Med Surg EXAM 2 QUIZZES

A nurse at a provider's office receives a phone call from a client who reports unrelieved chest pain after taking a nitroglycerin (Nitrostat) tablet 5 minutes ago. Which of the following is an appropriate response by the nurse? Tell the client to take an aspirin. Instruct the client to call 911. Have the client take another nitroglycerin tablet in 15 min. Advise the client to come to office.

Instruct the client to call 911. The standard dosing regimen for nitroglycerin is one tablet sublingually. If anginal pain is not relieved after 5 min, the client should call 911 or go to the emergency department. An additional two tablets can be taken at 5 min intervals while awaiting emergency care. While taking an aspirin may not cause additional harm, with unrelieved chest pain this is not an appropriate response by the nurse. Having the client take another nitroglycerin tablet in 15 min or advising the client to come into the office delays needed treatment for the client, and is not appropriate.

A nurse is caring for a client who has congestive heart failure (CHF) and was started on digoxin (Lanoxin). Which of the following client statements should alert the nurse that the client may be experiencing a side effect of digoxin? "I can walk a mile a day." "I've had a backache ever since I got home." "I've lost half a pound in the last 2 days." "I feel nauseated and have no appetite."

"I feel nauseated and have no appetite." Anorexia, nausea, vomiting, and abdominal discomfort are early signs of digitalis toxicity. Improving the client's cardiac output, which in turn will improve the client's exercise tolerance, is a desired response to digoxin. Backaches are not related to the use of digoxin for CHF. A weight loss of half a pound is not significant and is not likely related to the use of digoxin.

A nurse is providing discharge instructions to a client who has congestive heart failure. Which of the following statements by the client indicates to the nurse that the teaching was effective? "I will do all of my activities in the morning and rest every afternoon." "I should attempt to exercise every day of the week." "I plan to slow down if I am tired the day after exercising." "I will take my diuretic before sleep and drink fluids during the day."

"I plan to slow down if I am tired the day after exercising." Clients who experience chest pain or dyspnea while exercising or experience fatigue the next day are probably advancing the activity too quickly and should slow down. Congestive heart failure results in decreased cardiac output. Clients should be encouraged to stay as active as possible without overdoing it. It might not be realistic for the client to do every activity in the morning without feeling tired, in which case the client should space out physical activity during the day. Clients with decreased cardiac output may not have the physical stamina to exercise on a daily basis. Therefore, the nurse should encourage the client to begin walking 200 to 400 feet per day. When at home, encourage the client to walk at least three times per week. The client should slowly increase the amount of time walked (perhaps 10 minutes a week) over several months. Clients should be advised to take diuretics in the morning to avoid waking during the night for voiding.

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI) and is reviewing the provider's orders. Which of the following prescriptions by the provider requires clarification? Morphine sulfate 2 mg IV bolus every 2 hr PRN pain Laboratory testing of serum potassium upon admission 0.9% normal saline IV at 50 mL/hr continuous PT and PTT Bumetanide (Bumex) 1 mg IV bolus every 12 hr

0.9% normal saline IV at 50 mL/hr continuous 0.9% sodium chloride is isotonic and will not cause the fluid shift needed in this client to reduce circulatory overload. Morphine sulfate is administered to clients with acute heart failure to reduce anxiety, decrease cardiac preload and afterload, slow respirations, and manage pain associated with MI. Serum potassium is monitored due to the use of diuretic therapy in a client with acute heart failure. Bumex, a loop diuretic, is administered as a first-line drug of choice for the client in acute heart failure.

A nurse is preparing teaching for a female client who smokes, is obese, and has hypertension. In establishing health promotion goals for the client, the nurse should recognize that which of the following is an inappropriate recommendation for the client? Eliminate sodium from the diet. Exercise moderately three times a week. Start a weight reduction diet. Use nicotine patches to stop smoking.

