Med surg exam 1 set 2
An older adult has asthma and asks the nurse about taking the pneumonia vaccine. The nurse should tell the patient:
"You should receive the vaccine."
The nurse is gathering a health history from a patient with a chief complaint of dizziness for one week. Past medical history includes hypertension and permanent pacemaker insertion 1 year prior. Which of the following sets vital signs helps to confirm a pacemaker malfunction?
BP 118/80 Pulse 50 Oxygen Saturation 93%
To improve cardiopulmonary function in a patient in acute heart failure, the nurse should assist the patient to which of the following positions?
High Fowler's, pillows under arms
While assessing a thoracotomy incisional area from which a chest tube exits, the nurse feels a crackling sensation under the fingertips along the entire incision. What should the nurse do next?
Mark the area with a skin pencil at the outer periphery of the crackling.
A nurse is caring for a client who recently underwent a tracheostomy. What is the nurse's first priority when caring for this client?
Suctioning to keep the airway patent.
Which of the following assessment findings would help confirm a diagnosis of decreased cardiac output and impaired tissue perfusion in a patient with left ventricular failure?
Urine output 10 ml/hour
A client with peripheral vascular disease has poor circulation. The nurse should assess the client for which of the following? Select all that apply.
a. Nail bed color. c. Pain in extremity. e. Skin temperature.
The nurse is providing pre-procedure information for a patient scheduled for a cardiac stress test scheduled at 12 noon the following day. Which of the following responses by the patient would indicate understanding of the preparation necessary for this procedure?
"I should not smoke before the exam."
A patient who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when the patient says:
"I'll stop being contagious when I have a negative acid-fast bacilli test."
The nurse is preparing to discharge a 84 year old client from the hospital on Digoxin (lanoxin) and diuretic therapy. What teaching would be most important for the nurse to include in the discharge teaching plan?
"Report gastrointestinal and visual distrubances
A patient with a history of heart failure is being discharged. Which priority instruction will assist the client in promoting health self-management and the prevention of complications associated with heart failure?
"Weigh yourself daily while wearing the same amount of clothing."
A patient has a tuberculin skin test as a pre-employment physical requirement. Which statement by the nurse is best made to the client who has the test result seen in the photograph below?
"You will need further testing."
The order reads: Heparin 2500 units sq q12h. On hand is Heparin 5,000 units/ml How many mls will the nurse inject?
0.5
The nurse is caring for a patient with a right chest tube. Which of the following assessment findings would require immediate intervention by the nurse? (Select all that apply.)
10 ml of serous drainage in the collection chamber Tracheal deviation bubling in the water seal chamber upon inspiration Tidaling in the water seal chamber with respirations absent breath sounds in right lung fields
On rounds at 7am the nurse notes that there is 500 ml LIB (left in the bag) of a client's Lactated Ringers IV solution. The IV order reads: LR 1000ml at 150ml/hr. If the IV is infusing correctly how many mls will be LIB at 9am?
200
The health care provider orders 900 units/hour of Heparin IV drip. The pharmacy delivers 25,000 units of Heparin in 250 ml of NS. Using a microdrip tubing, the nurse should administer how many ml/hr?
9
During morning assessment, a nurse assesses four clients. Which client is the priority for follow up?
A 73-year-old client who has pneumonia with coarse crackles, is receiving 2 L/minute of oxygen, and has an I.V. line.
A patient with bacterial pneumonia is coughing up tenacious, purulent sputum. Which measure would most likely help liquefy these viscous secretions?
Administering intravenous fluids.
During routine vital sign assessment the nurse notes a paitent to have a regular apical pulse of 49 beats per minute. What action should the nurse take next?
Assess blood pressure
The nurse is assessing a patient with COPD exacerbation. Scattered wheezes and rhonchi are noted, and the patient's oxygen saturation is 85%. What other assessments are essential for the nurse to perform? (Select all that apply.)
Assess for accessory muscle use Assess the suprasternal notch. Assess mucous membranes Assess blood pressure and heart rate
A high school athlete presents to the emergency department with a nasal fracture. What priority action should the nurse perform?
Assess for airway patency
The nurse is caring for a patient on the telemetry unit who is 4 days post myocardial infarction (MI) and notes the following rhythm on the cardiac monitor. Which of the following priority actions should the nurse take upon entering the patient's room?
Assess for responsiveness and pulse
A patient with chronic obstructive pulmonary disease (COPD) is recovering from a right lobectomy. Because the patient is extremely weak and can't produce an effective cough, the nurse should monitor closely for which of the following?
Atelectasis
The nurse assesses a client with pneumonia and notes decreased lung sounds on the left side and decreased lung expansion. What is the nurse's best action?
Check oxygen saturation and notify the health care provider.
The nurse is concerned that a patient who is not entirely reliable is being discharged home on therapy for multidrug-resistant tuberculosis. What medication adminsitration strategy is the best to use for this patient?
Directly observed therapy
The nurse is assessing a patient who underwent percutaneous coronary intervention (PCI) eight hours ago and notes the patient's right leg is cool to touch and mottled. Which of the following actions should the nurse take?
Escalate care to the primary health care provider immediately
A patient is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Physician prescriptions include the following: oxygen 2 L/minute via nasal canula, may increase to 4L/min as needed,oximetry at all times, and I.V. administration of 5% dextrose in water at 100 ml/hour. The patient has increasing dyspnea, is restless, and has a respiratory rate of 32 breaths/minute. The nurse should first:
Increase the oxygen flow rate from 2 to 4 L/minute.
The nurse administers intravenous dobutamine (Dobutrex) to a patient in acute heart failure. Which clinical manifestations indicate that the patient's status is improving? (Select all that apply.)
