Med Surge Adaptive Quizzing
Which action will the nurse take first when treating a client who is having an anaphylactic reaction? Give epinephrine 0.5 mg intramuscularly Infuse normal saline 500 mL IV Inject methylprednisolone 120 mg IV Administer oxygen through a non-rebreather mask
1. The initial action for anaphylaxis would be administration of epinephrine to correct bronchoconstriction and arterial dilation. The other actions are also appropriate, but evidence indicates that successful treatment of anaphylaxis requires early administration of epinephrine. Normal saline is given to correct hypotension caused by arterial dilation. Use of steroids such as methylprednisolone decreases the inappropriate inflammatory response that causes symptoms of anaphylaxis. Administration of high levels of oxygen is needed to correct hypoxemia but will not be effective until bronchoconstriction is corrected through epinephrine administration.
After surgery, a client is extubated in the PACU. Which clinical manifestations would the nurse expect if the client is experiencing acute respiratory distress? Select all that apply. Confusion Hypocapnia Tachyardia Constricted pupils Slow respiratory rate
1, 2, 3. Inadequate cerebral oxygenation produces restlessness and confusion. Tachycardia occurs as the body attempts to compensate for lack of oxygen. A low CO2 level in the blood occurs with an increase in respiratory rate. The pupils dilate, not constrict, with hypoxia. An elevated respiratory rate, now slowed respiratory rate, occurs.
Which assesment findings would indicate the need for atenolol in a client diagnosed with hyperthyroidism? Select all that apply. Tachycardia Atrial fibrillation Distant heart sounds Systolic HTN Decreased cardiac output
1, 2, 4. In hyperthyroidism, atenolol is prescribed to reduce cardiac manifestations. Tachycardia, atrial fibrillation, and systolic HTN are cardiac manifestations associated with hyperthyroidism. Distant heart sounds are associated with hypothyroidism. The cardiac output is increased in hyperthyroidism.
A client has a surgical creation of a colostomy for cancer of the rectum. The client asks, "What's the difference between irrigating a colostomy and having an enema?" The nurse should differentiate between the two procedures by explaining that the colostomy irrigation procedure involves which step? Using a cone-shaped tip catheter Lubricating the catheter tip with a water-soluble jelly Clearing the tubing of air before inserting the solution Taking measures to prevent cramping in the client's abdomen
1; A cone-shaped tip controls the depth of insertion of the catheter, preventing perforation of bowel and limits leakage of water from the stoma during fluid insertion. In both procedures, the catheter tip should be lubricated with water-soluble jelly, which limits trauma to intestinal mucosa. In both procedures, the tubing should be clear of air to facilitate the tolerance of a larger volume of irrigating solution. In both procedures, cramping can occur.
The nurse is caring for a client who had a skin graft applied over a full-thickness burn on the chest. Which observation of the donor site during the first 24 hours after surgery would the nurse report to the primary health care provider immediately? Small amount of yellowish-green oozing Moderate area of serosanguineous oozing Epithelialization under the nonadherent dressing Separation of the edges of the nonadherent dressing
1; Any amount of yellowish-green oozing indicates infection and should be reported immediately. Serosanguineous oozing is expected. Epithelialization under the nonadherent dressing indicates healing and is desirable. Separation of the edges of the nonadherent dressing is not a problem.
Which clinical maifestations would the nurse expect to find in a client with hypokalemia? Select all that apply. Thirst Anorexia Leg cramps Rapid, thready pulse Dry mucous membranes
2, 3,. The GI manifestations associated with hypokalemia are caused by decreased neuromuscular irritability of the GI tract; resulting in anorexia, nausea, vomiting, and decreased peristalsis. Because of potassium's role in the sodium-potassium pump, hypokalemia results in altered neuromuscular functioning, which precipitates leg cramps. Thirst and dry mucous membranes are associated with hypernatremia. Rapid, thready pulse is associated with dehydration and hyponatremia.
