Med-Surg Exam #3
Which adult will the nurse plan to teach about risks associated with obesity? a. Man who has a BMI of 18 kg/m2 b. Man with a 42 in waist and 44 in hips c. Woman who has a body mass index (BMI) of 24 kg/m2 d. Woman with a waist circumference of 34 inches (86 cm)
ANS: B The waist-to-hip ratio for this patient is 0.95, which exceeds the recommended level of <0.80. A patient with aBMI of 18 kg/m2 is considered underweight. A BMI of 24 kg/m2 is normal. Health risks associated withobesity increase in women with a waist circumference larger than 35 in (89 cm) and men with a waistcircumference larger than 40 in (102 cm).
The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient's postoperative care? A. Bed rest for the first 24 hours B. Positioning only on the right side C. Frequent use of an incentive spirometer D. Chest tube placement to continuous suction
ANS: C Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. In a pneumonectomy, chest tubes may or may not be placed in the space from which the lung was removed. If a chest tube is used, it is clamped and only released by the surgeon to adjust the volume of serosanguineous fluid that will fill the space vacated by the lung. If the cavity overfills, it could compress the remaining lung and compromise cardiovascular and pulmonary function. Daily chest x-rays can be used to assess the volume and space.
Which statement by the nurse is most likely to help a morbidly obese 22-year-old man in losing weight on a 1000-calorie diet? A. It will be necessary to change lifestyle habits permanently to maintain weight loss B. You will decrease your risk for future health problems such as diabetes by losing weight now C. You are likely to notice changes in how you feel with just a few weeks of diet and exercise D. Most of the weight that you lose during the first weeks of dieting is water weight rather than fat.
ANS: C Motivation is a key factor in successful weight loss and a short-term outcome provides a higher motivation. A22-year-old patient is unlikely to be motivated by future health problems. Telling a patient that the initialweight loss is water will be discouraging, although this may be correct. Changing lifestyle habits is necessary,
After successfully losing 1 lb weekly for several months, a patient at the clinic has not lost any weight forthe last month. The nurse should first a. review the diet and exercise guidelines with the patient. b. instruct the patient to weigh and record weights weekly. c. ask the patient whether there have been any changes in exercise or diet patterns. d. discuss the possibility that the patient has reached a temporary weight loss plateau.
ANS: C The initial nursing action should be assessment of any reason for the change in weight loss. The other actionsmay be needed, but further assessment is required before any interventions are planned or implemented.
What information will the nurse include for an overweight 35-year-old woman who is starting a weightlossplan? a. Weigh yourself at the same time every morning and evening. b. Stick to a 600- to 800-calorie diet for the most rapid weight loss.Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 472 c. Low carbohydrate diets lead to rapid weight loss but are difficult to maintain. d. Weighing all foods on a scale is necessary to choose appropriate portion sizes.
ANS: C The restrictive nature of fad diets makes the weight loss achieved by the patient more difficult to maintain.Portion size can be estimated in other ways besides weighing. Severely calorie-restricted diets are notnecessary for patients in the overweight category of obesity and need to be closely supervised. Patients shouldweigh weekly rather than daily.
A 61-year-old man is being admitted for bariatric surgery. Which nursing action can the nurse delegate tounlicensed assistive personnel (UAP)? a. Demonstrate use of the incentive spirometer. b. Plan methods for bathing and turning the patient. c. Assist with IV insertion by holding adipose tissue out of the way. d. Develop strategies to provide privacy and decrease embarrassment.
ANS: C UAP can assist with IV placement by assisting with patient positioning or holding skinfolds aside. Planning for care and patient teaching require registered nurse (RN)level education and scope of practice.
The nurse is assessing a 22-year-old patient experiencing the onset of symptoms of type 1 diabetes. Which question is most appropriate for the nurse to ask?a. Are you anorexic?b. Is your urine dark colored?c. Have you lost weight lately?d. Do you crave sugary drinks?
ANS: CWeight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar-containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute.
After vertical banded gastroplasty, a 42-year-old male patient returns to the surgical nursing unit with anasogastric tube to low, intermittent suction and a patient-controlled analgesia (PCA) machine for pain control.Which nursing action should be included in the postoperative plan of care? A. Offer sips of fruit juices at frequent intervals. B. Irrigate the nasogastric (NG) tube frequently. C. Remind the patient that PCA use may slow the return of bowel function. D. Support the surgical incision during patient coughing and turning in bed.
