med surg exam 2 lippincott quiz

The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiratory rate of 46 breaths/minute, and blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action? 1. Call the rapid response team. 2. Administer a sedative. 3. Try to elicit a positive Homan's sign. 4. Increase the flow rate of intravenous fluids.

1

The nurse receives a report on the assigned clients at the beginning of the second shift. Which client should the nurse plan to assess first after receiving the report? 1. an older adult client with pneumonia who is exhibiting periods of confusion 2. a client who is scheduled for an abdominal perineal resection in the morning and is visiting with the family 3. a client receiving total parenteral nutrition (TPN) via a central line with 400 mL remaining in the IV fluid bottle 4. a young client with chest tubes placed for treatment of a pneumothorax who is resting comfortably

1

A nurse is preparing to teach a client recovering from an anaphylaxis reaction about the prevention and management of reactions. What should the nurse include in the teaching? Select all that apply. 1. antigens that should be avoided 2. how to administer emergency medications 3. take vital signs every day 4. monitor daily weight 5. administer emergency medications until symptoms are severe

1,2

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first? 1. Instruct the client to breathe into a paper bag. 2. Administer oxygen by nasal cannula as ordered. 3. Auscultate breath sounds bilaterally every 4 hours. 4. Encourage the client to deep-breathe and cough every 2 hours.

2

A client with end-stage chronic obstructive pulmonary disease (COPD) requires bi-level positive airway pressure (BiPAP). While caring for the client, the nurse determines that bilateral wrist restraints are required to prevent compromised care. Which client care outcome is best associated with restraint use in the client who requires BiPAP? 1. The client will remain safe. 2. The client will maintain adequate oxygenation. 3. The client will understand the rationale for restraints. 4. The client, in collaboration with the health care team, will begin discharge planning.

2

A client with sepsis begins having labored breathing, confusion, and lethargy. What complication should the nurse assess for in this client? 1. Anaphylaxis 2. Acute respiratory distress syndrome (ARDS) 3. Chronic obstructive pulmonary disease (COPD) 4. Mitral valve prolapse

2

The nurse is assessing a client who has been in a car accident. The client reports sore ribs and painful breathing on the left side of the chest wall. A chest X-ray confirms fracture of two ribs and left-sided hemopneumothorax. What can the nurse anticipate? 1. Aspirational thoracentesis will be performed to remove the accumulated bloody fluid. 2. A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device. 3. Splinting of the affected ribs will be initiated and limitation of upper body activity recommended. 4. Oxygen will be initiated and a bronchoscopy will be performed to identify the area of damage.

2

When assessing a client for early sepsis, which assessment finding would most concern the nurse? 1. pale, yellow urine 2. mean arterial pressure less than 70 mmHg 3. two-second capillary refill 4. purulent drainage from surgical site

2

Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg? 1. Administer an ordered decongestant. 2. Instruct the client to breathe into a paper bag. 3. Offer the client fluids frequently. 4. Administer ordered supplemental oxygen.

2

A client diagnosed with thyroid cancer signed a living will that states the client doesn't want ventilatory support if the condition deteriorates. As the client's condition worsens, the client states, "I changed my mind. I want everything done for me." Which response by the nurse is best? 1. "I'll ask your physician to revoke your do-not-resuscitate order." 2. "Do you understand that you'll be placed on a ventilator?" 3. "What exactly do you mean by wanting 'everything' done for you?" 4. "Maybe you should talk with your family."

3

A client has been diagnosed with septic shock. The nurse would anticipate implementing which order? 1. intravenous dextrose in water at 75 mL/hour 2. vital signs every 4 hours 3. blood chemistry of serum lactate 4. blood chemistry of AST, alkaline phosphates

3

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? 1. pH 2. bicarbonate (HCO3-) 3. partial pressure of arterial oxygen (PaO2) 4. partial pressure of arterial carbon dioxide (PaCO2)

3

A client requires long-term ventilator therapy. The client has a tracheostomy in place and requires frequent suctioning. Which technique should the nurse use? 1. intermittent suction while advancing the catheter 2. continuous suction while withdrawing the catheter 3. intermittent suction while withdrawing the catheter 4. continuous suction while advancing the catheter

3

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? 1. tracheostomy cleaning kit 2. water-seal chest drainage set-up 3. manual resuscitation bag 4. oxygen analyzer

3

A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? 1. An obstruction is present in the chest tube. 2. The client is developing subcutaneous emphysema. 3. The chest tube system is functioning properly. 4. There is a leak in the chest tube system.

3

A nurse is caring for an adolescent involved in a motor vehicle crash. The adolescent has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately: 1. reintroduce the tube and attach it to water seal drainage. 2. call a physician and obtain a chest tray. 3. cover the opening with petroleum gauze. 4. clean the wound with povidone-iodine and apply a gauze dressing.

