Med Surg Exam #4

Chapter 41 1. Which risk factor would the nurse focus on when teaching a patient who has a 5-cm abdominal aortic aneurysm? a. Male gender b. Hypertension c. Age over 60 years d. Family history of vascular disease

B

25. The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? a. Skin cool and clammy b. Heart rate of 118 beats/min c. Blood pressure of 92/56 mm Hg d. O2 saturation of 93% on room air

A

. When assessing a patient with possible peripheral artery disease (PAD), the nurse obtains a brachial blood pressure (BP) of 154/82 mm Hg and an ankle pressure of 112/74 mm Hg. The nurse calculates the patient's ankle-brachial index (ABI) as (round up to the nearest hundredth).

0.73

10. A 78-kg patient in septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. After initial fluid volume resuscitation, the patient's urine output has been 30 mL/hr for the past 3 hours. Which intervention prescribed by the health care provider would the nurse question? a. Administer furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 250 mL/hr. c. Give hydrocortisone (Solu-Cortef) 100 mg IV.

A

16. A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is high, and cardiac output is low. Which treatment would the nurse expect to be prescribed? a. Furosemide b. Hydrocortisone c. Epinephrine drip d. 5% albumin infusion

A

16. Which patient statement is consistent with their experiencing venous insufficiency? a. "I can't get my shoes on at the end of the day." b. "I can't ever seem to get my feet warm enough." c. "I have burning leg pain after I walk two blocks." d. "I wake up during the night because my legs hurt."

A

23. Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patient's serum creatinine level is elevated. b. The patient reports intermittent chest pressure. c. The patient's extremities are cool and pulses are weak. d. The patient has bilateral crackles throughout lung fields.

A

26. The nurse is caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty. Which action would the nurse perform first? a. Obtain vital signs. b. Teach wound care. c. Assess pedal pulses. d. Check the wound site.

A

27. A patient has been admitted with dehydration and hypotension after 4 days of vomiting and diarrhea. Which finding is most important for the nurse to report to the health care provider? a. New onset of confusion b. Decreased bowel sounds c. Heart rate 112 beats/min d. Pale, cool, and dry extremities

A

27. A patient who is 2 days post femoral popliteal bypass graft to the right leg is being cared for on the vascular unit. Which action by a licensed practical/vocational nurse (LPN/VN) caring for the patient requires the registered nurse (RN) to intervene? a. The LPN/VN tells the patient sit in a chair for 2 hours. b. The LPN/VN gives the prescribed aspirin after breakfast. c. The LPN/VN assists the patient to walk 40 ft in the hallway.

A

28. The nurse is developing a discharge teaching plan for a patient diagnosed with thromboangiitis obliterans (Buerger's disease). Which expected outcome has the highest priority for this patient? a. Cessation of all tobacco use b. Control of serum lipid levels c. Maintenance of appropriate weight d. Demonstration of meticulous foot care

A

4. Which group of drugs will the nurse plan to include when teaching a patient who has a new diagnosis of peripheral artery disease (PAD)? a. Statins b. Antibiotics c. Thrombolytics d. Anticoagulants

A

9. Which action by the patient with newly diagnosed Raynaud's phenomenon demonstrates that the nurse's teaching about managing the condition has been effective? a. The patient exercises indoors during the winter months. b. The patient immerses hands in hot water when they turn pale. c. The patient takes pseudoephedrine (Sudafed) for cold symptoms. d. The patient avoids taking nonsteroidal antiinflammatory drugs (NSAIDs).

A

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital? a. Ambulate postoperative patients as soon as possible after surgery. b. Use aseptic technique when manipulating invasive lines or devices. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Administer prescribed antibiotics within 1 hour for patients with possible sepsis. e. Advocate for parenteral nutrition for..

A, B, C, D

1. A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take? (Select all that apply.) a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Infuse large volumes of lactated Ringer's solution. d. Provide high-flow O2 (100%) by nonrebreather mask. e. Prepare for emergent intubation and mechanical ventilation.

A, B, D, E

11. A nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of 92/54 mm Hg, a pulse of 64 beats/min, and an elevated pulmonary artery wedge pressure (PAWP). Which intervention prescribed by the health care provider would the nurse question? a. Elevate head of bed to 30 degrees. b. Infuse normal saline at 250 mL/hr. c. Hold nitroprusside if systolic BP is less than 90 mm Hg. d. Titrate dobutamine to keep systolic BP is greater than 90 mm Hg.

B

12. A patient with a venous thromboembolism (VTE) has new prescriptions for enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is accurate? a. "Taking two medications dissolves the blood clot much faster." b. "Enoxaparin works right away, but warfarin takes several days to prevent clots. " c. "Enoxaparin will start to dissolve the clot, and warfarin will prevent any more clots from forming."