1 and 4, Eliminate sodium from the diet and Use nicotine patches to stop smoking. Eliminating sodium from the client's diet is not a reasonable goal. A diet appropriate for a hypertensive client will restrict intake of sodium, not eliminate it. Exercising moderately three times a week is an appropriate initial goal for an obese, hypertensive client. Starting a weight reduction diet to stop smoking are realistic goals for this client. Using nicotine patches to stop smoking is not recommended because any nicotine products can cause vasoconstriction which can make the PAD get worse.

A nurse is caring for a client who was admitted to the hospital with congestive heart failure (CHF) and is taking digoxin (Lanoxin) 0.25 mg daily. The client refused breakfast and is complaining of nausea and generalized weakness. Which of the following actions should the nurse perform first? Check the client's vital signs. Request a dietitian consult. Suggest that the client rests before eating the meal. Request an order for an antiemetic.

Check the client's vital signs. It is possible that the client's nausea is secondary to digoxin toxicity. By obtaining vital signs, the nurse can assess for bradycardia, which is a symptom of digoxin toxicity. The nurse should withhold the drug and call the provider if the client has bradycardia. All other options may be appropriate, but are not the priority action.

A nurse is obtaining informed consent from a client prior to surgery. Which of the following is necessary for informed consent to be valid? (Select all that apply.) A client's ability to pay for the consented surgical procedure. A client's ability to read the consent form. Disclosure of the treatment is provided. Client understands the surgical procedure. Voluntary consent is given.

Disclosure of the treatment is provided, Client understands the surgical procedure and Voluntary consent is given. The client's ability to pay for the consented surgical procedure is not related to informed consent. It is also not necessary for the client to personally read the consent form. The client should be informed of treatment that is to be provided as well as the risks. The client should understand the surgical procedure as well as the risks. Informed consent protects the client, provider, and institution/employees. The client should give voluntary consent without influence for the procedure.

A nurse is assessing a client who has an acute myocardial infarction (MI). Which of the following clinical manifestations should the nurse expect to find? (Select all that apply.) Orthopnea Headache Nausea Tachycardia Diaphoresis

Nausea, Tachycardia and Diaphoresis Orthopnea is a manifestation of heart failure, which can develop from a myocardial infarction, but it is not a common manifestation of acute MI. Chest pain and sometimes jaw and shoulder pain, not headache, are classic manifestations of acute MI. Nausea, vomiting, tachycardia, dysrhythmias profuse sweating and anxiety are also classic manifestations of acute MI.

A client who has a history of myocardial infarction (MI) is prescribed aspirin (Ecotrin) 325 mg. The nurse correctly understands that the aspirin is ordered due to its action as an... analgesic. anti-inflammatory. antiplatelet aggregate. antipyretic.

antiplatelet aggregate. Aspirin is used to prevent blood from clotting. It also is used to reduce the risk of a second heart attack or stroke by reducing blood clotting in an artery, a vein, or the heart. Although aspirin does have an analgesic, anti-inflammatory and antipyretic effect, cardiac clients who take 325 mg daily are taking it for a different purpose.

A nurse is caring for a client who is scheduled for cardiac surgery, has an advance directive health care proxy form, and asks for clarification regarding the form. Which of the following responses by the client should indicate a need for clarification? "I can cancel or change my health care proxy at any time." "My health care and end-of-life choices will be made by my proxy." "The person designated as my health care proxy is legally obligated to abide by the wishes set forth in my living will." "The health care proxy does not go into effect until I am incapable of making decisions."

"The person designated as my health care proxy is legally obligated to abide by the wishes set forth in my living will." An advance directive is NOT a legal document. The health care proxy is MORALLY bound to follow the wishes of the client, not LEGALLY. All the other options are correct statements regarding a health care proxy.

A nurse provides health screening education to a group of clients. Which of the following clients has the greatest risk for hypertension? A 56-year old Chinese male. A 62-year-old Jewish female A 53-year-old Spanish female A 65-year-old African American male

A 65-year-old African American male The incidence of hypertension is higher in African Americans than in European Americans. African Americans tend to develop more severe hypertension at an earlier age and have twice the risk for complications, such as stroke and heart attack. Hypertension-related deaths are also higher among African Americans. An adult's blood pressure tends to rise with advancing age. Older adults often have a rise in systolic pressure related to decreased vessel elasticity. Blood pressure greater than 140/90 mm Hg is defined as hypertension and increases an older adult's risk for hypertension-related illnesses.

