Passpoint Med Surg
A nurse is comparing the neurological status of a client who suffered a head injury with the status on the previous shift. Using the Glasgow Coma Scale, the nurse determines that the client's score has changed from 11 to 15. Which responses did the nurse assess in this client? Select all that apply.
A nurse is comparing the neurological status of a client who suffered a head injury with the status on the previous shift. Using the Glasgow Coma Scale, the nurse determines that the client's score has changed from 11 to 15. Which responses did the nurse assess in this client? Select all that apply.
A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of
acute pulmonary edema. Shortness of breath, agitation, and pink-tinged, foamy sputum signal acute pulmonary edema. This condition results when decreased contractility and increased fluid volume and pressure in clients with heart failure drive fluid from the pulmonary capillary beds into the alveoli. In right-sided heart failure, the client would exhibit hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike and sputum that varies in color. Cardiogenic shock is indicated by signs of hypotension and tachycardia.
A client has had abdominal surgery and is using an incentive spirometer. Which is the most effective way to evaluate the effectiveness of the client's use of the spirometer? The client:
can breathe more easily. Incentive spirometry promotes lung expansion and increases respiratory function. When used properly, an incentive spirometer causes sustained maximal inspiration and increased cardiac output.
When assessing a client who has experienced a spinal injury, the nurse notes diaphragmatic breathing and loss of upper limb use and sensation. At what level does the nurse anticipate the injury has occurred?
C5 The nurse should anticipate that the injury has occurred at level C5. Injuries above C3 result in the loss of spontaneous respiratory function. Clients with injuries at T6 and L1 retain some degree of upper limb use and sensation.
A client is at risk for acute pyelonephritis. The nurse should instruct the client about which health promotion behaviors that will be most effective in preventing pyelonephritis?
Wash the perineum with warm water and soap, cleaning from front to back. Acute pyelonephritis usually begins with a bacterial infection of the lower urinary tract via the ascending urethral route; most infections are due to gram-negative bacilli, such as Escherichia coli, normally found in the gastrointestinal tract. Thorough perineal care using soap and warm water, and cleansing from front to back, decreases the likelihood that organisms will be introduced into the urinary tract and ascend upward toward the kidneys. Although preventing and treating all infections are appropriate, fungal infections from the feet and bacterial infections in the throat or skin are less likely to be immediate sources of infection causing pyelonephritis.
The nurse is administering eye drops to a client with glaucoma. Which technique is correct for instilling the eye drops? The eye drops are placed:
in the lower conjunctival sac. Eyedrops are correctly instilled by placing them in the lower conjunctival sac. Eyedrops should not be placed near the lacrimal ducts, to decrease the chance of the medication's being systemically absorbed. Placing the drops on the cornea or sclera is uncomfortable for the client and may cause the medication to run out of the eye socket instead of being absorbed.
A client is receiving sulfonamide cream as topical treatment for burns. When reviewing the daily laboratory tests, the nurse notices that the client's white blood cell (WBC) count has decreased. The nurse reviews the data and determines that:
this is abnormal; the health care provider needs to be alerted. Leukopenia, or a decreased WBC count, is an adverse reaction to sulfonamide cream. A decreased WBC count should be reported to the health care provider immediately. Sulfonamide cream should be discontinued until WBC count returns to normal.
A female client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?
"Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days." A client with primary herpes genitalis should apply topical acyclovir ointment in sufficient quantities to cover the lesions every 3 hours, six times per day for 7 days. Terconazole and tioconazole treat vulvovaginal candidiasis. Sulconazole nitrate treats tinea versicolor.
After the nurse teaches a client about wearing a back brace after a spinal fusion, which statement indicates effective teaching?
"I should wear a thin cotton undershirt under the brace." The client should wear a thin cotton undershirt under the brace to prevent the brace from abrading directly against the skin. The cotton material also aids in absorbing any moisture, such as perspiration, that could lead to skin irritation and breakdown. Applying lotion is not recommended before applying the brace because further skin breakdown can result (related to the collection of moisture where microorganisms can grow). Applying extra padding (e.g., to the iliac crests) is not recommended because the padding can become wrinkled, producing more pressure sites and skin breakdown. Use of baby or talcum powder and lotion is not recommended, because they can cause irritation and skin breakdown.