ANS: D The incision should be protected from strain to decrease the risk for wound dehiscence. The patient should beencouraged to use the PCA because pain control will improve the cough effort and patient mobility. NGirrigation may damage the suture line or overfill the stomach pouch. Sugar-free clear liquids are offered duringthe immediate postoperative time to decrease the risk for dumping syndrome.
A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first? A. Administer anticoagulant drug therapy. B. Notify the patient's health care provider. C. Prepare the patient for a spiral computed tomography (CT). D. Elevate the head of the bed to a semi-Fowler's position.
ANS: D The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and O2 is started). A spiral CT may be ordered by the health care provider to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE.
A 28-year-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching? a. The patient always carries hard candies when engaging in exercise. b. The patient goes for a vigorous walk when his glucose is 200 mg/dL. c. The patient has a peanut butter sandwich before going for a bicycle ride. d. The patient increases daily exercise when ketones are present in the urine.
ANS: D When the patient is ketotic, exercise may result in an increase in blood glucose level. Type 1 diabetic patients should be taught to avoid exercise when ketosis is present. The other statements are correct.
The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? A. A 23-yr-old patient with cystic fibrosis who has pulmonary function testing scheduled B. A 46-yr-old patient on bed rest who is complaining of sudden onset of shortness of breath C. A 77-yr-old patient with tuberculosis (TB) who has four medications due in 15 minutes D. A 35-yr-old patient who was admitted with pneumonia and has a temperature of 100.2° F (37.8° C)
B. A 46-yr-old patient on bed rest who is complaining of sudden onset of shortness of breath Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as O2 administration. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.
The surgical nurse is caring for a client who is postoperative day 1 following a thyroidectomy. The client reports tingling in her lips and fingers. She states that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should the nurse first suspect?A. Hypophosphatemia B. Hypocalcemia C. Hypermagnesemia D. Hyperkalemia
B. Hypocalcemia
A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance? A. Respiratory acidosis B. Respiratory alkalosis C. Increased PaCO2 D. CNS disturbances
B. Respiratory alkalosis
A medical nurse educator is reviewing a client's recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis? A. The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. B. The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. C. The kidneys react rapidly to compensate for imbalances in the body. D. The kidneys regulate the bicarbonate level in the intracellular fluid.
B. The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.
When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? A. HCO 21 mEq/L B. pH 7.48 C. PaCO 36 D. O saturation 95%
B. pH 7.48
Which set of arterial blood gas (ABG) results requires further investigation? A. pH 7.38, partial pressure of arterial carbon dioxide (PaCO2) 36 mm Hg, partial pressure of arterial oxygen (PaO2) 95 mm Hg, bicarbonate (HCO3-) 24 mEq/L B. pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/LpH 7.44, PaCO2 43 mm Hg, PaO2 99 mm Hg, and HCO3- 26 mEq/L C. pH 7.35, PaCO2 40 mm Hg, PaO2 91 mm Hg, and HCO3- 22 mEq/L
B. pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/LpH 7.44, PaCO2 43 mm Hg, PaO2 99 mm Hg, and HCO3- 26 mEq/L
A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution? A. Neutral B. Alkaline C. Acidic D. Basic
C. Acidic
To evaluate a client for hypoxia, the physician is most likely to order which laboratory test? A. Red blood cell count B. Sputum culture C. Total hemoglobin D. Arterial blood gas (ABG) analysis
D. Arterial blood gas (ABG) analysis
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? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis
D. Metabolic acidosis
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: A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
D. Respiratory alkalosis
A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings? A. Metabolic acidosis B. Respiratory acidosis C. Metabolic alkalosis D. Respiratory alkalosis
D. Respiratory alkalosis
The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
Metabolic acidosis
A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is most important for the nurse to ask? A. "How much alcohol do you drink in an average week?" B. "Do you have a family history of head or neck cancer?" C. "Have you had frequent streptococcal throat infections?" D. "Do you use antihistamines for upper airway congestion?"
A. "How much alcohol do you drink in an average week?" Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patient's symptoms are not suggestive of this diagnosis. Streptococcal throat infections also may cause these clinical manifestations, but patients with this type of infection will also have pain and a fever.
