MEDSURG QUIZ 4

A 52 years old woman has a papule on her nose that has rounded pearly borders and a central red ulcer. She said first noticed it several months ago and that it has slowly grown larger . The nurse suspects which condition.

basal cell carcinoma

Which assessment finding indicates that the nurse should take immediate action for an older patient?

bilateral basilar crackles

The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement , if made by the patient indicates that yhe teaching was successful

"I will keep my head elevated for 48 hours to minimize swelling

A patient schedule for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse. will i be able talk normally after surgery. what is the most accurate response by the nurse?

"You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration."

A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.)

. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth.

A nurse uses the rule of ninesto assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the clients body that sustained burns?

27%

A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first?

airway patency

A nurse assesses patients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea?

A 55-year-old woman who is 50 pounds overweight

A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development?

A 65-year-old with hemi-paralysis and incontinence

The nurse observes that a patient with respiratory disease experiences a decrease in SpO2 FROM 93% TO 88 % while the patient is ambulating. What is the priority action of the nurse?

Administer PRN supplemental O2.

Which action should the nurse take first when a patient develops epistaxis.

Apply squeezing pressure to the nostrils for 10 minutes

A patient has multiple areas of ecchymosis on both arms. Which question should the nurse ask first?

Are you taking any medication

After a laryngectomy, a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first

Attempt to reinsert the tracheostomy tube with the obturator in place.

A man has become in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notice several areas of pigmentation that look gravity, dark and stuck on his skin. Which is the best description of these.

Seborrheic keratoses, which do not become cancerous

The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination?

Change gloves between wound care on different parts of the clients body.

A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next?

Collect the nasal drainage on a piece of filter paper.

Which is the major muscle of respiration

Diaphragm muscle

A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.)

Ecchymosis behind the ear stridor

22. A nurse reviews the following data in the chart of a client with burn injuries: Admission Notes Wound Assessment 36-year-old female with Bilateral leg burns present bilateral leg burns NKDA Health history of asthma and seasonal allergies with a white and leatherlike appearance. No blisters or bleeding present. Client rates pain 2/10 on a scale of 0- 10. Based on the data provided, how should the nurse categorize this clients injuries?

Full thickness

A nurse plans care for a client who has a wound that is not healing. Which focused assessments should the nurse complete to develop the clients plan of care? (Select all that apply.)

Height Alcohol use d. Prealbumin laboratory results

A nurse assesses a client who has developed epistaxis. Which conditions in the clients history should the nurse identify as potential contributors to this problem? (Select all that apply.)

Hypertension c. Leukemia d. Cocaine use

The nurse educator is preparing an education module on skin, hair, and nails for the nursing staff. Which of these statements about the dermal layer of the skin should be included in the module?

Is replaced every 4 hour

During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient's scleras are not yellow. From this finding, the nurse could probably rule out:

Jaundice

A nurse is caring for a client who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action

Keep the patient in semi-Fowler's position.

A diabetic patient arterial blood gas (ABG) results are pH 7.28 PaCO2 34 mm Hg: PaO2 85 mm Hg: HCO2 18 mEq/L. The nurse would expected which finding

Kussmaul respirations

The nurse educator is teaching a student nurse how to auscultate the lungs. which action by the student nurse indicate the need for futher education

Listens to the sound over bony structures

The nurse is assessing for clubbing of the fingernails. Which is the best description of clubbing?

Nail bases an angle of 180 degrees or greater and nail bases that feel spongy

A nurse assess a patient who is at risk for neck cancer . Which symptoms would the nurse assess for?

Oral mucosa is gray or dark brown oral lessions that are over 2 weeks old change in the patient voice quality

A nurse who manages client placements prepares to place four clients on a medical-surgical unit. Which client should be placed in isolation awaiting possible diagnosis of infection with methicillin-resistant Staphylococcus aureus(MRSA)?

Patient admitted from a nursing home with furuncles and folliculitis

A nurse assesses an older adult client with the skin disorder shown below: How should the nurse document this finding?

Petechiae

A nurse plans care for a client who is immobile. Which interventions should the nurse include in this clients plan of care to prevent pressure sores? (Select all that apply.)

Place a small pillow between bony surfaces. Use a lift sheet to assist with re-positioning. Keep the clients heels off the bed surfaces.

A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.)

The client does not allow smoking in the house. b. Electrical cords are in good working order. c. Flammable liquids are stored in the garage.

A nurse delegates care for a client who has open skin lesions. Which statements should the nurse include when delegating this clients hygiene care to an unlicensed assistive personnel (UAP)? (Select all that apply.

Wash your hands before touching the client. b. Wear gloves when bathing the client.

After being hit by a baseball a patient arrives in the emergency departemnet with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider?

clear nasal drainage

The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis. what sound will the nurse hear

dullness

A 40 year old patient reports a change in mole size, accompanied by color changes, itching , burning and bleeding over the past month. she has a dark complexion and has no family history of skin cancer , but she has had many blistering sunburns in the past . what is the best response by the nurse.

refer the patient because of the suspicion of melanoma on the basis of her symptoms.

When percussing the patients lungs the nurse notes a moderate low pitched sound over the chest. Which term does nurse use to describe these sounds?

resonance

A nurse assesses a client who has a lesion on the skin that is suspicious for skin cancer, as shown below: Which diagnostic test should the nurse anticipate being ordered for this client?

skin biopsy

Which structure is located in the lower respiratory tract?

trachea

During in examination the nurse finds that a patient has excessive dryness skin. How should the nurse document this finding?

xerosis