A 45-year-old client had a complete abdominal hysterectomy with bilateral salpingo-oophorectomy 2 days ago. The client's abdominal dressing is dry and intact. While sitting up in the chair, the client has severe pain and numbness in her left leg. What should the nurse do first?
Assess color and temperature of the left leg. The client is likely suffering from an embolus as a result of abdominal surgery. The nurse should inspect the left leg for color and temperature changes associated with tissue perfusion. Administering pain medication without gathering more information about the pain can mask important signs and symptoms. Although assessing for edema is important, it is not critical to this situation. Encouraging the client to change her position does not adequately address the need for gathering more data.
The client with colon cancer has an abdominal-perineal resection with a colostomy. To promote hygiene following surgery, what should the nurse do?
Assist the client with warm sitz baths. Appropriate nursing interventions after an abdominal-perineal resection with a colostomy include assisting the client with warm sitz baths three to four times a day to clean the perineal incision. The client will be more comfortable assuming a side-lying position because of the perineal incision. It would be inappropriate to administer milk of magnesia to stimulate colostomy activity. Stool passage will begin as peristalsis returns. It is not necessary or desirable to change the ostomy pouch daily to assess the stoma. The ostomy pouch should be transparent to allow easy observation of the stoma and drainage.
A nurse is reviewing laboratory values for a client diagnosed with hyperlipidemia 6 months ago. Which results indicate that the client has been following their therapeutic regimen?
High density lipoproteins (HDL) increase from 25 mg/dl (0.65 mmol/L) to 40 mg/dl (1.03 mmol/L). The goal of treating hyperlipidemia is to decrease total cholesterol and LDL levels while increasing HDL levels. HDL levels should be greater than 35 mg/dl. This client's increased HDL levels indicate that the client followed the therapeutic regimen. Recommended total cholesterol levels are below 200 mg/dl. LDL levels should be less than 160 mg/dl, or, in clients with known coronary artery disease (CAD) or diabetes mellitus, less than 70 mg/dl. Triglyceride levels should be between 100 and 200 mg/d.
When assessing a client with diabetes for diabetic nephropathy, the nurse should determine if the client has:
asymptomatic proteinuria. Asymptomatic proteinuria is an initial sign of diabetic nephropathy. Microscopic proteinuria should be monitored yearly in all clients with diabetes for over 5 years. Polyuria and increasing glycosuria are symptoms of poorly managed diabetes. Ketonuria is a sign of diabetic ketoacidosis.
A coworker asks another nurse if a client received their pathology report. The coworker is not directly involved in the care of the client. How should the nurse respond? Select all that apply.
The nurse should tell the coworker that information about the client cannot be shared due to health privacy laws. In addition, client information can only be shared with those who are involved in the immediate care of the client. Hospital policies usually address such issues, and this information is covered during orientation and annually as an update.
After surgery for bilateral adrenalectomy, the client is kept on bed rest for several days. Which exercise will be most effective for preparing a client for ambulation after a period of bed rest?
alternately flexing and relaxing the quadriceps femoris muscles Alternately flexing and relaxing the quadriceps femoris muscles helps prepare the client for ambulation. This exercise helps maintain the strength in the quadriceps, which is the major muscle group used when walking.The other exercises listed do not increase a client's readiness for walking.
A client with a nagging cough makes an appointment to see the healthcare provider. For what other signs or symptoms will the nurse assess as a priority?
change in voice and unexplained weight loss. A nagging cough is one of the warning signs of lung cancer. The nurse will assess for other findings associated with lung cancer such as hemoptysis, change in voice, weight loss, dyspnea, and fatigue. The other options represent warning signs of different cancers--change in moles is associated with melanoma; change in bowel habits with gastrointestinal cancers; urinary frequency and weak stream with prostate or bladder cancer. Hematuria, bladder cancer, and swollen lymph nodes can occur with lung cancer if it has metastasized to the lymph system.