The nurse is caring for a client with hypoglycemia. The nurse anticipates a prescription for which medications? Select all that apply. Insulin Glucagon IV glucose Oran hydrocortisone Somatostatin
2, 3, 4. A client with hypogylcemia suffers with weakness and vision disturbances due to low glucose levels. Glucagon is the hormone secreted by the pancreas that elps with increasing the blood glucose levels. Administering IV glucose would immediately improve blood glucose levels. Hydrocortisone is a glucocorticoid that prevents hypoglycemia by increasing liver gluconeogenesis and inhibiting peripheral glucose use. Insulin is administered when glucose levels are high as it increases glucose reuptake, thereby reducing blood glucose levels. Somatostatin is a hormone released by delta cells of the pancreas that inhibbits insulin and glucagon.
While providing care for a client with a second-degree left ankle sprain, the nurse raises the injured part above heart level. Which statement provides the reason behind this intervention? To promote bone density Tp prevent further edema To reduce pain perception To increase muscle strength
2; A client with seond-degree sprain may have a deeply torn ankle ligament with swelling and tenderness. Elevation of the injured lower limb above heart level helps mobilixation of excess fluid from the area and mprevents further edema. Strengthening exercises help build bone density and muscle strength and significantly reduce risk of sprains and strains. Cryotherapy and adequate rest helpr educe pain by reducing transmission and perception of pain impulses
Which lab test would the nurse review for a client suspected to have rheumatoid arthritis? Pancreatic lipase Bence jones protein Antinuclear antibody Alkaline phosphatase
3. An antinuclear antibody test may be positive in clients with autoimmine disorders such as RA and SLE. Pancreatic lipase is an enzyme that catalyzes the breakdown of lipids; this is a test used to diagnose pancreatic problems. Bence jones protein is a urine test helpful in diagnosing multiple myeloma. Alkaline phosphatase is a blood test that determines phosphorus activity; it is used in diagnosing liver and biliary tract disocers and identifying periods of active bone growth or metastasis of cancer to bone.
The parents of a young man suspected of having Cushing Syndrome express anxiety about their son's condition. Which would the nurse tell the parents to help them better understand the illness? He will need to take exogenous steroids for several months His condition will indicate improvement when he gains weight He may have mood swings or depression as a result of the illness His physical changes are permanent but may imrpvoe with therapy
3. High levels of steroids result in emotional changes; the actual cause is unknown, but knowing the response may help the parents better cope with the behavior. The need to recieve exogenous steroids is unneccesary. Cushing syndrome is related to an excessive production of steroids. Weight loss, not weight gain, indicates an improving condition. The changes may not be permanent with adequate therapy.
Which increased physiological response would the nurse include when explaining the need for weight loss to a client who is diagnosed with diabetes? Fattty acid storage Glucose oxidation Insulin requirement Cellular entry of glucose
3. Obesity causes insulin resistance at cellular level, so more insulin is required for transfer of glucose across cell membranes. Fatty acid metabolism is altered. Fatty acids break down; storage decreases. With obesity, oxidation of glucose decreases and insulin needs increase. Obesity causes peripheral cellular resistance to glucose entry into cells.
A 16-month-old toddler has had large, frothy, foul-smelling stools since the introduction of table foods and is irritable and apathetic. The child is diagnosed with celiac disease and a gluten-free diet is prescribed. Which response would the nurse anticipate in the child after 2 days on the diet? Return of appetite Increase in weight Improved behavior Cessation of diarrhea
3; A favorable change in behavior occurs in 2-3 days and attests to the effectiveness of the diet; other improvements take longer. A return of appetite takes more than several days (anorexia redevelops during episodes of diarrhea) along with an increase in weight and cessation of diarrhea.
A client is admitted to the hospital with a potential diagnosis of excess antidiuretic hormone. Which clinical indicator would the nurse identify when assessing the client? Polyuria Dehydration Hyponatremia Hyperglycemia
3; ADH causes increased resorption of water by renal tubules, which dilutes sodium levels, causing hyponatremia. ADH will decrease urine volume. It causes fluid retention and does not alter glucose metabolism.
Which clinical finding would the nurse expect when assessing a client with varicose veins? Positive Homan's sign Pallor of the affected extremity Prolonged capillary refill in toes Sensation of heaviness in lower legs
4. Because of dilation in veings, decrease in venous return, and edema, the client may experience heaviness in the leggs. Homans sign is calf pain when ankle is dorsiflexed, usually related to VTE. Pallor indicates decreased tissue perfusion that may be caused by decreased arterial blood flow. Prolonged capillary refill is seen with decreased arterial perfusion to the feet.