B

12. A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse would be consistent with a diagnosis of neurogenic shock? a. Inspiratory crackles b. Heart rate 45 beats/min c. Cool, clammy extremities d. Temperature 101.2F (38.4C)

B

13. The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) after hospitalization for venous thromboembolism (VTE). Which patient statement indicates a need for additional teaching? a. "I should get a Medic Alert device stating that I take warfarin." b. "I should reduce the amount of green, leafy vegetables that I eat." c. "I will need routine blood tests to monitor the effects of the warfarin."

B

17. Which action would the nurse include in the plan of care for a patient after endovascular repair of an abdominal aortic aneurysm? a. Record hourly chest tube drainage. b. Monitor fluid intake and urine output. c. Assess the abdominal incision for redness. d. Counsel the patient to plan for a long recovery time.

B

18. Which action would the nurse take when giving fondaparinux (Arixtra) to a patient with a lower leg venous thromboembolism (VTE)? a. Massage the site after giving the injection. b. Inject the drug into the abdominal subcutaneous tissue. c. Ejects the air bubble from the syringe before giving the drug. d. Check partial thromboplastin time (PTT) before giving the drug.

B

19. Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Check temperature every 2 hours. b. Monitor breath sounds frequently. c. Maintain patient in supine position. d. Assess skin for flushing and itching.

B

2. An 81-yr-old patient who has been in the intensive care unit (ICU) for a week with sepsis is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion with stable vital signs and oxygen saturation. What would the nurse plan to do? a. Give PRN lorazepam (Ativan) and cancel the transfer. b. Inform the receiving nurse and then transfer the patient. c. Notify the health care provider and postpone the transfer.

B

2. Which finding on a patient's nursing admission assessment is congruent with the initial medical diagnosis of a 6-cm thoracic aortic aneurysm? a. Low back pain b. Difficulty swallowing c. Abdominal tenderness d. Changes in bowel habits

B

20. Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which data indicate that the nurse should consult with the health care provider before starting the norepinephrine? a. The patient is receiving low dose dopamine. b. The patient's central venous pressure is 3 mm Hg. c. The patient is in sinus tachycardia at 120 beats/min. d. The patient has had no urine output since admission.

B

20. Which patient statement supports a history of intermittent claudication? a. "When I stand too long, my feet start to swell." b. "My legs cramp when I walk more than a block." c. "I get short of breath when I climb a lot of stairs." d. "My fingers hurt when I go outside in cold weather."

B

21. A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective? a. No heart murmur b. Skin is warm and pink c. Decreased troponin level d. Blood pressure of 92/40 mm Hg

B

21. Which instructions would the nurse include in a teaching plan for an older adult patient newly diagnosed with peripheral artery disease (PAD)? a. "Exercise only if you do not experience any pain." b. "It is very important that you stop smoking cigarettes." c. "Try to keep your legs elevated whenever you are sitting." d. "Put elastic compression stockings on early in the morning."

B

22. An older patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which action would the nurse take first? a. Draw blood for laboratory testing. b. Check the patient's blood pressure. c. Assess the patient for an abdominal bruit. d. Determine any family history of heart disease.

B

23. After receiving change-of-shift report, which patient admitted to the emergency department would the nurse assess first? a. A 67-yr-old patient who has a gangrenous foot ulcer with a weak pedal pulse b. A 50-yr-old patient who is reporting sudden sharp and severe upper back pain c. A 39-yr-old patient who has right calf tenderness and swelling after a plane ride d. A 58-yr-old patient taking anticoagulants for atrial fibrillation who has black stools

B

24. A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider would the nurse implement first? a. Acetaminophen (Tylenol) 650 mg rectally. b. Administer normal saline IV at 500 mL/hr. c. Start norepinephrine to keep blood pressure above 90 mm Hg. d. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL.

B

24. The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action would the nurse take first? a. Wrap both legs in a warming blanket. b. Notify the surgeon and anesthesiologist. c. Document the findings and recheck in 15 minutes. d. Review the preoperative assessment in the health record.

B

28. A patient who was involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention prescribed by the health care provider would the nurse implement first? a. Insert two large-bore IV catheters. b. Provide O2 at 100% per non-rebreather mask. c. Draw blood to type and crossmatch for transfusions. d. Initiate continuous electrocardiogram (ECG) monitoring.

