MIDTERM MEDSURG

§ An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive care first?

A 26-year-old male who has pale, cool, clammy skin

· A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first?

A 45-year-old reporting chest pain and diaphoresis

· A nurse is triaging clients in the emergency department. Which client should be considered urgent?

A 75-year-old female with a cough and a temperature of 102 F

An HIV positive client comes into the clinic complaining of increasing pain in his feet and legs. The nurse realizes that this client is demonstrating :

A nervous system manifestation of the disease

A nurse in the family clinic is teaching a patient newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching?

Acetaminophen (Tylenol)

· After teaching a client about advance directives, a nurse assesses the clients understanding. Which statement indicates the client correctly understands the teaching?

An advance directive will specify what I want done when I can no longer make decisions about health care.

A nurse is concerned that a preoperative patient has a great deal of anxiety about the upcoming procedure. What action by the nurse is the best?

Ask the patient to describe current feelings.

A client is informed that the tumor removed from his abdomen had well- defined borders, was encapsulated, and totally removed. The nurse realizes that this client has just learned the tumor was most likely:

Benign

§ The best indicator of fluid volume changes in the body is:

Blood pressure

An older patient is hospitalized after an operation. When assessing the patient for postoperative infection, the nurse places priority on which assessment?

Change in behavior

· A nurse on the medical-surgical unit has received a hand-off report. Which client should the nurse see first?

Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale

A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the AIDS guy and wondering how the client contracted the disease. What action by the nurse is best?

Confront the staff members about unethical behavior.

· A nurse suspects a client has serum sickness. What laboratory result would the nurse correlate with this condition?

Creatinine: 3.2 mg/Dl

An inpatient nurse brings an informed consent for to a patient for an operation scheduled for tomorrow. The patient asks about possible complications from the operation. What response by nurse is best?

Do not have the patient sign the consent and call the surgeon

· A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next?

Ensure an x-ray is completed to confirm placement

A patient with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply?

Ice pack

· The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate?

Inform the surgeon that the sterile field has been broken.

A client is signing a surgical consent. Afterwards, the nurse also signs the form. What is the meaning of the nursing signature?

It means the client was alert and aware of what was being signed.

A client is demonstrating signs of anaphylactic shock. Which of the following should the nurse do first to assist this client?

Maintain an airway

An elderly client is competing preoperative diagnostic testing. The nurse notes that the client carbon dioxide level is elevated. which of the following nursing interventions would be indicated for this client?

Monitoring respiratory status and arterial blood gases

The post anesthesia care unit (PACU) charge nurse notes vital signs on four postoperative patients. Which patient would the nurse assess first?

Patient with a respiratory rate of 6 breaths/min

A client who is newly diagnosed with cancer says to the nurse. I DON'T want to spend my final days on earth in a hospital bed. The best response by the nurse is;

Please tell me more about how are you feeling right now.

§ Hypokalemia can occur in patients with prolonged diarrhea and is caused by a decrease in:

Potassium

A preoperative nurse is reviewing morning laboratory values on four patients waiting for surgery. Which results warrant immediate communication with the surgical team?

Potassium 2.9 mEq/L (2.9 mmol/l)

· An older client is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9 g/dL, hematocrit: 32%. What intervention by the nurse is most appropriate?

Prepare to administer epoetin alfa (Epogen).

· A student nurse asks the nursing instructor what apoptosis means. What response by the instructor is best?

Programmed cell death

· A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the clients blood pressure is much higher than previous readings, and the clients mental status has changed. What action by the nurse would most likely have prevented this negative outcome?

Providing more appropriate supervision of the UAP

· A nurse is assessing a female client who is taking progestins. What assessment finding requires the nurse to notify the provider immediately?

Red, warm, swollen calf

The nursing student learning about cancer development remembers characteristics of normal cells. Which characteristics does this include? Select all apply

Specific morphology - nonmigratory - differentiated function

A patient with HIV/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug regimen when the patient does not have a history of seizures. What response by the nurse is best?

This drug helps treat the pain from nerve irritation

A differential diagnosis for a client is food allergies. The nurse escorts the client into an examination room and begins to ask questions about what the client has most recently eaten. Which of the following has the nurse observed about this client?