A client with emphysema is at a greater risk for developing which acid-base imbalance? A. Chronic respiratory acidosis B. Metabolic alkalosis C. Metabolic acidosis D. Respiratory alkalosis
A. Chronic respiratory acidosis
A client who complains of an "acid stomach" has been taking baking soda (sodium bicarbonate) regularly as a self-treatment. This may place the client at risk for which acid-base imbalance? A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Respiratory alkalosis
A. Metabolic alkalosis
A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? A. Prepare to assist with ventilation. B. Monitor the client's heart rhythm. C. Prepare for gastric lavage. D. Obtain a urine specimen for drug screening.
A. Prepare to assist with ventilation.
A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? A. Respiratory acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Metabolic acidosis
A. Respiratory acidosis
A client is diagnosed with hypocalcemia and the nurse is teaching the client about symptoms. What symptom would the nurse include in the teaching? A. Tingling sensation in the fingers B. Polyuria C. Flank pain D. Hypertension
A. Tingling sensation in the fingers
To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply. A. pH B. PaCO2 C. HCO3 D. Glucose E. Na+ F. K+
A. pH B. PaCO2 C. HCO3
When teaching a patient about testing to diagnose metabolic syndrome, which topic would the nurse include? a. Blood glucose test b. Cardiac enzyme tests c. Postural blood pressures d. Resting electrocardiogram
ANS: A A fasting blood glucose test >100 mg/dL is one of the diagnostic criteria for metabolic syndrome. The othertests are not used to diagnose metabolic syndrome although they may be used to check for cardiovascularcomplications of the disorder.
The nurse is coaching a community group for individuals who are overweight. Which participant behavior isan example of the best exercise plan for weight loss? A. Walking for 40 minutes 6 or 7 days/week B. Lifting weights with friends 3 times/week C. Playing soccer for an hour on the weekend D. Running for 10 to 15 minutes 3 times/week
ANS: A Exercise should be done daily for 30 minutes to an hour. Exercising in highly aerobic activities for short burstsor only once a week is not helpful and may be dangerous in an individual who has not been exercising.Running may be appropriate, but a patient should start with an exercise that is less stressful and can be donefor a longer period. Weight lifting is not as helpful as aerobic exercise in weight loss.
The nurse will be teaching self-management to patients after gastric bypass surgery. Which information willthe nurse plan to include? A. Drink fluids between meals but not with meals. B. Choose high-fat foods for at least 30% of intake. C. Developing flabby skin can be prevented by exercise. D. Choose foods high in fiber to promote bowel function.
ANS: A Intake of fluids with meals tends to cause dumping syndrome and diarrhea. Food choices should be low in fat and fiber. Exercise does not prevent the development of flabby skin.
The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? A. Document the amount of drainage every 8 hours B. Obtain samples of drainage for culture from the system C. Assess patient pain level associated with the chest tube D. Check the water-seal chamber for the correct fluid level
ANS: A UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel.
Which nursing action is appropriate when coaching obese adults enrolled in a behavior modification program? A. Having the adults write down the caloric intake of each meal B. Asking the adults about situations that tend to increase appetite C. Suggesting that the adults plan rewards, such as sugarless candy, for achieving their goals D. Encouraging the adults to eat small amounts frequently rather than having scheduled meals
ANS: B Behavior modification programs focus on how and when the person eats and de-emphasize aspects such as calorie counting. Nonfood rewards are recommended for achievement of weight-loss goals. Patients are oftentaught to restrict eating to designated meals when using behavior modification.
Which assessment action will help the nurse determine if an obese patient has metabolic syndrome? a. Take the patients apical pulse. b. Check the patients blood pressure. c. Ask the patient about dietary intake. d. Dipstick the patients urine for protein.
ANS: B Elevated blood pressure is one of the characteristics of metabolic syndrome. The other information also may beobtained by the nurse, but it will not assist with the diagnosis of metabolic syndrome.
The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which acid-base imbalance. A. Metabolic acidosis B. Respiratory acidosis C. Metabolic alkalosis D. Respiratory alkalosis
A. Metabolic acidosis
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? A. Headache or blurry vision B. Abdominal pain or diarrhea C. Hallucinations or tinnitus D. Light-headedness or paresthesia
D. Light-headedness or paresthesia
