Med Surg Exam 3

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?

The client develops a life-threatening situation

If pt has DVT what med will they be on?

- IV hep at hospital - And po warfarin at home - Continue IV hep for first few days of warfarin so warfarin can reach therapeutic range and then remove the hep once warfarin is at therapeutic range.

A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of following values?

Amylase

If client has cardiac arrest. Given IV lidocaine, why?

Antidysrhythmic medication

A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication?

Antiplatelet aggregate

Pt has HTN and Dr ordered propranolol, you question this is pt has what?

Asthma

Pt has angina pectoris and receiving propranolol hydrochloride. What history findings should you report to provider?

Asthma

A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr. postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis?

Hip arthroplasty

Caring for 4 clients. Pt is getting niphetapine. Gave to another client on accident, what do you do?

Check THAT clients vitals for reaction to drugs

While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?

Discontinue the existing IV line

Pt has cellulitis in their lower extremities. What intervention should the nurse include in the plan of care?

Elevate the extremity

A nurse working in an emergency room is caring for a client who has third degree frostbite to both lower extremities. The nurse should plan to take which of the following actions?

Elevate the legs

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?

Establish the ability to communicate effectively

A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?

Fever

In ED, caring for client with compression fracture of spinal vertebrae. Client was given IV morphine. Urgent surgical indication, unable to reach family.

Get 2 doctors to sign off on the surgery

Nurse working in ED, pt had a gunshot wound in chest. Pt has BP of 100/60, BPM 118, RR is 40. What action should the nurse take?

Give oxygen therapy

A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?

Hemolytic reaction

What does Heparin do?

Heparin stops new clots from forming.

Pt has thrombophlebitis and will be getting this medication

IV heparin

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

Inability to recognize his family members.

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication?

Increased respiratory rate from 18 to 44/min.

Indwelling urinary catheter - blood-tinged urine noted in catheter bag. This means?

Infection

Pt has a chest tube, connected to closed drainage system. We must transport the patient to the x ray department. What is your role in transporting the patient?

Keep closed system below chest level

Client just returned from the surgical suite. He had a fractured mandible. He now has an intermaxillary fixation. What action is priority for the nurse to take?

Make sure they do not aspirate

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?

Massaging her legs

Appendicitis if pt has a decrease in abdominal pain, this indicated that pt has a ruptured appendix. If it is ruptured and pain disappeared in a short period of time.

May suddenly feel a relief of pain

Verapamil IV bolus for cardiac dysrhythmia. What is the adverse effect that the nurse should be aware of and monitor for?

Monitor for hypotension.

A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. Which of the following actions should the nurse take?

Monitor sensory perception of the lower extremities

RECOGNIZE WHICH PATIENT HAS HYPOKALEMIA

NG tube suctioning has the highest risk bc of water loss.

Warfarin for artificial heart valve. What is the lab value that you the nurse should monitor for?

PT/INR

A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?

Pantoprazole 80 mg IV bolus twice daily

A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period?

Perform neurovascular checks of the extremities

A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications?

Propranolol

A nurse is teaching about risk factors of developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include in the teaching?

Race

A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?

Stop the infusion of blood.

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?

These tests help determine the degree of damage to the heart tissues. Rationale: Cardiac enzyme studies are obtained because the degree of enzyme elevation reflects the degree of damage to the myocardium. The enzymes most commonly measured are CPK and troponin. These enzymes have a characteristic rise and fall pattern after an MI. It may take 4 hr or more after the onset of manifestations for the test to become abnormal and up to 24 hr for the level to peak. Eventually, the levels in the blood fall back to normal. Consequently, serial blood tests must be taken from the client to document and evaluate enzyme levels.

Pt has pneumothorax, chest tube in place. What should you report to the provider?

Trachea will be on the unaffected side

Toddler has Heart failure, what findings are expected?

Trouble (labored) breathing

A nurse is caring for a client who has a severe gangrenous infection of the right lower extremity. The nurse should plan preoperative teaching based on the possibility of which of the following amputation procedures?

Your pain will gradually become less severe

Doctor just applied Fiberglass cast for fractured tibia, what priority action should the nurse take?

peripheral pulses