MedSurg Quiz 3

A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take?

d. Gather appropriate equipment and prepare for an emergency airway.

A student nurse asks for an explanation of refractory hypoxemia. What answer by the nurse instructor is best?

d. It is hypoxemia that persists even with 100% oxygen administration

A client has the diagnosis of valley fever accompanied by myalgias and arthralgias. What treatment should the nurse educate the client on?

d. Oral fluconazole (Diflucan)

A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important?

d. What is your occupation?

A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question should the nurse ask first?

d. What medications are you taking?

A client has been hospitalized with tuberculosis (TB). The clients spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best?

a. Ask the spouse to explain the fear of visiting in further detail.

A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?

a. Assess for other manifestations of hypoxia.

A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?

a. Assess the cause of the agitation.

A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying I have been drinking tons of water. How am I dehydrated? What response by the nurse is best?

a. Breathing so quickly can be dehydrating.

A nurse assesses a client who has a chronic skin disorder. Which finding indicates the client is effectively coping with the disorder?

a. Clean hair and nails

A nurse administers topical gentamicin sulfate (Garamycin) to a clients burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy?

a. Creatinine

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority?

a. Educating the client on adherence to the treatment regimen

The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury?

a. It is normal to feel some depression.

A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity?

a. Keep the water temperature constant when showering the client.

A nurse assesses a client who has open lesions. Which action should the nurse take first?

a. Put on gloves.

A nurse assesses a client who has two skin lesions on his chest. Each lesion is the size of a nickel, flat, and darker in color than the clients skin. How should the nurse document these lesions?

a. Two 2-cm hyperpigmented patches

A nurse assesses a client who is admitted with inflamed soft-tissue folds around the nail plates. Which question should the nurse ask to elicit useful information about the possible condition?

a. What do you do for a living?

During skin inspection of a client, a nurse observes lesions with wavy borders that are widespread across the clients chest. Which descriptors should the nurse use to document these observations?

b. Linear and circinate

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?

b. Notify the Rapid Response Team.

An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best?

b. Older people often have vague symptoms, so an x-ray is essential.

While assessing a clients lower extremities, a nurse notices that one leg is pale and cooler to the touch. Which assessment should the nurse perform next?

b. Palpate the clients pedal pulses bilaterally

A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred?

b. Platelet count: 82,000/L

A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals the client has an alteration in the gene CYP2C19. What action by the nurse is best?

b. Prepare preoperative teaching for an inferior vena cava (IVC) filter.

A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management?

b. Strict vegetarian

Which teaching point is most important for the client with bacterial pharyngitis?

b. Take all antibiotics as directed.

A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication?

b. Urine output of 20 mL/hr

While assessing a client, a nurse detects a bluish tinge to the clients palms, soles, and mucous membranes. Which action should the nurse take next?

b. Use pulse oximetry to assess the clients oxygen saturation.

A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority?

a. Alteplase (Activase)

The emergency department (ED) manager is reviewing client charts to determine how well the staff performs when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met?

a. Antibiotics started before admission

An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first?

a. Apply oxygen and continuous pulse oximetry.

A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication?

b. Large chefs salad and muffin

A nurse working in a geriatric clinic sees clients with cold symptoms and rhinitis. Which drug would be appropriate to teach these clients to take for their symptoms?

c. Fexofenadine (Allegra)

A nurse admits a client from the emergency department. Client data are listed below: History Physical Assessment Laboratory Values 70 years of age History of diabetes On insulin twice a day Reports new-onset dyspnea and productive cough Crackles and rhonchi heard throughout the lungs Dullness to percussion LLL Afebrile Oriented to person only WBC: 5,200/mm3 PaO2 on room air 65 mm Hg What action by the nurse is the priority?

a. Administer oxygen at 4 liters per nasal cannula.

A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the clients pain?

a. Administer the prescribed intravenous morphine sulfate

A client in the emergency department has several broken ribs. What care measure will best promote comfort?

a. Allowing the client to choose the position in bed

A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The clients urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question?

b. Administer furosemide (Lasix) 40 mg IV push.

A client has been taking isoniazid (INH) for tuberculosis for 3 weeks. What laboratory results need to be reported to the health care provider immediately?

b. Alanine aminotransferase (ALT): 180 U/L

A client is in the family medicine clinic reporting a dry, sore throat. The provider asks the nurse to assess for odynophagia. What assessment technique is most appropriate?

b. Assess the client for pain when swallowing.

The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination?

b. Change gloves between wound care on different parts of the clients body.

A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse?

b. Choosing an 18-gauge, 2-inch needle

The charge nurse on a medical unit is preparing to admit several clients who have possible pandemic flu during a preparedness drill. What action by the nurse is best?

b. Cohort the clients in the same area of the unit.

A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take?

b. Draw blood for a carboxyhemoglobin level.