Urticaria

A nurse is assessing a client with hypokalemia, and notes that the clients handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first?

a. Assess the clients respiratory rate, rhythm, and depth.

§ While at a public park, a nurse encounters a person immediately after a bee sting. The persons lips are swollen, and wheezes are audible. Which action should the nurse take first?

o Administer an EpiPen from the first aid kit and call 911.

· A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are best? (Select all that apply.)

o Admit the client to a negative-airflow room. o Order specialized masks/respirators for caregiving.

§ A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first?

o Apply oxygen by mask or nasal cannula.

§ A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next?

o Assess clients rate, rhythm, and depth of respiration.

· A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess?

o Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg

· Which findings are AIDS-defining characteristics? (Select all that apply.)

o CD4+ cell count less than 200/mm3 or less than 14% o Infection with Pneumocystis jiroveci o Presence of HIV wasting syndrome

· A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?

o Call the Rapid Response Team.

· A nurse admits an older adult client to the hospital. Which criterion should the nurse use to determine if the client can make his own medical decisions? (Select all that apply.)

o Can communicate his treatment preferences o Is oriented enough to understand information provided o Can evaluate and deliberate information

§ A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first?

o Cardiac rate and rhythm

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

o Clean hair and nails

· The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further?

o Creatinine: 3.9 mg/Dl

· While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?

o Grade 3 phlebitis at IV site

· A nurse plans care for a client who has a wound that is not healing. Which focused assessments should the nurse complete to develop the clients plan of care? (Select all that apply.)

o Height b. c. Alcohol use d. Prealbumin laboratory results

§ After providing discharge teaching, a nurse assesses the clients understanding regarding increased risk for metabolic alkalosis. Which statement indicates the client needs additional teaching?

o I take sodium bicarbonate after every meal to prevent heartburn.

· A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that apply.)

o Increased pulse rate o Distended neck veins · Skeletal muscle weakness

· A nurse teaches a client to perform total skin self-examinations on a monthly basis. Which statements should the nurse include in this clients teaching? (Select all that apply.)

o Look for asymmetry of shape and irregular borders. b. Assess for color variation within each lesion.

§ A nurse is caring for a client who has chronic emphysema and is receiving oxygen therapy at 6 L/min via nasal cannula. The following clinical data are available: Arterial Blood Gases Vital Signs pH = 7.28 Pulse rate = 96 beats/min PaO2 = 85 mm Hg Blood pressure = 135/45 PaCO2 = 55 mm Hg Respiratory rate = 6 breaths/min HCO3 = 26 mEq/L O2 saturation = 88% Which action should the nurse take first?

o Notify the Rapid Response Team and provide ventilation support.

§ Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (Select all that apply.)

o Partial-thickness burns covering both legs o Neck injury and numbness of both legs o Small pieces of shrapnel embedded in both eyes § f. Bruising and pain in the right lower abdomen

· A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection cultured from the urine. What action by the nurse is most appropriate?

o Prepare to administer vancomycin (Vancocin).

§ A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider order should the nurse expect to receive?

o Sodium bicarbonate 100 mEq diluted in 1 L of D5W

§ A nurse is planning care for a client who is hyperventilating. The clients arterial blood gas values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L. Which question should the nurse ask when developing this clients plan of care?

o You appear anxious. What is causing your distress?

§ A nurse triages client arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.)

§ A 35-year-old female with severe chest pain: red § A 60-year-old male with an open fracture with distal pulses: yellow tag

A nurse is triaging clients in the emergency department. Which client should the nurse classify as nonurgent?

§ A 62-year-old with a simple fracture of the left arm

§ A nurse is triaging clients in the emergency department. Which client should be considered urgent?

§ A 75-year-old female with a cough and a temperature of 102 F

§ A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L. Which clinical situation should the nurse correlate with these values?

§ Bronchial obstruction related to aspiration of a hot dog

§ A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? (Select all that apply.)

§ Client who had open reduction and internal fixation of a femur fracture 3 days ago § Client on the medical unit for wound care

§ A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?

§ Connect the client to a cardiac monitor.

o The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction?

§ Correctly identifying the client prior to a blood transfusion

§ A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan?

§ Decreased orthostatic light-headedness and dizziness

§ A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.)

§ Hypokalemia Flaccid paralysis with respiratory depression § Hyponatremia Decreased level of consciousness

§ A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an example of the clients compensation mechanism?

