MED SURG EXAM I

A nurse is discharging a patient after a total hip replacement. What statement by the patient indicates good potential for self-management? A. "I can bend down to pick something up." B. "I no longer need to do my exercises." C. "I will not sit with my legs crossed." D. "I won't wash my incision to keep it dry."

C. "I will not sit with my legs crossed."

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess? A. Premature ventricular contractions B. Atrial fibrillation C. Symptomatic bradycardia D. Sinus tachycardia

B. Atrial fibrillation

On assessment you note redness to the area of the leg that Mrs. Jane points to and a DVT was suspected immediately. What diagnostic btesting would you anticipate preparing your patient for? A. CBC and CT Scan B. D-Dimer and Duplex Ultrasound C. Chest X-Ray and D-Dimer D. CBC and V/Q scan

B. D-Dimer and Duplex Ultrasound

A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the client's stenosis has progressed? A. Oxygen saturation of 92% B. Dyspnea on exertion C. Muted systolic murmur T D. Upper extremity weakness

B. Dyspnea on exertion

A client is ordered heparin 5000 units at 7 AM. The heparin is provided in a vial labeled 20,000 units per mL. How much does the nurse administer? ______ mL

.25

A patient is scheduled to have a hip replacement. Preoperatively, the patient is found to be mildly anemic and the surgeon states the patient may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important? A. Administer preoperative medications as prescribed. B. Ensure that a consent for transfusion is on the chart. C. Explain to the patient how anemia affects healing. D. Teach the patient about foods high in protein and iron.

B. Ensure that a consent for transfusion is on the chart.

A nurse is making initial rounds on assigned clients at the beginning of the shift. One client is receiving a heparin infusion at 5 mL/hr. The nurse notes that 25,000 units of heparin are mixed in 250 mL of solution. How many units per hour is the client receiving?

500 units per hour

The health care provider has prescribed a client sodium warfarin (Coumadin) while he is still receiving intravenous heparin. Which is the nurse's best action? A. Administer both heparin and warfarin as prescribed. B. Turn off the heparin before administering the warfarin. C. Clarify the warfarin order with the nursing supervisor. D. Hold the warfarin dose until the heparin is discontinued

A. Administer both heparin and warfarin as prescribed. Heparin- blood thinner Warfarin- blood thinner

The nurse on the post operative inpatient unit assesses a patient after total hip replacement. The patient's surgical leg is visibly shorter than the other and the patient reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best? A. Assess neurovascular status in both legs. B. Elevate the affected leg and apply ice. C. Prepare to administer pain medication. D. Try to place the affected leg in abduction

A. AssessNeurovascular status in both legs.

A lung tumor can cause changes in what component of Virchow's triad? A. Blood coagulability B. Vessel walls C. Blood flow D. Blood viscosity

A. Blood coagulability

A 67-year-old woman who lives alone is admitted after tripping on a rug in her home and fractures her hip. A hip fracture can cause changes in what component of Virchow's triad? Select all that apply A. Blood coagulability B. Vessel walls C. Blood flow

A. Blood coagulability B. Vessel walls

A home health care nurse is visiting a patient discharged home after a hip replacement. The patient is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the patient? (Select all that apply.) A. Buy and install an elevated toilet seat. B. Install grab bars in the shower and by the toilet. C. Step into the bathtub with the affected leg first. D. Remove all throw rugs throughout the house. E. Use a shower chair while taking a shower.

A. Buy and install an elevated toilet seat. B. Install grab bars in the shower and by the toilet. D. Remove all throw rugs throughout the house. E. Use a shower chair while taking a shower.

A nurse is care for a patient who has undergone surgical repair of an abdominal aortic aneurysm (AAA). The patient develops coolness of the extremities and reports a bloated feeling in the abdomen. What is the nurse's best action? A. Check for abdominal distention and check pulses. B. Raise the head of the bed to 90 degrees C. Assess urine output D. Auscultate the abdomen

A. Check for abdominal distention and check pulses.

A student nurse is learning about blood transfusion compatibilities. What information does this include? (Select all that apply.) A. Donor blood type A can donate to recipient blood type AB. B. Donor blood type B can donate to recipient blood type O. C. Donor blood type AB can donate to anyone. D. Donor blood type O can donate to anyone. E. Donor blood type A can donate to recipient blood type B.