Increased heart rate Improved cogntion Increased respiratory rate Capillary refill 2 seconds Increased pulse strength
A client with a deflated cuffed tracheostomy tube goes into respiratory arrest and becomes unresponsive. After calling for help, what action should the nurse take?
Inflate the cuff and ventilate with an ambu-bag
A client tells the nurse at an outpatient clinic that after he walks a few blocks he has bilateral leg pain, but that the pain goes away when he stops walking. This describes what clinical manifestation of peripheral arterial disease?
Intermittent Claudication
What is the best way for the nurse to decrease the risk of ventilator-associated pneumonia (VAP) in a ventilator-dependent client? (Select all that apply.)
Perform chest percussion frequently Keep the head of the bed elevated Provide prophylactic antibiotics. Provide frequent oral care Maintain good hand hygiene
The nurse is caring for a patient with left-sided heart failure. Which of the following assessment
Pulmonary crackles Dependent edema Jugular vein distention Cough worsens at night S3/S4 summation gallop Confusion, restlessness
The nurse is caring for a patient with a history of COPD and notes the patient is receiving oxygen via nasal cannula at 10 L/min, has a respiratory rate of 7, and is lethargic. Which of the following actions by the nurse would be a priority?
Reduce the oxygen level
The nurse is discussing appropriate food selections with patient on a low-cholesterol, low sodium diet. Which food selections by the patient would indicate that teaching was effective?
Skim milk, oatmeal, banana, apple juice, tea
The nurse is caring for a patient with a diagnosis of atrial fibrillation and has included ongoing assessment for complications of this health problem in the plan of care. Which of the following patient data would alert the nurse to a possible serious complication of this health problem.
Speech alterations
On a routine visit to the health care provider, a patient with chronic arterial occlusive disease reports that they stopped smoking after 34 years. To relieve symptoms of intermittent claudication, the patient asks what additional measures can the nurse recommend?
Take daily walks.
The nurse gives a report to the next shift about a ventilated client. She indicates that the ventilator has frequently been alarming "high pressure," but that she has not had time to assess the client. The oncoming nurse notes that the patient's 02 sat has decreased to 87% and heart rate increased to 110. The patient is restless with asymmetrical chest rise. Which of the following would best explain this change in vital signs and physical assessment?
The patient developed a pneumothorax
The nurse is preparing to begin discharge planning for a patient treated for a pulmonary embolism. Which factor has first priority during this process?
The patient's identified needs and goals.
The nurse evaluates diagnostic results for a patient who was admitted for evaluation of chest pain. Which laboratory test is most specific for acute coronary syndromes?
Troponin markers
Which interventions help to prevent aspiration during eating for a patient with atracheostomy
a. Instruct the patient to dry swallow to clear food particles from the throat b. Let the patient indicate readiness for another bite when being fed c. Have the patient tuck the chin down and forward while swallowing d. Provide close supervision for the patient during eating and drinking e. Add liquids to foods to make them thinner and easier to swallow
What interventions should the nurse provide when a patient presents with epistaxis?
assist the patient to sit up, lean forward,and apply direct pressure by pinching the entire soft lower portion of the nose
At 11 p.m., a male client is admitted to the emergency department. He is anxious with audible wheezes and has a respiratory rate of 44. The client is given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client's arterial blood oxygen saturation level is 92% and he's still wheezing. The nurse should plan to administer which of the following?
c. Albuterol (Proventil).
The nurse is caring for several clients on the respiratory unit who are receiving the adrenergic agonist bronchodilator albuterol (Accuneb) in the prescribed nebulizer treatments. Which side effects would the nurse expect to assess following administration? Select all that apply.
c. Anxiety e. Irritability and nervousness f. Tachycardia a. Increased tachypnea b. Increased somnolence
The nurse is caring for a patient on a mechanical ventilator when the high-pressure alarm sounds. What actions are most appropriate?
c. Assess the tubing for kinks. d. Determine the need for suctioning. e. Auscultate the client's lungs.
Upon transferring a patient from the stretcher to bed, his chest tube was pulled out and is lying on the floor. Describe what immediate action you will take to maintain your patient's safety. List 2 actions in order of priority.
call for help apply an occlusive dressing (or 3 sided dressing)
A patient who was admitted with symptoms of hypoxemia, is changed from a 40% venti-mask to a nasal cannula for oxygen delivery. The nurse realizes that this patient's condition is:
d. Improving.
To prevent post-procedure complications, nursing care of a patient following percutaneous coronary intervention (PCI) generally would include:
encourage increased fluid intake
Which information would be most important for the emergency department nurse to communicate to the medical team for a patient who has just been diagnosed with an acute myocardial infarction?
history of peptic ulcer disease
A 72 year old male patient presents to the community clinic with complaints of bilateral lower leg pain upon walking more than one block. Past medical history includes: HTN, CAD, and angina. Assessment findings include: cool lower extremities, pedal pulses +1/3, and decreased hair on lower extremities. A medical diagnosis of intermittent claudication is made by the provider. Which of the following nursing diagnoses will the nurse use to develop and implement a plan of care?
ineffective peripheral tissue perfusion
A patient with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold left calf. While the health care provider determines the appropriate therapy, the nurse should:
keep the affected leg level or slightly dependent.
The nurse is caring for a patient with a diagnosis of DVT who receiving a continuious IV heparin infusion. The morning PTT lab result is 131 seconds (normal 25 to 30 seconds). What actions should the nurse take? (Select all that apply)
notify the provider turn off the infusion institute bleeding precautions
When caring for a patient immediately post- MI, the nurse's first priority would be
relieving pain.