§ Increased rate and depth of respirations

§ A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy?

§ Metabolic alkalosis

§ A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag?

§ Multiple fractured ribs and shortness of breath

§ A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3 18 mEq/L. For which clinical manifestations should the nurse assess? (Select all that apply.)

§ Reduced deep tendon reflexes § Drowsiness § Increased respiratory rate

A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take?

§ Teach the client fall prevention measures.

§ A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first?

§ b. A 45-year-old reporting chest pain and diaphoresis

· A nurse prepares to admit a client who has herpes zoster. Which actions should the nurse take?(Select all that apply.)

· . Assess staff for a history of or vaccination for chickenpox. · Check the admission orders for analgesia. · Ensure that gloves are available in the room.

· A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development?

· A 65-year-old with hemi-paralysis and incontinence

· A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of heparin. The pharmacy supplies a multi-dose vial of heparin with a concentration of 100 units/mL. Which of the syringes shown below should the nurse use to draw up and administer the heparin?

· Always use a 10-mL syringe when flushing PICC lines

§ A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results?

· Anxiety-induced hyperventilation

· A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important?

· Assess the IV site every hour

§ A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first?

· Assess the airway.

· A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client?

· Assessing vaccination records for booster shot needs

· A nurse on the postoperative inpatient unit receives a hand-off report on four clients using patient- controlled analgesia (PCA) pumps. Which client should the nurse see first?

· Client with a respiratory rate of 8 breaths/min

· A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?

· Connect the client to a cardiac monitor.

· The nurse in the surgery clinic is discussing an upcoming surgical procedure with a client. What information provided by the nurse is most appropriate for the clients long-term outcome?

· Discuss acceptable pain control after your operation with the surgeon.

· A client is put on twice-daily acetaminophen (Tylenol) for osteoarthritis. What finding in the clients health history would lead the nurse to consult with the provider over the choice of medication?

· Drinking 3 to 5 beers a day

· A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL. What medication should the nurse prepare to administer?

· Epoetin alfa (Epogen)

· A nurse is talking with a client who is moving to a new state and needs to find a new doctor and hospital there. What advice by the nurse is best?

· Find a hospital that is accredited by The Joint Commission.

· The nursing instructor explains the difference between normal cells and benign tumor cells. What information does the instructor provide about these cells?

· Growing in the wrong place or time is typical of benign tumors.

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

· Hemoglobin and hematocrit

· A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, Why are the individuals with black tags not receiving any care? How should the nurse respond?

· In a disaster, extensive resources are not used for one person at the expense of many others.

· A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered at high risk? (Select all that apply.)

· Morbidly obese client · Client who underwent a prolonged surgical procedure · Client with severe heart failure · Wheelchair-bound client

· A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag?

· Multiple fractured ribs and shortness of breath

· A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next?

· Notify the Rapid Response Team.

· A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first?

· Perform hand hygiene and apply gloves.

· A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which complications should the nurse assess? (Select all that apply.)

· Phlebitis , thrombophlebitis

· A client is admitted with fever, myalgia, and a papular rash on the face, palms, and soles of the feet. What action should the nurse take first?

· Place the client on Airborne Precautions.

· A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?

· Prepare to assist with chest tube insertion.

§ A nurse is planning interventions that regulate acid-base balance to ensure the pH of a clients blood remains within the normal range. Which abnormal physiologic functions may occur if the client experiences an acid- base imbalance? (Select all that apply.)

· Reduction in the function of hormones o Fluid and electrolyte imbalances o Increase in the effectiveness of many drugs

· A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?

· Report of headache and stiff neck

· A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?

· Stop the infusion of intravenous fluids.

· 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?

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

· The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.)

· Type I Examples include hay fever and anaphylaxis · Type III Immune complex deposits in blood vessel walls d. · Type IV Examples are poison ivy and transplant rejection

· Which statements are true regarding Standard Precautions? (Select all that apply.)

· Use personal protective equipment as needed for client care. · Wear gloves when touching client excretions or secretions.

· 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?

· Use pulse oximetry to assess the clients oxygen saturation.

· A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the clients oral chemotherapy medications. What action by the nurse is most appropriate?

· Wear personal protective equipment when handling the medications.

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

· What medications are you taking?