A. Donor blood type A can donate to recipient blood type AB. D. Donor blood type O can donate to anyone.

Which of the following characteristics is typical of the pain associated with DVT? A. Dull ache B. No pain C. Tingling

A. Dull ache

The nurse is caring for a postoperative client who suddenly reports difficulty breathing and sharp chest pain. After notifying the Rapid Response Team, what is the nurse's priority action? A. Elevate the head of the bed and apply oxygen. B. Listen to the client's lung sounds. C. Pull the call bell out of the wall socket. D. Assess the client's pulse oximetry.

A. Elevate the head of the bed and apply oxygen.

A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find? A. Heart rate that speeds up and slows down B. Friction rub at the left lower sternal border C. Presence of a regular gallop rhythm D. Coarse crackles in bilateral lung bases

B. Friction rub at the left lower sternal border

A student nurse is helping a registered nurse with a blood transfusion. Which actions by the student are most appropriate? (Select all that apply.) A. Hanging the blood product using normal saline and a filtered tubing set B. Taking a full set of vital signs prior to starting the blood transfusion C. Telling the patient someone will remain at the bedside for the first 5 minutes D. Using gloves to start the patient's IV if needed and to handle the blood product E. Verifying the patient's identity, and checking blood compatibility and expiration time

A. Hanging the blood product using normal saline and a filtered tubing set B. Taking a full set of vital signs prior to starting the blood transfusion D. Using gloves to start the patient's IV if needed and to handle the blood product

The dose of warfarin (Coumadin) is based on what laboratory parameter? A. INR B. Partial thromboplastin time C. Platelet count D. Template bleeding time

A. INR

It is determined that a client has a large pulmonary embolism (PE). Fibrinolytic therapy is initiated. What is the nurse's priority action? A. Monitor the client's oxygenation and monitor for bleeding. B. Teach the client about potential side effects. C. Monitor the IV insertion site. D. Teach the patient to avoid green, leafy vegetables

A. Monitor the client's oxygenation and monitor for bleeding.

During the first 15 minutes of the blood administration the nurse stays with the patient obtaining baseline vital signs and vital signs after 15 minutes. The nurse notes that the patient's temperature has increased from 37.0C to 38.2C, the blood pressure has decreased from 120/80 to 90/40, and the patient complains of itching, and shortness of breath. What is the nurse's priority action? A. Stop the packed red blood cells and start Normal saline to keep vein open B. Call the blood bank C. Give Tylenol D. Find the charge nurse to double check the primary nurse's findings

A. Stop the packed red blood cells and start Normal saline to keep vein open

The nurse is caring for a client with a high risk for pulmonary embolism (PE). Which prevention measures does the nurse add to the client's care plan? (Select all that apply.) A. Use antiembolism stockings. B. Massage calf muscles per client request. C. Maintain supine position with the legs flat. D. Turn every 2 hours if client is in bed. E. Refrain from active range-of-motion exercises.

A. Use antiembolism stockings. D. Turn every 2 hours if client is in bed.

Which symptoms in a client assist the nurse in confirming the diagnosis of pulmonary embolus (PE)? (Select all that apply.) A. Wheezes throughout lung fields B. Hemoptysis C. Sharp chest pain D. Flattened neck veins E. Hypotension F. Pitting edema

B. Hemoptysis (coughing up blood) C. Sharp chest pain E. Hypotension

Mrs. Jane and her new husband just returned from their honeymoon on a 9 hour flight from Hawaii two days ago. She presents to the ED complaining of a severe burning pain and warmth in the right leg. The client reported this began 24-48 hours prior and had increasingly worsened to the point where she knew she had to come in. Mrs. Jane takes an oral contraceptive and smokes ½ pack of cigarettes each day. The nurse identifies that Mrs. Jane has which risk factors? A) Pregnancy B) Travel, Smoking, oral contraceptive use C) Smoking and travel

B) Travel, Smoking, oral contraceptive use

A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" How should the nurse respond? A. "The prosthetic valve places you at greater risk for a heart attack." B. "Blood clots form more easily in artificial replacement valves." C. "The vein taken from your leg reduces circulation in the leg." D. "The surgery left a lot of small clots in your heart and lungs."

B. "Blood clots form more easily in artificial replacement valves."

A nurse is providing preoperative teaching for a patient who will undergo percutaneous insertion of an inferior vena cava filter. The nurse explains to the patient that the vena cava filter is placed because: A. "This will catch the PE that you have before it goes to your heart." B. "This is recommended therapy for patients who do not have therapeutic results for anticoagulation, or anticoagulation is contraindicated." C. "This is an experimental procedure to see if it works better than anticoagulation."