A client with severe chronic rheumatoid arthritis reports that pain lasts for 2-3 hours after exercising. Which information would the nurse teach the client? Substitute isometric exercises for isotonic exercises Stop the exercises for a day and then resume them Delay doing aerobic exercises until the pain subsides Decrease the time and number of exercise repititions
4. Exercise should be decreased to a level of tolerance. Isometric exercises promote muscle contraction, not joint movement. The exercise should not be stopped. The purpose of aerobic exercises is to improve cardiovascular functioning, not joint movement, there is no reason to interrupt aerobic exercises if they are tolerated.
The nurse provides self-care instructions to a client who is receiving external radiation therapy for bone metastasis. Which client activity demonstrates a need for further teaching? Protecting the skin from direct sunlight Wearing loose-fitting cottom clothing over the area Drying the area with a patting motion using a soft towel Rubbing on talcum powder after washing the area
4. Intending to use talcum power indicates the client needs more teaching. Powders, lotions, creams, and ointments should not be applied to the area unless prescribed; some substances interfere with the path of the radiation and should not be used. The other intended actions are appropriate and do not need follow up. Sun rays, a form of radiation, can damage the skin further and should be avoided. Cotton is a natural fiber that is soft against the skina nd allows air to circulate. The skin should be protected by patting dry with a soft towel.
A client is a candidate for intubation as a result of bleeding esophageal varices. Which type of tube would the nurse anticipate will most likely be used to meet the needs of this client? 1 Levin 2 Salem Sump 3 Miller-Abbott 4 Sengstaken-Blakemore
4. Sengstaken-Blakemore includes an esophageal balloon that exerts pressure on inflation, which retards hemorrhage. A Levin tube is used for gastric decompression, gavage, or lavage; it has one lumen. A Salem sump tube is used for gastric decompression; it has two lumens, one for decompression and one for an air vent. A Miller-Abbott tube is used for intestinal decompression.
A client with osteomyelitis is receiving antibiotic therapy through a central line. Trough blood levels were obtained immediately before a prescribed dose of antibiotics was administered, and peak levels were obtained 30 minutes after the infusion was completed. The laboratory results reveal that the trough level is higher than the peak level. What would the nurse conclude that this finding probably indicates? The dose should be increased The dose is in excess of the client's needs There was an adequate administration of the medication There was a problem with obtaining of blood specimens
4; Peak levels will always be higher than trough levels; therefore this result indicates that there has been some mix-up while drawing the samples. Increasing the dose would be appropriate action if the trough level was too low. Concluding that the dose is in excess would be appropriate if the trough was too high; however, the trough level still should never exceed peak level. There is not enough info provided to determine whether there was adequate antibiotic administration.
Which complication is most likely to occur in the immediate postoperative period after a client has had a splenectomy? Infection Peritonitis Hemorrhage Intestinal obstruction
Because the spleen is highly vascular, hemorrhage may occur in the immediate postoperative period. Although risk for some types of infection is higher after splenectomy because of lower immunoglobulin levels, risk for immediate postoperative infection is not higher than usual after splenectomy. Peritonitis is possible after splenectomy, but it would not be apparent in the immediate postoperative period and is not a common complication. The incidence of intestinal obstruction is not higher than for other abdominal surgery, and symptoms would not be apparent in the immediate postoperative period.
A client with heart failure weighed 175 lb (79.4 kg) yesterday, and today's weight is 181 lb (82.1 kg). How many milliliters of fluid has the client retained? Round your answer using a whole number
One liter of fluid equals 1000 mL; each liter of fluid is equal to 1 kg of weight. 82.1 - 79.4 =2.7 kg = 2700 ml.
A client is scheduled for a kidney ultrasound. Which instructions would be given by the nurse? Select all that apply. One, some, or all responses may be correct. "Drink plenty of fluids." "Eat foods rich in fiber." "Do not urinate before the examination." "Lie flat and perfectly still during the test." "A urinary catheter may be needed temporarily for the test."