3

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? 1. The system is functioning normally. 2. The client has a pneumothorax. 3. The system has an air leak. 4. The chest tube is obstructed.

3

Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis? 1. myasthenia gravis 2. type 1 diabetes mellitus 3. extreme anxiety 4. opioid overdose

3

The client is admitted in septic shock. Which assessment data warrants immediate intervention by the nurse? 1. a Sa02 reading of 92% 2. a white blood cell count of 19,000/mm3 3. a urinary output of 50 mL in the past 3 hours 4. vital signs T 38° C (100.4° F), P 104, R 26, and B/P 100/60

3

The nurse is caring for a client 1 day after having a colectomy. The client is lethargic and difficult to arouse; the temperature is 101.5°F (38.6°C), blood pressure is 92/36 mm Hg (mean arterial pressure [MAP 55 mm Hg]), and heart rate is 114 bpm, with a percutaneous oxygen saturation (SpO2) of 88% on oxygen at 2 L per minute per nasal cannula (previously 94%). A saline lock has been established and is patent. Which prescription should the nurse implement first? 1. Obtain stat portable chest x-ray. 2. Administer vancomycin intravenously. 3. Draw blood cultures. 4. Insert an indwelling urinary catheter.

3

The nurse is caring for a client who is 30 years of age with a fracture of the right femur and left tibia. Both legs have casts. The nurse assesses that the client's respiration rate is 30 breaths/min and respirations are rapid and shallow; there is the presence of a faint expiratory wheeze; and coughing produces thin pink sputum. The client is yelling at the nurse and wants to be released from the hospital; this is behavior unlike that previously reported. The last pain medication was administered 3 hours ago. What should the nurse do first? 1. Cut slits in the top of the casts. 2. Administer pain medication. 3. Notify the health care provider (HCP). 4. Obtain a chest x-ray.

3

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? 1. nausea or vomiting 2. abdominal pain or diarrhea 3. hallucinations or tinnitus 4. light-headedness or paresthesia

4

A client who has just had a triple-lumen catheter placed in their right subclavian vein complains of chest pain and shortness of breath. The client's blood pressure is decreased from baseline and, on auscultation of the chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? 1. pulmonary embolism 2. myocardial infarction (MI) 3. heart failure 4. pneumothorax

4

After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. What is an expected outcome of these exercises? 1. The elevated diaphragm enlarges the thorax and increases the lung surface available for gas exchange. 2. There is increased blood flow to the lungs to allow them to recover from the trauma of surgery. 3. The rate of air flow to the remaining lobe is controlled so that it will not become hyperinflated. 4. The alveoli expand and increase the lung surface available for ventilation.

4

The health care provider (HCP) has inserted a chest tube in a client with a pneumothorax. The nurse should evaluate the effectiveness of the chest tube: 1. for administration of oxygen. 2. to promote formation of lung scar tissue. 3. to insert antibiotics into the pleural space. 4. to remove air and fluid.

4

The nurse is planning care for an older adult with an indwelling catheter who is at risk for septic shock. Which nursing action will be most important for this client? 1. administering intravenous (IV) fluid replacement therapy as ordered 2. obtaining vital signs every 4 hours for all clients 3. monitoring red blood cell counts for elevation 4. using aseptic technique when caring for the catheter

4

A client arrives via ambulance with a suspected pelvic fracture from a motor vehicle collision. The client's vital signs are: blood pressure 85/50 mm Hg, heart rate 120 beats/min, respiratory rate 22 breaths/min, and an oxygen saturation of 98% on room air. The client is afebrile. The health care provider has written several prescriptions. What is the nurse's priority action? 1. Obtain STAT hemoglobin and group and match. 2. Draw blood cultures and white blood cell count. 3. Administer 5 mg morphine intravenously. 4. Send client to diagnostic imaging for pelvic x-ray.

1

A client diagnosed with acute pancreatitis 5 days ago is experiencing respiratory distress. Which finding should the nurse report to the health care provider (HCP)? 1. arterial oxygen level of 46 mm Hg (6.1 kPa) 2. respirations of 12 breaths/min 3. lack of adventitious lung sounds 4. oxygen saturation of 96% on room air

1

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? 1. kinking of the ventilator tubing 2. a disconnected ventilator tube 3. an ET cuff leak 4. a change in the oxygen concentration without resetting the oxygen level alarm

1

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn, yielding the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? 1. respiratory acidosis 2. metabolic alkalosis 3. respiratory alkalosis 4. metabolic acidosis

1

A client who underwent surgery 12 hours ago has difficulty breathing. The client has petechiae over their chest and complains of acute chest pain. What action should the nurse take first? 1. Initiate oxygen therapy. 2. Administer a heparin bolus and begin an infusion at 500 units/hour. 3. Administer analgesics as ordered. 4. Perform nasopharyngeal suctioning.