A nurse is giving discharge instructions to a client who had an internal repair of a right hip fracture. The nurse knows that teaching has been effective when the client tells her that he will rest during the day sitting on which of the following pieces of furniture? A reclining chair with an ottoman A straight-backed chair with an elevated seat A couch with plush cushions A rocking chair with a curved back

A straight-backed chair with an elevated seat A straight-backed chair with an elevated seat allows the client to assume proper positioning when sitting. An elevated seat decreases the risk of his hip dislocation. All other positions may increase the risk of hip dislocation.

In preparation for the discharge of a client with peripheral arterial disease (PAD), the nurse should include which of the following instructions? Apply a heating pad on a low setting to help relieve leg pain. Adjust the thermostat so that the environment is warm. Wear antiembolic stockings during the day. Rest with the legs above heart level.

Adjust the thermostat so that the environment is warm. The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will help prevent vasoconstriction. Clients who have PAD should not apply heat directly to a limb because sensation is diminished and burns could result. Clients who have PAD should not wear any constrictive clothing. Extreme elevation of the legs can slow the flow of arterial blood to the feet.

A nurse is caring for a client following arthroscopic knee surgery. To prevent postoperative complications, the nurse should have the client do which of the following? Remain on bedrest for the first 24 hrs. Keep the leg in a dependent position. Apply ice to the affected area. Begin active range of motion.

Apply ice to the affected area. Arthroscopy is a surgical procedure used to visualize, diagnose and treat problems inside a joint. Applying ice to the affected area in the immediate postoperative period reduces pain and swelling. When the client has recovered from sedation, the client will be allowed to walk, as tolerated, but should be instructed not to overuse or strain the joint for a few days. Elevating the affected area in the postoperative period reduces pain and swelling. Although the client will be allowed to walk as tolerated, joint use should be minimized for the first few days to reduce postoperative pain and swelling.

A nurse is assessing a client who will undergo abdominal surgery in 2 hr. The nurse finds that the client has mild anxiety about the surgery, last had food and fluids at 2330 the previous evening, and signed the surgical consent 2 days ago. Which of the following is an appropriate nursing action regarding these findings? Call the anesthesiologist to sedate the client. Notify the surgeon of the client's food and fluid consumption. Witness the surgical consent. Document the findings in the client's medical record.

Document the findings in the client's medical record. Whenever a nurse collects data from a client, documentation is essential. However, in this case, all these findings are expectations for a client who is preoperative, so there is no need for the nurse to take any action other than documenting. Mild preoperative anxiety is an expected finding. There is no need to sedate the client at this time. As long as the client has not ingested food or fluids after midnight, there is no need to notify the surgeon. The nurse may only witness a client's signature when the nurse is present at the signing. If there was no witness present, the nurse should notify the surgeon, who will then have to obtain a witnessed consent.

A nurse is caring for a client who is postoperative following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus? Positive Kernig's sign. Positive Homan's sign. Dull, aching calf pain. Soft, pliable calf muscle.

Dull, aching calf pain. Dull, aching calf pain is a sign of deep-vein thrombosis. Other manifestations are edema, warmth, and redness in the calf. Kernig's sign indicates meningeal irritation. Homan's sign is unreliable as only a small percentage of clients who have a thrombus develop it, and performing it could mobilize the clot. A thrombus is more likely to cause muscle rigidity than a soft and pliable muscle.