1, 3, 4. A kidney ultrasound requires a full bladder. Asking the client to drink plenty of fluids will increase the volume of blood, thereby increasing the volume of urine collected in the urinary bladder. Because of this, the client should be advised not to urinate before the examination. A urinary catheter may be needed for a cystometrography test; this is performed to determine the bladder wall muscle functions. Eating foods rich in fiber is good for overall health, but has no effect on the kidney ultrasound. The ultrasound is performed by placing the client in the supine position, wherein the client lies flat with the abdomen exposed, but the client is draped.
After the nurse teaches a client with coronary artery disease about healthy food choices, which dietary choices by the client indicate that the teaching was effective? Select all that apply. One, some, or all responses may be correct. Olive oil Whole milk Whole-grain bread vegetables and fruits Red meats, such as beef Liver and other glandular organ meats
1, 3, 4. Olive oil is an unsaturated fat, which is a healthy choice. Whole-grain bread is high in soluble fiber, which may lower the risk for heart disease. Vegetables and fruits are low in fat and high in soluble fiber, thus lowering risk for heart disease. Whole milk is high in saturated fats, and low-fat or nonfat milk are recommended. Red meats are high in saturated fats and should be limited. Liver and other glandular meats are high in saturated fats and cholesterol and should be limited or avoided.
Which information would the nurse provide to the client before a myelogram? You may have a severe headache after the procedure The maching will make loud noises during the procedure Electrodes will be applied to your skin during the procedure There may be some blood on the kneww dressing after the procedure
1. A myelogram is a sensitive test for nerve impingement that can detect subtle lesions and injuries. Spinal headache is common after a myelogram because it involves incision of spinal roots. Diagnostic studies involving the use of MRI produce loud nosies. Electrodes are applied to skin in somatosensory evoked potential studies. Leakage of blood on the dressing is onserved after arthrocentesis.
After a spontaneous pneumothorax, a client's assessment findings include extreme drowiness, tachycardia, and tachypnea. The nurse suspects which condition? Hypercapnia Hypokalemia Increased PO2 Respiratory alkalosis
1. Pneumothorax results in decreased surface area for gas exchange. If unaffected pleural regions cannot compensate, carbon dioxide builds up in the body (hypercapnia). The client will become drowsy and may lose consciousness. The body attempts to compensate by increasing respiratory and pulse rates and by the kidneys retaining bicarbonate. Hypokalemia causes extreme muscle weakness, abdominal distention, and changes in the ECG pattern. The PO2 is decreased with a pneumothorax because of decreased surface area for gas exchange. Respiratory acidosis occurs with an elevated PCO2.
The nurse is providing care for a client who is hospitalized for dehydraiton and expects which assessment findings? Select all that apply. Protruding eyeballs Postural hypotension The client reports eating an average of two meals daily. The skin on the client's forehead remains tented after being pinched. Within 4 days, the client lost 4 ounces (0.11 kg) of weight.
2, 4. Postural hypotension is an indicator of dehydration. To determine dehydration in the adult, the nurse should test for decreased skin turgor. To assess for dehydration, pinch the skin over a bone with little or no underlying fat, such as the sternum or forehead. If the skin remains tented after it is released, the client is dehydrated. The eyeballs may be sunken, not protruding, in the presence of dehydration. The client's report of eating two meals a day does not indicate dehydration. A weight loss of 4 ounces (0.11 kilogram) does not indicate dehydration
Which action would the nurse take when caring for a client with pneumothorax who has a chest tube and closed drainage system? Avoid adding any additional water to the suction control chamber Check the water-seal chamber for evidence of bubbling during expiration Milk the chest tube periodically to prevent clots from obstructing tubing Call HCO if there is bubbling in suction control chamber
2. With a pneumothorax, air will escape from the pleural space and into the water-seal chamber; because intrapleural pressure increases with expiration, bubbling in water-seal chamber is usually seen during expiration. Water evaporates from the suction control chamber and the nurse will need to add water to keep the suction at prescribed level. Milking chest tubes should generally be avoided and will not be needed with a pneumothorax because there will only be a few mL of bleeding. Bubbling in the suction control chamber is expected.