B

3. A patient had an open surgical repair of an abdominal aortic aneurysm earlier today. The patient's total urinary output for the past 2 hours was 45 mL. What would the nurse anticipate will be prescribed? a. Hemoglobin count b. Increased IV fluids c. Additional antibiotics d. Serum creatinine level

B

3. Which hemodynamic parameter best reflects the effectiveness of drugs that the nurse gives to reduce a patient's left ventricular afterload? a. Mean arterial pressure (MAP) b. Systemic vascular resistance (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP)

B

30. Several interventions are prescribed by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which action will the nurse complete first? a. Give diphenhydramine. b. Administer epinephrine. c. Start continuous ECG monitoring. d. Draw blood for complete blood count (CBC)

B

35. The nurse is admitting a patient newly diagnosed with peripheral artery disease who takes clopidogrel. Which admission order would the nurse question? a. Cilostazol drug therapy b. Omeprazole drug therapy c. Use of treadmill for exercise d. Exercise to the point of discomfort

B

4. After surgery for an abdominal aortic aneurysm, a patient's central venous pressure (CVP) monitor indicates low pressures. Which action would the nurse take? a. Administer IV diuretic medications. b. Increase the IV fluid infusion per protocol. c. Increase the infusion rate of IV vasodilators. d. Elevate the head of the patient's bed to 45 degrees.

B

7. The central venous oxygen saturation (ScvO2) is decreasing in a patient who has severe pancreatitis. Which information would the nurse analyze to determine the possible cause of the decreased ScvO2? a. Lipase level b. Temperature c. Urinary output d. Body mass index

B

8. The nurse is evaluating the discharge teaching outcomes for a patient with chronic peripheral artery disease (PAD). Which patient statement indicates a need for further instruction? a. "I will buy loose clothes that do not bind across my legs or waist." b. "I will use a heating pad on my feet at night to increase the circulation." c. "I will walk to the point of pain, rest, and walk again for at least 30 minutes 3 times a week."

B

11. The health care provider prescribes heparin infusion and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). Which action would the nurse include in the plan of care? a. Obtain a Doppler for monitoring bilateral pedal pulses. b. Decrease the infusion when the PTT value is 65 seconds. c. Avoid giving IM medications to prevent localized bleeding. d. Have vitamin K available in case reversal of the heparin is needed.

C

10. The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with a venous thromboembolism of the left lower leg. Which action would the nurse take? a. Place a rolled towel under the patient's left ankle. b. Place the patient's bed in the Trendelenburg position. c. Place a pillow under the thighs and 2 pillows under the lower legs. d. Elevate the bed at the head and knee and place pillows under both feet.

C

13. An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention would the nurse anticipate? a. Increase the rate for the dopamine infusion. b. Decrease the rate for the nitroglycerin infusion. c. Increase the rate for the sodium nitroprusside infusion. d. Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion.

C

14. After a patient who has septic shock receives 2 L of IV normal saline, the central venous pressure is 10 mm Hg and the blood pressure is 82/40 mm Hg. Which medication would the nurse anticipate being prescribed? a. Furosemide b. Nitroglycerin c. Norepinephrine d. Sodium nitroprusside

C

14. An adult whose employment requires long periods of standing undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Which instructions would the nurse provide to the patient before discharge? a. Sitting at the work counter, rather than standing, is recommended. b. Exercise, such as walking or jogging, can cause recurrence of varicosities. c. Elastic compression stockings should be applied before getting out of bed.

C

15. Which assessment will the nurse perform to evaluate the effectiveness of the pantoprazole given to a patient with systemic inflammatory response syndrome (SIRS)? a. Auscultate bowel sounds. b. Ask the patient about nausea. c. Check stools for occult blood. d. Palpate for abdominal tenderness.

C

18. Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective? a. There are no signs of hemorrhage. b. Hemoglobin is within normal limits. c. Urine output 65 mL over the past hour. d. Mean arterial pressure (MAP) is 72 mm Hg.

C

19. A young adult patient tells the health care provider about having cold, numb fingers. After Raynaud's phenomenon is diagnosed, which condition would the nurse anticipate as a likely comorbidity? a. Hyperglycemia b. Hyperlipidemia c. Coronary artery disease d. Systemic lupus erythematosus

C

25. When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider? a. Presence of flatus b. Hypoactive bowel sounds c. Maroon-colored liquid stool d. Abdominal pain with palpation

C

26. A patient is admitted to the emergency department (ED) in shock of unknown etiology. Which action would the nurse take first? a. Obtain the blood pressure. b. Check the level of orientation. c. Administer supplemental oxygen. d. Obtain a 12-lead electrocardiogram.

C

29. A patient who has neurogenic shock is receiving phenylephrine through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action? a. The patient's heart rate is 58 beats/min. b. The patient's extremities are warm and dry. c. The patient's IV infusion site is cool and pale. d. The patient's urine output is 28 mL over the past hour.

