Quiz 3 Med Surg

** 14. A nurse is caring for a client following cataract surgery. Which of the following comments from the clients should the nurse report to the client's provider?

: "I need something for the pain in my eye. I can't stand it." Rationale: following cataract surgery, the client should expect only mild pain and should immediately report any pain, decrease in vision, or increase in discharge from the eye. Severe eye pain after surgery might indicate increased intraocular pressure or hemorrhage - itching is common after cataract surgery. The nurse should remind the client not to rub or place pressure on the eyes - clients who wear an eye patch lose their depth perception and part of their peripheral vision, temporarily decreasing visual acuity - the client may find that exposure to bright lights is uncomfortable after cataract surgery. Wearing sunglasses can prevent most of the client's discomfort

17. A nurse is assessing a client who reports numbness and pain in his right paln, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request the client to perform? a) hold the arm straight b) hold wrist at a 90-degree flexion c) flex the arm at the elbow d) extend the right arm upward

: B This is Phalen's sign

18. A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider? A. "I drink at least 2 quarts of fluid every day." B. "The last time I voided it was painful and red-tinged." C. "My period ended 2 days ago." D. "I don't eat shellfish because it gives me hives."

: D The client says she experiences hives after eating shellfish, which indicates a sensitivity. The contrast dye typically used for an IVP is an iodine derivative, and the client with a shellfish sensitivity may have cross-sensitivity to iodine and a serious iodine allergy. This nurse should report these finding to the client's provider.

21. A nurse is caring for a client who has chronic kidney disease (CKD) and states she has heartburn. The provider prescribes aluminum hydroxide. The client asks, "Why can't I just take the antacid magaldrate my husband has a home?" The nurse explains to the client that aluminum hydroxide is the preferred antacid because it lowers which of the following? A. Serum potassium levels B. Serum magnesium levels C. Serum calcium levels D. Serum phosphorus levels

: D Serum phosphorus levels. (Aluminum-based formulas are also a phosphate binder, helping to lower serum phosphorus levels in clients who have CKD.)

4. A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was? A. hoarseness B. weight loss C. dyspnea D. dysphagia

: A

1. The nurse is caring for patients on an orthopedic unit who are being treated with variety of therapies, including immobilization with bandage, a splint, a cast, specialized orthopedic shoe, and traction. What is the priority nursing concern for all of these patients? a. assessment and prevention of neurovascular dysfunction and compromise b. assessment and management of pain and discomfort c. assessment of abilities to do activities of daily living after discharge d. assessment and intervention for concerns related to disability and immobility

: A Assessment and prevention of neurovascular dysfunction and compromise (CMS)

3. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a peripherally inserted central catheter (PICC) line. When assessing the client, the nurse notes that the client's arm seems swollen above the PICC insertion site. Which of the following actions should the nurse take first? A. Measure the circumference of both upper arms. B. Notify the provider who inserted the PICC line. C. Remove the PICC line. D. Apply a cold pack to the client's upper arm.

: A Measure the circumference of both upper arms. This could be due to a blood clot

15. A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take? A. Check the results of the client's most recent CBC. B. Assess the client for a hypersensitivity reaction. C. Evaluate the client for hypercalcemia. D. Examine the client for hepatomegaly.

: A. Check the results of the client's most recent CBC. The client might have anemia as a result of myelosuppression (bone marrow suppression) from the chemotherapy. If so, she might require treatment for the anemia (transfusion, medication) and the provider might have to delay further chemotherapy until her blood counts are higher.

10. A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function? A. Serum creatinine B. Blood urea nitrogen (BUN) C. Serum sodium D. Urine-specific gravity

: A. Serum Creatinine Rationale: A renal function disorder reduces the excretion of creatinine, resulting in increased levels of blood creatinine. Creatinine is a specific and sensitive indicator of renal function. The BUN is used as a gross index of glomerular function and the production and excretion of urea. High-protein diets, rapid-protein catabolism, and dehydration are conditions that will cause an elevation in the BUN. This is not the best indication of the client's renal function.

8. A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect? a.) pH 7.25, HCO3- 19mEq/L, PACO2 30 mm Hg b.) pH 7.30, HCO3 - 26 mEq/L, PACO2 50 mm Hg c.) pH 7.50 7.50, HCO3-20 mEq/L, PaCO2 32 mm Hg d.) pH 7.55, HCO3 - 30 mEq/L, PaCO2 31 mm Hg

: A. pH 7.25, HCO3- 19mEq/L, PACO2 30 mm Hg The nurse should expect a client who has renal failure to have metabolic acidosis, which is characterized by a low HCO3-, a low pH, and a low or normal PaCO2. Expected reference ranges for these laboratory values are as follows: pH 7.35 to 7.45, HCO3- 21 to 28 mEq/L, and PaCO2 35 to 45 mm Hg.