When determining the main difference between type 1 and type 2 diabetes, the nurse recognizes which clinical presentation about type 1? Onset is slow Excessive weight is a contributing factor Complications are not present at the time of diagnosis Treatment involves diet, exercise, and oral medications
3. Clinical rpesentation of type 1 diabetes is characterized by acute onset, and there is no time to develop the long-term complications that are common with long-standing disease; 20% of newly diagnosed clients with type 2 diabetes demonstrate complications because the diabetes has gone undetected for an extended period of time. Clinical presentation of type 1 diabetes is rapid, not slow, ebcause pancreatic beta cells are destroyed by an autoimmune process; un type 2, the body is still producing some insulin, and the onset of symptoms is slow. Intype 1, clients generally are lean or have an ideal weight; 80-90% of clients with type 2 diabetes are overweight. Type 1 diabetes requires diet control, exercise, and subcutaneous adminsitration of insulin, not oral medications; these are used in type 2.
A client who has been receiving treatment for osteomyelitis reports hives, mouth sores, and bloody diarrhea. Which medication would the nurse expect to see in the client's medication adminsitration record? Cefazolin Neomycin Tobramycin Ciprofloxacin
1. Cephalosporin antibiotics, such as cefazolin, are used to treat ozteomyelitis. Cefazolin can alter GI function, resulting in adverse effects such as watery diarrhea, bloody stools, and mouth or throat sores. Cefazolin can also alter skin integrity and cause hives. Aminoglycosides such as neomycin and tobramycin do not generally alter GI system, instead they can cause ototoxicity and nephrotoxicity. Fluoroquinolones such as ciprofloxacin generally do not alter the GI system; tendon rupture, especially Achilles tendon, can occur with fluoroquinolones
A client reports a facial lesion that has recently grown and is changing in appearance. The client is on oral methoxsalen. Which condition would the nurse expect? Melanoma Actinic keratosis Basal cell carcinoma Photosensitizing effect
1. Clients who take oral methoxsalen may be at a greater risk for melanoma. Evolving melanoma lesions show changes in shape, size, color, or other characteristics over time. Actinic keratosis consists of hyperkeratotic papules and plaques on sun-exposed areas. Basal cell carcinoma is related to excessive sun exposure, genetic skin type, x-ray radiation, scars, and some types of nevi and may not be due to medications. The chemicals in some medications such as ketoconazole and methotrexate absorb light when exposed to natural sunlight and release energy that harms cells and tissues, which is known as a photosensitizing effect
A client recently had an abdominoperineal resection and colostomy. While the nurse changes the dressing, the client states, "You think that it looks repulsive." The nurse identifies that the client is using which defense mechanism? 1 Projection 2 Sublimation 3 Compensation 4 Intellectualization
1. Projection is the attribution of unacceptable feelings and emotions onto others. Sublimation is the substitution of socially acceptable feelings or instincts to replace those that are threatening to the ego. Compensation is overachievement in a more comfortable area, thereby covering up a weakness. Intellectualization is the use of mental reasoning processes to deny facing emotions and feelings involved in a situation.
The nurse is caring for a 75-year-old client who had radical head and neck surgery. Thirty minutes after awakening from anesthesia, the client becomes agitated, disoriented, and confused. Which action would the nurse take? Adminsiter prescribed oxygen Administer the prescribed antianxiety medication Notify HCP immediately Record observations and continue to observe the client
1. The cardiovascular and nervous systems of older adults are less flexible than those in a younger age group; postoperative hypoxia responds to oxygen. Notifying HCP is unneccesary because it is a common reaction of older adults to anesthesia, which may be alleviated by oxygen. Although neccesary, recording the observations will not help the client. An anxiolytic may increase agitation.
A client has a leaking thoracic duct after a radical neck surgery. The nurse expects that the postoperative plan of care will include which prescriptions? A gastrostomy tube, a high-fat diet, and bed rest A chest tube, TPN, and bed rest A rectal tube, low-fat diet, and increased activity An NG tube, a moderate-fat diet, and increased activity
2. A chest tube drains the leaking chyle from the thoracic area; TPN provides nutrition, boosts immune defenses, and decreases thoracic duct flow. Bed rest is recommended because lymphatic flow increases with activity. A gastrostomy tube is not used because the client can eat and drink; a high-fat diet is contraindicated, but bed rest is recommended. A rectal tube has no relationship to the drainage of chyle from the thoracic area; a low-fat diet and bed rest are recommended. A low-fat diet of medium-chain triglycerides will reduce the production and flow of chyle.