An elderly client has suffered a cerebrovascular accident (CVA). The right side of the client's face has visible ptosis. The nurse would be alert to which finding?
dysphagia Dysphagia is difficulty swallowing. The same nerve that controls the drooping of the face can cause dysphagia. The other choices are not associated with CVA. Agenesis is absence or incomplete development of an organ or body part. Epistaxis is a nose bleed. Xerostomia is a dry mouth.
A client is ordered continuous bladder irrigation at a rate of 60 gtt/minute. The nurse hangs a 2 L bag of sterile solution with tubing on a three-legged I.V. pole. The nurse then attaches the tubing to the client's three-way urinary catheter, adjusts the flow rate, and leaves the room. Which important procedural step did the nurse fail to follow?
evaluating patency of the drainage lumen The nurse should evaluate patency of the drainage tubing before leaving the client's room. If the lumen is obstructed, the solution infuses into the bladder but isn't eliminated through the drainage tubing, a situation that may cause client injury. Balancing the pole is important; however, the nurse would have had to address this issue immediately after hanging the 2 L bag. Using an I.V. pump isn't necessary for continuous bladder irrigation. Unless specifically ordered, obtaining a urine specimen before beginning continuous bladder irrigation isn't necessary.
Before surgery to repair an aortic aneurysm, the client's pulse pressure begins to widen, suggesting increased aortic valvular insufficiency. If the branches of the aortic arch are involved, the nurse should assess the client for:
loss of consciousness. If the aortic arch is involved, there will be a decrease in the blood flow to the cerebrum. Therefore, loss of consciousness will be observed. A sudden loss of consciousness is a primary symptom of rupture and no blood flow to the brain.Anxiety is not a sign of aortic valvular insufficiency.The end result of decreased cerebral blood flow is loss of consciousness, not headache or disorientation.
After being seen in the oncology clinic, a client with severe bone marrow suppression is admitted to the hospital. The client's cancer therapy consisted of radiation and chemotherapy. When developing the care plan for this client, the nurse prioritizes which nursing intervention?
monitoring temperature and blood cell count Risk for infection takes highest priority in clients with severe bone marrow depression. This is because they have a decrease in the number of white blood cells, which are the cells that fight infection. Therefore, the nurse should monitor temperature and blood cell count. While the other interventions are helpful in the care of this client, the risk for infection takes precedence.
A client with iron deficiency anemia is taking iron supplements. What nutrient should the nurse instruct the client to take the supplements with in order to increase the absorption of iron?
orange juice Ascorbic acid (vitamin C) increases iron absorption. Taking iron with a food rich in ascorbic acid, such as orange juice, increases absorption. Milk delays iron absorption. It is best to give iron on an empty stomach to increase absorption. Beta-carotene does not affect iron absorption.
The nurse is creating a plan of care for an older adult client with osteoarthritis. Which nursing diagnosis is most appropriate?
risk for injury related to altered mobility Typically, a client with osteoarthritis has stiffness in large, weight-bearing joints, such as the hips. This joint stiffness alters functional ability and range of movement, placing the client at risk for falling and injury. Therefore, risk for injury is the most appropriate nursing diagnosis. Activity intolerance related to sedentary lifestyle assumes that the client with osteoarthritis is limited in physical activity. Self-care deficit related to immobility assumes that the client with osteoarthritis is unable to complete self-care activities. Imbalanced nutrition: Less than body requirements is incorrect because osteoarthritis does not affect nutrition.
A nurse working on a neurologic floor has received reports on four clients. After identifying priority assessment data for each client, which client should the nurse investigate first?
the client admitted after a head injury in a motor vehicle who reports nausea The nurse should first assess the client with nausea, because this may indicate increased intracranial pressure (ICP). The client scheduled for discharge, the client who recently had a laminectomy, and the client with paraplegia are all stable.