A nurse is preparing to administer IV therapy to a client who is compromised. Which of the following are clinical manifestations of left-sided heart failure. (Select all that apply.) Dyspnea Gastrointestinal bloating Jugular vein distention Orthopnea Paroxysmal nocturnal dyspnea

Dyspnea, Orthopnea and Paroxysmal nocturnal dyspnea Dyspnea, orthopnea and paroxysmal nocturnal dyspnea are clinical manifestations of left-sided heart failure. Gastrointestinal bloating and jugular vein distention are clinical manifestations of right-sided heart failure.

A nurse is planning care for a client following surgery who is having headaches due to receiving spinal anesthetic. Which of the following is included in the plan of care? Encourage increased intake of fluids. Encourage increased physical activity. Maintain the client in high Fowler's position. Apply an ice bag at the injection site of the spinal anesthetic.

Encourage increased intake of fluids. Increased oral fluid intake promotes DECREASES intracranial pressure which may relieve spinal headaches. Decreased, not increased, physical activity is helpful in relieving spinal headaches. Keeping the client flat, not in high fowlers, is helpful in relieving spinal headaches. A cold pack at the injection site may decrease pain in this area but does not relieve a spinal headache.

A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the responsibility of the nurse? Assess the current health status of the client. Explain the operative procedure, risks, and benefits. Review preoperative laboratory tests results. Ensure that a signed surgical consent form was completed.

Explain the operative procedure, risks, and benefits. Explaining the procedure and any risks that may be associated with the procedure is the responsibility of the person performing the procedure. This is not a nursing responsibility.

A client complains of shortness of breath and chest pain the first day following multiple long bone fractures. The nurse would consider which of the following client complications when assessing the client? Pneumonia Fat emboli Cardiac dysrhythmia Hypoxic condition

Fat emboli The client with a compound long bone fracture is at high risk for developing a fat embolus within 24 to 96 hours, which may lead to cardiac dysrhythmia or a hypoxic condition.

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect? Frothy sputum Dependent edema Nocturnal polyuria Jugular distention

Frothy sputum Left-sided heart failure reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking cough, frothy sputum, wheezing, fatigue, and weakness. Dependent edema, Nocturnal polyuria and Jugular distention all indicate right-sided heart failure.

A nurse is caring for a client who has heart failure and has a potassium level of 2.4 mg/dL. An adverse effect of which of the following medications is a possible cause of this potassium level? Furosemide (Lasix) Nitroglycerin (Nitro-Bid) Metoprolol (Lopressor) Spironolactone (Aldactone)

Furosemide (Lasix) Anorexia, nausea, vomiting, and abdominal discomfort are early signs of digitalis toxicity. Improving the client's cardiac output, which in turn will improve the client's exercise tolerance, is a desired response to digoxin. Backaches are not related to the use of digoxin for CHF. A weight loss of half a pound is not significant and is not likely related to the use of digoxin.

A client comes to the emergency department via ambulance to report severe radiating chest pain and shortness of breath. The client appears restless, frightened, and slightly cyanotic. The provider prescribes oxygen by nasal cannula at 4 L/min stat, cardiac enzyme levels, IV fluids, and a 12-lead ECG. Which of the following actions should the nurse take first? Attach the leads for a 12-lead ECG Obtain the blood sample. Initiate oxygen therapy. Begin IV fluid infusion.

Initiate oxygen therapy. The greatest risk to the client's safety is myocardial ischemia. Thus the priority is to administer oxygen to help minimize this. It is important to determine the client's heart rhythm and cardiac enzyme levels and to begin the IV fluid infusion, but these are not the highest priorities at this time.

A nurse is caring for a client with peripheral arterial disease (PAD). Which of the following symptoms is typically the initial reason clients with PAD seek medical attention? Intermittent claudication Dependent rubor Rest pain Foot ulcers

Intermittent claudication Intermittent claudication is ischemic pain that is precipitated by exercise, resolves with rest, and is reproducible. The pain associated with claudication arises when cellular oxygen demand exceeds supply, and is typically the initial reason clients with PAD seek medical attention. Dependent rubor, rest pain and foot ulcers are manifestations that occur in later stages of chronic PAD.