A severely burned client has been hospitalized for 3 days and is now in the acute phase. Until now recovery has been uneventful, but the client begins to exhibit extreme restlessness. Which complication would the nurse conclude the client is most likely developing? Kidney failure Cerebral hypoxia Metabolic acidosis Hypovolemic shock
2. Cerebral cells require high levels of oxygen. When the partial pressure of oxygen within the circulatory system falls, the client becomes restless, and cognitive functions become impaired. With kidney failure the client becomes progressively confused and lethargic because of the buildup of toxins in the body. Hypovolemic shock is more likely to occur in the emergent (resuscitation) phase. With metabolic acidosis the client is lethargic.
When teaching a client with peripheral arterial disease about the prescribed walking program, which action will the nurse tell the client to take if leg cramps occur with walking? Chew 1 aspirin to relieve pain Stop to rest until pain resolves Walk more slowly while pain is present Notify HCP about pain
2. During an exercise program for peripheral arterial disease, the client walks to the point of claudication, stops and rests until the pain resolves, and then walks a little farther. Because the pain is caused by ischemia of the muscles, aspirin will not relieve the pain. Muscles will still be ischemic if the client continues to walk, even if walking pace is slower. Because pain with exercise is expected in clients with intermittent claudication, the nurse would not teach the client to notify the provider about the pain.
When a client is admitted to the postanesthesia care unit after surgery, how frequently will the nurse plan to assess the blood pressure? Every 3-5 minutes Every 10-15 minutes Every 20-30 minutes Every 40-60 minutes
2. During the first 2 postoperative hours, the BP is monitored every 10-15 minutes to detect unstable VS that may indicate shock. Checking every 3-5 minutes is unneccesary, unless the client becomes hemodynamically unstable. Checking every 20 minutes or longer is unsafe.
A client develops subcutaneous emphysema after a chest injury with a suspected pneumothorax. Which method would the nurse use to assess for this complication? Percussing the neck and chest Palpating neck or face Auscultating for abnormal breath sounds Observing for asymmetry of chest movement
2. Subcutaneous emphysema refers to the presence of air in the tissue that surrounds an opening in the normally closed respiratory tract; the tissue appears puffy and a crackling sensation is detected when trapped air is compressed between the njurse's palpating fingertips and the client's tissue. Percussion is not appropaite; breath sounds are not affected. Asymmetry of chest movements may occur because of the pneumothorax, not the subcutaneous emphysema.
While changing a newborn girl's diaper, the nurse ovserves a brick-red stain on the diaper. How would the nurse interpret this clinical finding? A sign of low iron excretion An uncommon benign occurence An expected occurence in female newborns The result of medications administered during labor
2. The brick-red color in the urine is caused by albumin and urates that are found in the first week of life. Iron is eliminated by way of the gastrointestinal tract. The finding is unrelated to the sex of the infant; it is not hormonally based. No medication administered during labor will cause this discoloration.
When a client with varicose veins has knee-length elastic support stockings prescribed, which information would the nurse include in client teaching? Pull the stocking on to mid-calf height Pull the stockings on before getting out of bed Wear the stocking at the first sign if discomfort Use elastic bandages if he stockings are too tight
2. To prevent distention of the veins, the stockings should be applied before the legs are placed in a dependent position. Knee-high stockings should end 2 inches (5 cm) below the knee to avoid popliteal pressure, which limits venous return. The stockings should be used preventatively before the discomfort associated with venous pressure and edema occurs. If the stockings are too tight, the client should be measured for larger stockings, because elastic bandages may slip when the client is active and be ineffective in applying adequate pressure.
Which parameter monitoring would be priority while caring for a client with hypothyroidism? Pulse rate BP Respiratory rate Body temperature
3. Hypothyroidism is associated with a decreased respiratory rate. Therefore, monitoring the client's respiratory rate should be the nurse's top priority. Although hypotension, hypothermia, and pulse rate are important, they are not priority.