A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?

b. Ensuring there is a bag-valve-mask in the room

A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information Laboratory Analysis Physical Assessment Shortness of breath for 20 minutes Feels frightened Cant catch my breath pH: 7.12 PaCO2 : 28 mm Hg PaO2 : 58 mm Hg SaO2 : 88% Pulse: 120 beats/min Respiratory rate: 34 breaths/min Blood pressure 158/92 mm Hg Lungs have crackles What action by the nurse is most appropriate?

b. Facilitate a STAT pulmonary angiography.

A client is in the family practice clinic reporting a severe cough that has lasted for 5 weeks. The client is so exhausted after coughing that work has become impossible. What action by the nurse is most appropriate?

b. Facilitate polymerase chain reaction testing.

A nurse assesses a client and identifies that the client has pallor conjunctivae. Which focused assessment should the nurse complete next?

b. Hemoglobin and hematocrit

A client is on intravenous heparin to treat a pulmonary embolism. The clients most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?

b. Increase the heparin rate.

A client seen in the emergency department reports fever, fatigue, and dry cough but no other upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the nurse is best?

b. Inform the client that antibiotics will be needed for 60 days.

A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the clients body that sustained burns?

c. 27%

A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first?

c. Auscultate breath sounds over the trachea and bronchi.

A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?

c. Ensure a patent airway.

A nurse reviews the following data in the chart of a client with burn injuries: Admission Notes Wound Assessment 36-year-old female with Bilateral leg burns present Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 206 Downloaded by josie urbina ([email protected]) lOMoARcPSD|5644690 bilateral leg burns NKDA Health history of asthma and seasonal allergies with a white and leatherlike appearance. No blisters or bleeding present. Client rates pain 2/10 on a scale of 0- 10. Based on the data provided, how should the nurse categorize this clients injuries?

c. Full thickness

After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the clients understanding. Which statement indicates the client has a good understanding of this condition?

c. I can use powder to keep this area dry.

A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance?

c. I will bathe and dress before breakfast.

A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this clients discharge teaching?

c. I will demonstrate how to change your wound dressing for you and your family

A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective?

c. I will take this medication on an empty stomach.

A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority?

c. Interrupt the procedure to give oxygen.

A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, Why am I taking this medication? How should the nurse respond?

c. It helps prevent stomach ulcers, which are common after burns

An intubated clients oxygen saturation has dropped to 88%. What action by the nurse takes priority?

c. Listen to the clients lung sounds.

After assessing an older adult client with a burn wound, the nurse documents the findings as follows: Vital Signs Laboratory Results Wound Assessment Heart rate: 110 beats/min Blood pressure: 112/68 mm Hg Respiratory rate: 20 Red blood cell count: 5,000,000/mm3 White blood cell count: 10,000/mm3 Platelet count: 200,000/mm3 Left chest burn wound, 3 cm 2.5 cm 0.5 cm, wound bed pale, surrounding tissues with edema Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 207 Downloaded by josie urbina ([email protected]) lOMoARcPSD|5644690 breaths/min Oxygen saturation: 94% Pain: 3/10 present Based on the documented data, which action should the nurse take next?

c. Prepare to obtain blood and wound cultures.

A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?

c. Provide frequent oral care per protocol.

A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)?

c. Provide oral care every 4 hours.

A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately?

c. Serum potassium: 6.5 mEq/L

The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern?

c. Sometimes I wake up at night and smoke.

A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate?

c. Teach the client about factor V Leiden testing.

A nurse cares for an older adult client who has a chronic skin disorder. The client states, I have not been to church in several weeks because of the discoloration of my skin. How should the nurse respond?

c. Tell me more about your concerns related to your skin.

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen saturation has not significantly improved. What response by the nurse is best?

c. The blood clot interferes with perfusion in the lungs.

A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful?

c. Try warm, moist heat packs on your face.

A nurse cares for a client who has facial burns. The client asks, Will I ever look the same? How should the nurse respond?

c. You will not look exactly the same but cosmetic surgery will help.

A client is on mechanical ventilation and the clients spouse wonders why ranitidine (Zantac) is needed since the client only has lung problems. What response by the nurse is best?

d. It will prevent ulcers from the stress of mechanical ventilation.

A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next?

d. Place the client in an upright position.

A client is brought to the emergency department after sustaining injuries in a severe car crash. The clients chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority?

d. Prepare to assist with intubation.

A client is in the family practice clinic reporting a severe cold that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best?

d. Teach the client to sneeze in the upper sleeve.

A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority?

d. The upper peak airway pressure limit alarm is on.

A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate?

d. Visiting Nurses for directly observed therapy

The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client?

d. Wash your hands on entering the clients room.

A nurse cares for a client who has burn injuries. The clients wife asks, When will his high risk for infection decrease? How should the nurse respond?

d. When all of his burn wounds have closed.