A nurse is preparing a presentation at a community center about knee disorders and injuries. The nurse should include which of the following as risk factors for developing osteoarthritis? (Select all that apply.) Obesity Family history of osteoarthritis Calcium deficiency Aging Regular, strenuous exercise

Obesity, Family history of osteoarthritis, aging and Regular, strenuous exercise

A nurse is caring for a client who enters the emergency department of severe chest pain. Which of the following interventions should the nurse implement to determine if the client is experiencing a myocardial infarction? Check the client's blood pressure. Auscultate heart tones. Perform a 12-lead ECG Determine if pain radiates to the left arm.

Perform a 12-lead ECG The nurse should perform a 12-lead ECG when a client complains of chest pain to determine if the client is experiencing a myocardial infarction. The nurse should check the client's vital signs and auscultate heart tones when chest pain is present, however, these findings will not determine if the client is experiencing a myocardial infarction. The nurse should also identify the location of pain as part of a complete assessment, however radiation to the left arm can be present in other conditions and therefore does not indicate that the client is experiencing a myocardial infarction.

A nurse is caring for a client who receives furosemide (Lasix) to treat heart failure. Which of the following laboratory values should the nurse be sure to monitor specifically for this client? Potassium Albumin Chloride Bicarbonate

Potassium Furosemide is a loop diuretic that promotes the excretion of potassium. The nurse should monitor the client's potassium level to watch for hypokalemia.

A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client has had intermaxillary fixation to repair and stabilize the fracture. The nurse should recognize that the most important goal in the immediate postoperative period is to do which of the following? Prevent aspiration. Ensure adequate nutrition. Promote oral hygiene. Relieve the client's pain.

Prevent aspiration. Because the jaws are wired together, if the client should vomit, aspiration of the emesis is a possibility. Therefore, the client should be given medication for nausea, as indicated, and wire cutters should be kept at the bedside, in case of vomiting. The client will be NPO (nothing by mouth) initially after surgery until the gag reflex has returned. Once the client is able to eat, the client will advance to a calorie-appropriate, high-protein liquid diet. While it is important that the client receive frequent mouth cleaning and adequate nutrition and may be in pain and will need to be medicated, these are not the most important concerns in the immediate postoperative period.

A nurse in a clinic is caring for a client who is postmenopausal and asks about medication to prevent osteoporosis. The nurse anticipates the client will be given a prescription for which of the following medications by the nurse practitioner? Levothyroxine (Synthroid) Calcitonin (Miacalcin) Raloxifene hydrochloride (Evista) Alendronate sodium (Fosamax)

Raloxifene hydrochloride (Evista) Raloxifene hydrochloride is prescribed for prevention of osteoporosis in postmenopausal women. Levothyroxine is prescribed to treat hypothyroidism. Calcitonin is prescribed to delay bone resorption in women who already have osteoporosis. Alendronate sodium is prescribed to increase bone mass in woman who already have osteoporosis.

A nurse is caring for a client who is one week postoperative following abdominal surgery. While changing the client's abdominal dressing the nurse notes the presence of serosanguineous drainage. The nurse should recognize which of the following? Serosanguineous drainage at this time is expected after abdominal surgery. Serosanguineous drainage at this time is a manifestation of possible dehiscence. Serosanguineous drainage at this time is a manifestation of hemorrhage. Serosanguineous drainage at this time is a manifestation of infection.

Serosanguineous drainage at this time is a manifestation of possible dehiscence. Serosanguineous drainage beyond the fifth postoperative is a manifestation of possible dehiscence and the provider should be notified. Serosanguineous drainage is not expected one week after abdominal surgery. Yellow crusting and a pink color to the incision line are expected at this time frame. Serosanguineous drainage is not a manifestation of hemorrhage or infection. Serosanguineous drainage is serum-like or yellow in color, instead of the thick, yellow pus considered a manifestation of infection.

A client who is 2 days postoperative following abdominal surgery is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray? Cranberry juice Flavored gelatin Skim milk Chicken broth

Skim milk Full liquids include milk and milk products, so the client may now ask for skim milk. All other options are a liquid diet.