13. A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate? A. "Don't worry; most clients dislike the prep more than the procedure itself." B. "Before the examination, your provider will give you a sedative that will make you sleepy." C. "I know you're anxious, but this procedure is recommended for people your age." D. "After you have signed the consent form, we can talk more about this."

: B

16. A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs? A. The client complains of pain. B. The client develops a life-threatening situation. C. The client needs to have an x-ray of the femur performed. D. The client has to be repositioned in the bed.

: B Traction weights, which are to hang freely at all times, are never to be removed without a specific provider prescription unless there is a life-threatening situation.

20. A nurse is caring for a client who has bleeding esophageal varices and is being treated with a Sengstaken-Blakemore tube. Which of the following actions should the nurse perform? A. Deflate the balloons for 5 min every 2 hr to prevent tissue necrosis. B. Maintain constant observation while the balloons are inflated. C. Suction the tube every 2 hr and as needed to maintain patency. D. Keep the head of the bed flat at all times to prevent the development of shock.

: B A Sengstaken-Blakemore tube is used to stop or slow bleeding from the esophagus and stomach. When the balloons are inflated, they put pressure on the areas that are hemorrhaging to tamponade the bleeding. While the balloons are inflated, the client must be observed constantly because displacement can cause airway obstruction.

2. A 20-year-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? a. Have the patient gently blow the nose. b. Check the drainage for glucose content. c. Teach the patient that rhinorrhea is expected after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity.

: B Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.

19. A nurse is providing teaching to a client who has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. Which of the following instructions should the nurse include in the teaching? a. A Papanicolaou (Pap) test should be performed every 6 months. b. Artificial lubrication can be used to treat vaginal itching and dryness. c. Increased vaginal drainage typically occurs 5 days following surgery. d. Resume sexual intercourse in 2 to 3 weeks.

: B The nurse should instruct the client that atrophic vaginal changes occur due to the loss of estrogen postoperatively and can also cause pain and dryness during sexual intercourse. Artificial lubricants can reduce the manifestations associated with diminished mucous production.

7. A nurse is teaching a client who has acute kidney disease about fluid restrictions. Which of the following statements by the client should the nurse identify as understanding of the teaching? A. "I should consume most of the fluid during the evening." B. "I will make a list of my favorite beverages." C. "I will put beverages in large containers to give the appearance of drinking a lot." D. "I will not add ice cream to the amount of fluid intake."

: B. "I will make a list of my favorite beverages." Rationale: The nurse should work with the client to develop a schedule for fluid restrictions, and should attempt to include the client's favorite beverages when possible to promote satisfaction.

9. A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections, Which of the following actions shouid the nurse include in the client's plan of care? A. Cleanse the perineum from back to front. B. Obtain a prescription for an indwelling urinary catheter. C. Encourage fluid intake at and between meals. D. Offer the client the bedpan every 2 hr.

: C Encourage fluid intake at and between meals. Increased fluid intake dilutes the urine, reduces stasis, and greatly reduces the urinary bacterial count. Consequently, the risk of nosocomial (hospital- acquired) UTI is reduced, even for a client who has a spinal cord injury.

5. A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take? A. Ambulate the client four times per day. B. Encourage the client to consume clear liquids. C. Provide frequent oral and nares care. D. Keep the client in a supine position.

: C. Rationale: A client who has a Sengstaken-Blakemore tube in place is unable to swallow. If the client is alert, the nurse should encourage the client to spit saliva into a tissue or basin. If the client is not alert, gentle suctioning of the oral cavity and nares might be required to remove secretions.

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

: C. Cheyne-Stokes respirations

6. The nurse is caring for a patient who is scheduled for a magnetic resonance imaging (MRI) scan. What explanation should be provided to the patient and family? a. "A scan of the brain will be done after injection of a radioisotope." b. "An MRI uses electrodes placed on the scalp to measure activity of the brain." c. "An MRI measures muscle contraction after stimulation by tiny needle electrodes." d. "An MRI is a noninvasive test that uses magnetic energy to visualize internal parts."

: D Teacher said: explain MRI is in a closed machine and is noisy. Patient may be giving ear plugs to cancel out noise.

11. Patient has DVT and just came out of surgery. What should the nurse instruct the patient not to do?

: Massage the calf 11-2. Nursing assistive personnel (NAP) are applying antiembolitic elastic stockings to the client. What instructions should the NAP give to the client? Select all that apply. ● It is necessary to elevate legs while sitting and before applying stockings to improve venous return. ● Antiembolitic stockings that are free of wrinkles will fit the legs more properly. ● Massaging the legs may further deteriorate the condition, so massage should be avoided. ● Sitting cross-legged and wearing garters promote venous stasis and should be avoided.