B. "This is recommended therapy for patients who do not have therapeutic results for anticoagulation, or anticoagulation is contraindicated."

A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.) A. Administer pain medication. B. Assess distal pulses every 10 minutes. C. Have the client sign a surgical consent. D. Notify the Rapid Response Team. E. Take vital signs every 10 minutes.

B. Assess distal pulses every 10 minutes. D. Notify the Rapid Response Team. E. Take vital signs every 10 minutes.

A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate? The goal PTT for Heparin is 60-90. So the 25 seconds is not therapeutic A. Decrease the heparin rate. B. Increase the heparin rate. C. No change to the heparin rate. D. Stop heparin; start warfarin (Coumadin).

B. Increase the heparin rate. The goal PTT for Heparin is 60-90. So the 25 seconds is not therapeutic

17. A patient is receiving heparin therapy and warfarin sodium (coumadin). The patient asks the nurse why both medications are being administered. The nurse understands that Warfarin: A. Stimulates the breakdown of specific clotting factors by the liver, and it several days for this is exhibit an anticoagulant effect. B. Inhibits synthesis of specific clotting factors in the liver, and it takes several days for this medication to exert an anticoagulation effect. C. Stimulates production of the body's own thrombolytic substances, but it takes several days for it to begin. D. Has the same mechanism action of heparin, and the crossover time is needed for the serum level of warfarin sodium to be therapeutic.

B. Inhibits synthesis of specific clotting factors in the liver, and it takes several days for this medication to exert an anticoagulation effect.

A patient who has been receiving heparin subcutaneously for 10 days has all of the following laboratory blood test values. Which value does the nurse report to the physician immediately? A. Prothrombin time (PT) 1.5 B. International normalized ration (INR) 1.7 C. Platelets 20,000/mm2

B. International normalized ration (INR) 1.7

Which clients are at highest risk for pulmonary embolism (PE)? (Select all that apply) A. Middle-aged client awaiting surgery B. Older adult with a 20-pack-year history of smoking C. Client who has been on bedrest for 3 weeks D. Obese client who has elevated platelets E. Middle-aged client with diabetes mellitus type 1 F. Older adult who has just had abdominal surgery

B. Older adult with a 20-pack-year history of smoking C. Client who has been on bedrest for 3 weeks D. Obese client who has elevated platelets F. Older adult who has just had abdominal surgery

What is a potential complication of deep vein thrombosis? A. Hemorrhagic stroke B. Pulmonary embolus C. Septic shock D. Increased ejection fraction

B. Pulmonary embolus

The nurse understands that all of the following are risk factors for DVT except: A. Tobacco use B. Running 2 miles every day C. Recent abdominal surgery D. Cancer E. Heart Failure

B. Running 2 miles every day

11. A patient with a previously diagnosed abdominal aortic aneurysm (AAA) develops lower back pain that is sharp and tearing. What is the nurse's interpretation of this assessment finding? A. The aneurysm clotted and is obstructing blood flow. B. The aneurysm has ruptured. C. The patient feels the inflammation of the aneurysm D. This is a normal sensation with a stable AAA.

B. The aneurysm has ruptured.

The nurse anticipates a patient who has undergone a hip arthroplasty procedure will require which of the following strategies to aid elimination on post-op day #2? A. Use of a urinary catheter to gravity drain B. Use of a bedside commode C. Use of an anti-diarrheal D. Fluid intake of 500 ml

B. Use of a bedside commode

Which technique is considered the gold standard for diagnosing DVT? A. CT Scan B. Venography C. MRI D. Doppler flow ultrasound study

B. Venography

20. Central venous catheters can cause changes in what component of Virchow's triad? A. Blood coagulability B. Vessel walls C. Blood flow D. Blood viscosity

B. Vessel walls

After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for additional teaching? A. "I'll be able to carry heavy loads after 6 months of rest." B."I will have my teeth cleaned by my dentist in 2 weeks." C. "I must avoid eating foods high in vitamin K, like spinach." D"I must use an electric razor instead of a straight razor to shave."

B."I will have my teeth cleaned by my dentist in 2 weeks."

The nurse is providing discharge education to a patient after repair of an abdominal aortic aneurysm (AAA). What priority instruction does the nurse include? A. "No restrictions are necessary." B. "Avoid sleeping on your left side for 6 weeks." C. "Avoid heavy lifting for about 3 months." D. "You will have a distended abdomen for 2 weeks."