A nurse is reviewing the causes of osteoporosis with a group of nursing students. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis? Thyroid hormones Warfarin NSAIDS Cardiac glycosides

THYROID HORMONES Long-term use of synthetic thyroid hormone, such as levothyroxine (Synthroid), can accelerate bone loss. Anticoagulants such as warfarin can cause blood loss, not bone loss. Long-term use of heparin can cause osteoporosis. NSAIDs do not cause bone loss, although they can cause many other adverse effects, such as gastrointestinal bleeding. Cardiac glycosides can cause muscle weakness, but not bone loss.

A client who has just had abdominal surgery returns to the unit from the postanesthesia care unit with an IV fluid infusion and an NG tube in place. Which of the following is the assessment priority for the nurse who is caring for the client? The IV catheter insertion site. The level of the client's pain. The surgical dressing. The patency of the NG tube.

The surgical dressing Although priorities may shift with the type of surgery and the client's postoperative status, in general, the greatest risk to the client's safety of these options immediately after surgery is HEMORRHAGE. Thus the nurse's priority assessment is the surgical dressing for bleeding

A nurse is providing teaching for a client who is preparing for a below the knee amputation. Which of the following statements is appropriate regarding the postoperative placement of a prosthesis? "The prosthesis will be in place immediately following surgery to... improve your ability to ambulate sooner." decrease the chance of phantom limb pain." decrease the frequency of dressing changes." improve the fit of the prosthesis."

improve your ability to ambulate sooner." The nurse correctly explains that the purpose of a prosthesis immediately following surgery is to promote postoperative ambulation.

A nurse is caring for a client with a compression fracture of a spinal vertebra. Just prior to an hour-long transport to the hospital, the client was medicated with intravenous morphine sulfate (Duramorph). On arrival, the neurosurgeon determines that urgent surgical intervention is indicated for the fracture. The nurse realizes that consent for the surgery... must be obtained from a relative of the client. can be inferred since the client consented to the transport. should be obtained from the client immediately. will be delayed until the morphine is metabolized.

must be obtained from a relative of the client. According to the case scenario, this client was given a narcotic that can alter his ability to understand within the subsequent 1 to 2 hours. Consequently, this client is not legally able to provide consent. Delaying consent until the morphine is metabolized could be dangerous to the client and may increase the chance of a life-long disability

A nurse is caring for a preoperative client who is sedated and awaiting surgery. While reviewing the client's preoperative forms, the nurse notes that the consent form has been signed by the client but has not been witnessed. The nurse should... proceed with client preparation because the signed form is valid without a witness. ask the client to resign the form so that the nurse can sign as the witness. sign as a witness after verifying the client's signature with the client. notify the nurse manager and the provider.

notify the nurse manager and the provider. The surgery cannot be performed without a signed, witnessed consent form. The nurse manager and the provider should be informed of the situation. Unless the original witness can be found and her signature obtained, a decision may be made to delay the surgery until the sedation wears off and the client can legally sign in the presence of a witness.

A nurse is caring for a client who has a fractured right hip and a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the purpose of this device is to... prevent fluid from accumulating in the wound. prevent bleeding from the surgical site. prevent the development of a wound infection. eliminate the need for wound irrigations.

prevent fluid from accumulating in the wound. The purpose of a JP drain is to promote healing by draining fluid from the wound. This prevents pooling of blood and fluid, which could contribute to discomfort, delay healing and provide a medium for infection. The JP drainage tube is threaded through the skin into the wound near the surgical incision and is held in place by sutures.

A nurse is preparing a client for surgery. She should begin preoperative teaching by exploring... what the client knows about the surgery. the client's usual coping mechanisms. the client's current home environment. which family members will help with postoperative care.

what the client knows about the surgery. The first step in client instruction is to determine the client's LEARNING NEEDS The nurse does this by determining what the client needs to know, in this case, about the perioperative experience. All of the other options will be done, but they are not the first step in initiating a preoperative discussion.