1

A client with a recent diagnosis of deep vein thrombosis (DVT) has sudden-onset shortness of breath and chest pain that increases with a deep breath. What should the nurse do first? 1. Assess the oxygen saturation. 2. Call the health care provider (HCP). 3. Administer morphine sulfate 2 mg intravenously (IV). 4. Perform range-of-motion exercises in the involved leg.

1

A nurse is caring for a client who is experiencing sinus bradycardia with a pulse rate of 40 beats/minute. The blood pressure is 80/50 mm Hg and the client reports dizziness. What is the nurse's priority action? 1. Administer atropine 0.5 mg I.V. push as ordered. 2. Notify the attending physician. 3. Administer a 500 ml I.V. bolus of normal saline solution (0.9% NaCl). 4. Administer lidocaine 100 mg I.V. push as ordered.

1

A client has a sucking stab wound to the chest. Which action should the nurse take first? 1. Draw blood for a hematocrit and hemoglobin level. 2. Apply a dressing over the wound and tape it on three sides. 3. Prepare a chest tube insertion tray. 4. Prepare to start an I.V. line.

2

A client receiving continuous mandatory ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. What should the nurse do? 1. Count the rate to be sure that ventilations are deep enough to be sufficient. 2. Notify the health care provider (HCP) of the client's breathing pattern. 3. Increase the rate of ventilations. 4. Increase the tidal volume on the ventilator.

2

A client recovering from a pulmonary embolism is receiving warfarin. To counteract a warfarin overdose, the nurse should administer 1. heparin. 2.vitamin K1 (phytonadione). 3.vitamin C. 4.protamine sulfate.

2

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? 1. Check for an apical pulse. 2. Suction the client's artificial airway. 3. Increase the oxygen percentage. 4. Ventilate the client with a handheld mechanical ventilator.

2

A nurse is caring for a newborn who has developed sepsis. The health care provider has given the following orders. Which order will the nurse implement first? 1. Obtain blood cultures. 2. Start ampicillin 125 mg IV now. 3. Give a 10 mL/kg bolus of fluid. .4 Place a urinary bag for drug screening.

obtain blood cultures

Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain? 1. fluid intake for the past 24 hours 2, baseline arterial blood gas (ABG) levels 3. prior outcomes of weaning 4. electrocardiogram (ECG) results

2

The client sustained an open fracture of the femur from an automobile accident. The nurse should assess the client for which type of shock? 1. cardiogenic 2. hypovolemic 3. neurogenic 4. anaphylactic

2

A client is admitted to the hospital with a diagnosis of a pulmonary embolism. Which problem should the nurse address first? 1. nonproductive cough 2. activity intolerance 3. difficulty breathing 4. impaired gas exchange

4

Which finding would suggest pneumothorax in a trauma victim? 1. pronounced crackles 2. inspiratory wheezing 3. dullness on percussion 4. absent breath sounds

4

A client with unresolved hemothorax is febrile, with chills and sweating. The client has a nonproductive cough and chest pain. The chest tube drainage is turbid. What should the nurse request in SBAR communication with the health care provider? 1. portable chest X-ray 2, antibiotic therapy 3. intubation and mechanical ventilation 4. arterial blood gasses

2

A client with severe acute respiratory syndrome privately informs the nurse of a desire not to be placed on a ventilator if the condition worsens. The client's partner and children have repeatedly expressed their desire that every measure be taken for the client. The most appropriate intervention by the nurse would be to: 1. encourage the client to consider a living will or power of attorney. 2. ask the physician to discuss the client's prognosis with the client and the family. 3. arrange a conference to discuss the matter with all involved. 4. assure the client that all possible measures will be taken.

1

The nurse is assessing a client whose blood pressure is dropping and heart rate and respiratory rate are increasing. Which finding indicates the client is at risk for hypovolemic shock? 1. severe hemorrhage 2. antigen-antibody reaction 3. gram-negative bacteria 4. massive vasodilation

1

A nurse assesses a client who is in cardiogenic shock. Which statement by the nurse best indicates an understanding of cardiogenic shock? 1. "a decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume" 2. "a decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into interstitial spaces" 3. "generally caused by decreased blood volume" 4. "severe hypersensitivity reaction resulting in massive systemic vasodilation."

2

A nurse is teaching a client who has a severe allergy to bee stings how to manage a reaction. What medication does the nurse encourage the client to take first after being stung by a bee? 1. diphenhydramine 2. epinephrine 3. albuterol (salbutamol) 4. prednisone

2

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects 1. metabolic acidosis. 2. metabolic alkalosis. 3. respiratory acidosis. 4. respiratory alkalosis.

4

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder? 1. respiratory alkalosis 2. respiratory acidosis 3. metabolic alkalosis 4. metabolic acidosis

4