weak and irregular pulse, muscle weakness, fatigue, and ventricular dysrhythmias.

a nurse is reviewing the ABG results for a client in the ICU who has kidney failure and determines the client has resp acidosis. Which of the following findings should the nurse expect? Widened QRS complexes Hyperactive deep tendon reflexes Bounding peripheral pulses Warm, flushed skin

Widened QRS complexes A client who has respiratory acidosis is likely to cardiac changes from delayed electrical conduction through the heart, such as widened QRS complexes, tall T waves, prolonged PR intervals, and a heart rate that ranges from bradycardia to heart block.

a nurse is caring for a client who just had a flexible bronchoscopy. Which of the following nursing actions is appropriate? Withhold food and liquids until the client's gag reflex returns. Irrigate the client's throat every 4 hr. Have the client refrain from talking for 24 hr. Suction the client's oropharynx frequently.

Withhold food and liquids until the client's gag reflex returns.

a nurse is caring for a client who is 12 hr postop and has a chest tube to a disposable water-seal drainage system with suction. the nurse should intervene for which of the following observations? Constant bubbling in the suction-control chamber Continuous bubbling in the water-seal chamber Bloody drainage in the collection chamber Fluid-level fluctuations in the water-seal chamber

Continuous bubbling in the water-seal chamber Continuous or excessive bubbling in the water-seal chamber indicates an air leak between the water seal and the client's chest. However, gentle bubbling on forceful exhalation or coughing is normal.

A nurse is assessing a client who has a pleural effusion. Which of the following findings should the nurse expect? Dullness percussed over the client's lung fields. Crepitus palpated on the client's chest. Substernal retractions noted on the client's chest. Crackles auscultated over the client's lung fields.

Dullness percussed over the client's lung fields.

a nurse is reviewing the lab values of a client who has resp acidosis. Which of the following findings should the nurse expect? HCO3- 30 mEq/L PaCO2 50 mm Hg pH 7.45 Potassium 3.3 mEq/L

PaCO2 50 mm Hg

a nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect? HCO3- 30 mEq/L PaCO2 50 mm Hg pH 7.45 Potassium 3.3 mEq/L

PaCO2 50 mm Hg

a nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the teaching? "If my breathing begins to feel tight, I will use the cromolyn immediately." "I will be sure to take the albuterol before taking the cromolyn." "I will use both medications immediately after exercising." "I will administer the medications 10 minutes apart."

"I will be sure to take the albuterol before taking the cromolyn." The client should always use the bronchodilator (albuterol) prior to using the leukotriene modifier (cromolyn). Using the bronchodilator first allows the airways to be opened, ensuring that the maximum dose of medication will get to the client's lungs.

A nurse is providing preoperative teaching to a client about pain management using a patient-controlled analgesia (PCA) system. Which of the following 3 statements should the nurse include? "Push the button on the PCA prior to your pain level becoming severe so you can remain comfortable." "Your family member should push the PCA button for you while you are sleeping." "Using the PCA regularly will provide a consistent level of pain relief." "There is minimal risk of an overdose of pain medication while using the PCA pump." "You will still have to request pain medication from the nurse from time to time."

"Push the button on the PCA prior to your pain level becoming severe so you can remain comfortable." "Using the PCA regularly will provide a consistent level of pain relief." "There is minimal risk of an overdose of pain medication while using the PCA pump."

a nurse is teaching a client about how to use a PCA pump. Which of the following instructions should the nurse include in the teaching? "Use the pain scale to determine if you need to self-administer." "Ask a family member to push the patient-control button when the client is sleeping." "There is a 30 minute lock-out limit programmed on your PCA pump." "Several bolus doses are infused if the button is pushed repeatedly within a 5 to 10 minute timeframe before lock-out."

"Use the pain scale to determine if you need to self-administer."

a nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately? Serosanguineous drainage from the puncture site Discomfort at the puncture site Increased heart rate Decreased temperature

Increased heart rate Clients are at risk for developing pulmonary edema or cardiovascular distress due mediastinal content shift after the aspiration of a large amount of fluid from the client's pleural space. Therefore, the client may experience an increase in heart and respiratory rate, along with coughing with blood-tinged frothy sputum, and tightness in the chest. These findings require notification of the provider immediately.

a nurse is assessing a client who is receiving a continuous IV infusion of dopamine. Which of the following findings should the nurse recognize as a therapeutic effect? Increased pulse Increased urine output Decreased blood pressure Decreased dysrhythmias

Increased urine output Dopamine is used for the treatment of shock and heart failure. It increases cardiac output by increasing myocardial contractility. This medication also dilates renal blood vessels, which increases renal perfusion and leads to an increase in the client's urinary output. This finding should indicate to the nurse a therapeutic effect has been achieved.

A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect? Abdominal pain Numbness of fingers Dry skin Lethargy

Lethargy Manifestations of respiratory acidosis can include anxiety, confusion, and lethargy.

A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take? Tape the connections on the client's chest tube. Strip the client's chest tube every 2 hrs. Loop the tubing of the chest tube on the client's bed. Place the chest tube drainage system above the level of the client's heart.

Tape the connections on the client's chest tube.