C

29. Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse? a. Report of right calf pain b. Redness of right lower leg c. New onset shortness of breath d. Temperature of 100.4F (38C)

C

31. The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider? a. Weak pedal pulses b. Absent bowel sounds c. Blood pressure of 148/88 mm Hg d. 25 mL of urine output over the past hour

C

31. Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to contact the health care provider? a. The patient's urine output is 18 mL/hr. b. The patient's peripheral pulses are weak. c. The patient reports diffuse chest pressure. d. The patient's heart rate is 110 beats/minute.

C

32. A patient is being evaluated for postthrombotic syndrome. Which assessment will the nurse perform? a. Ask about pain with leg elevation. b. Determine the ankle-brachial index. c. Inspect for edema and color changes. d. Assess capillary refill in the patient's toes.

C

32. After reviewing the information shown in the accompanying chart for a patient with pneumonia and sepsis, which information is most important for the nurse to report to the health care provider? a. Temperature and IV site appearance b. Oxygen saturation and breath sounds c. Platelet count and presence of petechiae d. Blood pressure, pulse rate, respiratory rate

C

33. Which action for a patient at risk for venous thromboembolism could the nurse delegate to assistive personnel (AP)? a. Monitor for any bleeding after anticoagulation therapy is started. b. Tell the patient to call immediately if any shortness of breath occurs. c. Apply sequential compression devices whenever the patient is in bed. d. Ask the patient about use of any herbal medicines or dietary supplements.

C

34. The nurse who works in the vascular clinic has several patients with venous insufficiency. Which patient would the nurse assign to an experienced licensed practical/vocational nurse (LPN/VN)? a. Patient who has a history of venous thromboembolism and reports dyspnea. b. Patient who has been reporting increased edema and skin changes in the legs. c. Patient who needs wound care for a chronic venous stasis ulcer on the lower leg.

C

5. When caring for a patient with pulmonary hypertension, which parameter will the nurse use to directly evaluate the effectiveness of the treatment? a. Central venous pressure (CVP) b. Systemic vascular resistance (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP)

C

7. A patient has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe. Which assessment finding would the nurse expect? a. Dilated superficial veins b. Swollen, dry, scaly ankles c. Prolonged capillary refill in all the toes d. Serosanguineous drainage from the ulcer

C

8. An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which data indicate to the nurse that the goals of treatment with the IABP are being met? a. Urine output of 25 mL/hr b. Heart rate of 110 beats/min c. Cardiac output (CO) of 5 L/min d. Stroke volume (SV) of 40 mL/beat

C

9. The nurse is caring for a patient receiving a continuous norepinephrine IV infusion. Which finding indicates that the infusion rate may need to be adjusted? a. Heart rate is slow at 58 beats/min. b. Mean arterial pressure (MAP) is 56 mm Hg. c. Systemic vascular resistance (SVR) is elevated. d. Pulmonary artery wedge pressure (PAWP) is low.

C

Chapter 42 1. After change-of-shift report in the progressive care unit, for which patient would the nurse provide care first? a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases b. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute c. Patient with suspected urosepsis who has new prescriptions for urine and blood cultures and antibiotics

C

15. Which topic would the nurse include in teaching for a patient with a venous stasis ulcer on the lower leg? a. Need to increase carbohydrate intake b. Methods of keeping the wound area dry c. Purpose of prophylactic antibiotic therapy d. Application of graduated compression stockings

D

17. The emergency department (ED) nurse receives report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. Which item would the nurse obtain in preparation for the patient's arrival? a. A dopamine infusion b. A hypothermia blanket c. Lactated Ringer's solution d. A 16-gauge IV catheter

D

22. Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective? a. Heart rate b. Orientation c. Blood pressure d. Oxygen saturation

D

30. Which intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously could the nurse delegate to assistive personnel (AP)? a. Monitor the quality and presence of the pedal pulses. b. Teach the patient the signs of possible wound infection. c. Check the lower extremities for strength and movement. d. Help the patient to use a pillow to splint while coughing.

D

5. An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. After the nurse notifies the health care provider, what would the nurse do next? a. Apply a compression stocking to the leg. b. Elevate the leg above the level of the heart. c. Assist the patient in gently exercising the leg. d. Keep the patient in bed in the supine position.

D

6. A patient at the clinic says, "I always walk after dinner, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop walking, though." Which focused assessment would the nurse make? a. Look for the presence of tortuous veins bilaterally on the legs. b. Ask about any skin color changes that occur in response to cold. c. Assess for unilateral swelling, redness, and tenderness of either leg. d. Palpate for the presence of dorsalis pedis and posterior tibial

D

6. When monitoring the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, which is the most pertinent measurement for the nurse to obtain? a. Central venous pressure (CVP) b. Systemic vascular resistance (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP)

D