C. "Avoid heavy lifting for about 3 months."

The nurse is discharging home a client at risk for venous thromboembolism (VTE) on low-molecular-weight heparin. What instruction does the nurse provide to this client? A. "You must have your aPTT checked every 2 weeks." B. "Massage the injection site after the heparin is injected." C. "Notify your health care provider if your stools appear tarry." D. "An IV catheter will be placed to administer your heparin."

C. "Notify your health care provider if your stools appear tarry."

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best? A. "Breathing so rapidly interferes with oxygenation." B. "Maybe the client has respiratory distress syndrome." C. "The blood clot interferes with perfusion in the lungs." D. "The client needs immediate intubation and mechanical ventilation."

C. "The blood clot interferes with perfusion in the lungs."

A female client taking oral contraceptives calls the internal medicine clinic and tells the nurse that she is experiencing calf pain. What action should the nurse implement? A. Determine if the client has also experienced breast tenderness and weight gain. B. Encourage the client to begin a regular, daily program of walking and exercise. C. Advise the client to present to the ED for immediate medical attention. D. Tell the client to stop taking the medication for a week to see if symptoms subside

C. Advise the client to present to the ED for immediate medical attention.

The nurse recognizes that a patient's level of activity post-op day 2 after hip arthroplasty should consist of which of the following? A. Bedrest B. Climbing stairs C. Ambulating in the hallway with PT and a walker D. Run on the treadmill

C. Ambulating in the hallway with PT and a walker

The nurse is caring for a client receiving heparin and warfarin therapy for a pulmonary embolus. The client's international normalized ratio (INR) is 2.5. What is the nurse's best action? A. Increase the heparin dose. B. Increase the warfarin dose. C. Continue the current therapy. D. Discontinue the heparin.

C. Continue the current therapy.

When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) A. Avoid drinking alcohol. B. Eat more omega-3 fatty acids. C. Exercise on a regular basis. D. Maintain a healthy weight. E. Stop smoking cigarettes.

C. Exercise on a regular basis. D. Maintain a healthy weight. E. Stop smoking cigarettes.

The nurse receives orders to begin a heparin infusion (FULL Bolus nomogram) for a patient with a DVT and PE. While implementing this order, a nurse ensures that which of the following antidote medications is available? A. Amicar B. Potassium chloride C. Protamine sulfate D. Fresh frozen plasma E. Vitamin K

C. Protamine sulfate

The nurse working in the orthopedic clinic knows that a patient with which factor has an absolute contraindication for having a total joint replacement? A. Needs multiple dental fillings B. Over age 85 C. Severe osteoporosis D. Urinary tract infection

C. Sever Osteoporosis

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? A. Encourage the client to walk 5 minutes each hour. B. Refer the client to smoking cessation classes. C. Teach the client about factor V Leiden testing. D. Tell the client that sometimes no cause for disease is found.

C. Teach the client about factor V Leiden testing.

The post anesthesia recovery unit (PACU) nurse is giving hand off report to the 6 East nurse for an 82 year old patient who had a total hip replacement 2 hours ago. For which reported information about the patient or surgery does the receiving nurse ask the reporting team more details? A. Estimated blood loss 150ml B. The patient reported an allergy to codeine C. The total intraoperative urine output is 25 ml

C. The total intraoperative urine output is 25 ml

10. A patient who recently had a valve replacement is taking warfarin (Coumadin) as prescribed. What health teaching will the nurse include before the patient is discharged? A. "Weigh yourself every day in the morning using the same scale." B. "Purchase a home kit to monitor your blood pressure every day." C. "You must take your pulse every day before taking this medication." D. "Avoid foods that are high in vitamin K, such as kale and spinach."

D. "Avoid foods that are high in vitamin K, such as kale and spinach."

Signs and symptoms of a moderate to severe systemic and inflammatory blood transfusion reaction includes all of the following except: allergic reactions as well as shock A. Itching and hives B. Bronchospasm and dyspnea C. Hypotension D. Hypertension

D. Hypertension

Mr. Jones is diagnosed with a 1.5mm abdominal aortic aneurysm (AAA). Part of the overall plan for Mr. Jones will include: A. Discussion of the diagnostic test. B. Evaluation of the non-modifiable risk factors that Mr. Jones has. C. Scheduling for further testing. D. Management of Mr. Jones's blood pressure to prevent expansion and rupture of the AAA.