The nurse is teaching a client about preventing toxic shock syndrome (TSS). Which action is a risk factor for toxic shock syndrome?
using only tampons at night Risk factors for TSS include the use of tampons at night, when the tampon would be in place for 7 to 9 hours. TSS can occur in other situations, but it is commonly associated with women during menses, particularly women who use tampons. The longer the tampon is left in place, the greater the risk for TSS. Changing tampons every 3 hours or more frequently, avoiding use of deodorized tampons, and alternating tampons with sanitary pads are actions that decrease the risk of TSS.
The nurse is preparing a client with sickle cell anemia for discharge. What information should the nurse include in the teaching plan? Select all that apply.
The nurse should teach the client to drink plenty of fluids when outside in hot weather to avoid becoming dehydrated. The client should avoid being in high altitudes, such as mountains above 5,000 feet (1,524 m), where the lower availability of oxygen could precipitate a sickle cell crisis. The nurse should alert young women with sickle cell anemia that pregnancy increases the risk of a crisis. People who are homozygous for HbS have sickle cell anemia; the heterozygous form is the sickle cell carrier trait. A client with sickle cell anemia may fly on commercial airlines; the airplane is pressurized and has an adequate oxygen level.
A client has been diagnosed with peripheral arterial occlusive disease. In order to promote circulation to the extremities, the nurse should instruct the client to:
participate in a regular walking program. Clients diagnosed with peripheral arterial occlusive disease should be encouraged to participate in a regular walking program to help develop collateral circulation. They should be advised to rest if pain develops and resume activity when pain subsides. With arterial disease, extremities should be kept in a dependent position to promote circulation; elevation of the extremities will decrease circulation. To avoid burns, heating pads should not be used by anyone with impaired circulation. Massaging the calf muscles will not decrease pain. Intermittent claudication subsides with rest.
Oxygen at the rate of 2 liters per minute through nasal cannula is prescribed for a client with chronic obstructive pulmonary disease (COPD). Which of the following statements best describes why the oxygen therapy is maintained at a relatively low concentration?
The client's respiratory center is so used to high carbon dioxide and low oxygen levels that changing these levels may eliminate his stimulus for breathing. Relatively low concentrations of oxygen are administered to clients with COPD so as not to eliminate their respiratory drive. Carbon dioxide content in the blood normally regulates respirations. Clients with COPD, though, are often accustomed to high carbon dioxide levels; the low oxygen blood level is their stimulus to breathe. If they receive excessive oxygen and experience a drop in the blood carbon dioxide level, they may stop breathing. Oxygen flow rate is not diminished at high levels when administered through a nasal cannula. The client's ability to absorb oxygen administered at a higher level is not affected. Increased oxygen levels and decreased carbon dioxide levels cannot cause cells to burst.
A nurse is working with a dying client and the client's family. Which communication technique is most important to use?
Use active listening and silence when communicating. When working with a dying client and the client's family, the nurse should use active listening and silence to assess their feelings, coping skills, and immediate and long-term needs. Active listening also helps the nurse select other appropriate strategies, such as reflection and clarification. Interpretation should be used sparingly to avoid making false inferences or putting the client or family on the defensive. Initiate the conversation whenever possible and assess the family and client's coping mechanisms, including what has worked for them in the past. If the nurse is uncertain how to respond, the nurse should ask for more information or clarification from the family not avoid speaking to them.
Which nurse should be assigned to a client receiving brachytherapy for the treatment of cervical cancer?
female nurse with 3 years' experience working in oncology Brachytherapy is internal radiation and nurses must use the principles of time, distance, and shielding. Radiation has cumulative effects and the nurse already working with a client receiving radiation should not be exposed to additional radiation. Working with clients who are receiving internal radiation takes a certain skill set, and the male nurse who has floated from the operating room is not the best person to work with this client. Radiation is harmful to the fetus, and the nurse who suspects she is pregnant should not be exposed to radiation.