D. Management of Mr. Jones's blood pressure to prevent expansion and rupture of the AAA.

A client with a large pulmonary embolism is receiving alteplase (Activase). The nurse notes frank red blood in the Foley catheter drainage bag. What is the nurse's first action? A. Irrigate the Foley. B. Administer an antibiotic. C. Clamp the Foley. D. Notify the health care provider.

D. Notify the health care provider.

The nurse is caring for a client with a pulmonary embolus who also has right-sided heart failure. Which symptom will the nurse need to intervene for immediately? A. Respiratory rate of 28 breaths/min B. Urinary output of 10 mL/hr for 4 hours C. Heart rate of 100 beats/min D. Dry cough

D. Notify the health care provider.

A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene? A. Assesses the client for back pain B. Auscultates over abdominal bruit C. Measures the abdominal girth D. Palpates the abdomen abdominal mass

D. Palpates the abdomen abdominal mass

The nurse is caring for a patient less than 24 hours post-op. In report the nurse learns that he rings his call light frequently, is anxious, and has had pain medications as ordered. Which of the following nondrug interventions should the nurse include when caring for this patient? A. Assure that patient his anxiety is understandable, because the pain medications need time to take effect. B. Assess other patients first, giving the patient time to relax. C. Call the MD to increase the amount or frequency of pain medications ordered. D. Provide a quiet environment, offer repositioning, straighten the bed linens, offer fluids, and assess the pain level.

D. Provide a quiet environment, offer repositioning, straighten the bed linens, offer fluids, and assess the pain level.

A nurse is discharging a patient to a short-term rehabilitation center after a joint replacement. Which action by the nurse is important? A. Administering pain medication before transport B. Answering any last-minute questions by the patient C. Ensuring the family has directions to the facility D. Providing a verbal hand-off report to the facility

D. Providing a verbal hand-off report to the facility

The nurse is completing a neurovascular assessment on a patient who has under gone a hip arthroplasty (post-op day 2). The nurse understands that components of a neurovascular exam include all of the following except: A. Temperature of extremity B. Capillary refill C. Peripheral pulses D. Sensory and motor function E. Heart sounds

D. Sensory and motor function

A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which non-pharmacologic comfort measure should the nurse implement? A. Apply an ice pack to the client's chest. B. Provide a neck rub, especially on the left side. C. Allow the client to lie in bed with the lights down. D. Sit the client up with a pillow to lean forward on.

D. Sit the client up with a pillow to lean forward on.

An older patient has returned to the surgical unit after a total hip replacement. The patient is confused and restless. What intervention by the nurse is most important to prevent injury? A. Administer mild sedation. B. Keep all four siderails up. C. Restrain the patient's hands. D. Use an abduction pillow.

D. Use abduction pillow

A nurse is caring for a patient after joint replacement surgery. What action by the nurse is most important to prevent wound infection? A. Assess the patient's white blood cell count. B. Culture any drainage from the wound. C. Monitor the patient's temperature every 4 hours. D. Use aseptic technique for dressing changes. Wash your hands.

D. Use aseptic technique for dressing changes. Wash your hands.

The nurse and orientee are caring for a patient who is postoperative day 1 from a total hip replacement. The nurse explains to the orientee that a major complication of this surgery is hip dislocation. All of the following are interventions to prevent hip dislocation except: A. Prevent adduction of hip with abduction pillow B. Prevent hip flexion beyond 90 degrees (hip) C. Ensure the abduction pillow is in place before turning D. Do not cross legs E. Encourage adduction while the patient is sitting in a chair

E. Encourage adduction while the patient is sitting in a chair

The nurse and orientee are caring for a patient who is postoperative day 1 from a total hip replacement. The nurse explains to the orientee that major nursing priorities for the patient include all of the following except: A. Pain control B. Decrease risk of infection C. DVT prophylaxis D. Regulate urination and bowel movements after surgery E. Only assess neurovascular assessment at discharge

E. Only assess neurovascular assessment at discharge

Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. What intervention should be most helpful to this client? i. Apply sequential compression devices (SCDs) bilaterally. ii. Assess for a positive Homan's sign in each leg. iii. Pad all bony prominences on the affected leg. iv. Advise the client to keep the leg elevated when in bed.

iv. Advise the client to keep the leg elevated when in bed.