MED SURG 1: EXAM ONE EAQ QUESTIONS

Which laboratory result would the nurse expect when reviewing the results for a client hospitalized with a chronic obstructive pulmonary disease exacerbation? 1. Hematocrit 2. partial pressure of carbon dioxide 3. Blood glucose 4. Serum potassium

1. Hematocrit 51% (0.51)

Which clinical finding in a child with a diagnosis of meningitis indicates an increase in intracranial pressure? SATA 1. irritability 2. bradycardia 3. hyperalertness 4. decreased pulse pressure 5. decreased systolic blood pressure

1. irritability 2. bradycardia

When a client with COPD reports a 5 lb weight gain in 1 week, the nurse will assess for other signs and symptoms of which complication? 1. polycythemia 2. cor pulmonale 3. compensated acidosis 4. left ventricular failure

2. cor pulmonale

Which assessment is most important for the nurse to perform before beginning a wound irrigation on a client who had a left hemispheric stroke 1 year ago? 1. neurological 2. wound 3. pain 4. skin

3. pain

What is the Glascow coma score for a client who opens the eyes when their name is stated, uses disorganized words, and is unable to follow commands, but attempts to remove the offending stimulus? Record in whole number

11

Which behavior would the nurse include when teaching a family what to expect from a client who experienced a stroke on the left side of the brain? SATA 1. impaired judgement 2. spatial-perceptual deficits 3. slow performance 4. impaired speech/language aphasias 5. tendency to deny or minimize problems 6. Awareness of deficits with depression and anxiety

3. slow performance 4. impaired speech/language aphasias 6. Awareness of deficits with depression and anxiety

Which explanation would the nurse provide to a client about transient ischemic attacks (TIAs)? 1. Temporary episodes of neurological dysfunction 2. Intermittent attacks caused by multiple small clots 3. Ischemic attacks that result in progressive neurological deterioration 4. Exacerbations of neurological dysfunction alternating with remissions

1. Temporary episodes of neurological dysfunction

Which statement describes the rationale for palpation of the trachea after a client has had a pneumonectomy? 1. examining for any mediastinal shift 2. assessing for subcutaneous emphysema 3. monitoring for possible tracheal edema 4. checking for endotracheal tube cuff inflation

1. examining for any mediastinal shift

Which action would the nurse take while a client is seizing on the hallway floor? 1. hold the client's extremities firmly 2. protect the client's head from injury 3. insert an airway between the client's teeth 4. have staff members move the client to a soft surface

2. protect the client's head from injury

Which change in the arterial blood gases would the nurse expect in a client with hyperventilation due to anxiety? 1. respiratory acidosis 2. respiratory alkalosis 3. respiratory compensation 4. respiratory decompensation

2. respiratory alkalosis

For a client with a history of COPD who develops a pneumothorax and has a chest tube inserted, which primary purpose of the chest tube will the nurse consider when planning care? 1. lessens the client's chest discomfort 2. restores negative pressure in the pleural space 3. drains accumulated fluid from the pleural activity 4. prevents subcutaneous emphysema in the chest wall

2. restores negative pressure in the pleural space

When providing care for a client with a traumatic brain injury and increased intracranial pressure, which health care provider prescription would the nurse question? 1. continue anticonvulsants 2. teach isometric exercises 3. continue osmotic diuretics 4. keep head of bed at 30 degrees

2. teach isometric exercises

Which phrase describes why a lumbar puncture is performed when meningitis is suspected? 1. to identify the presence of blood 2. to determine the causative agent 3. to reduce the intracranial pressure 4. to measure the spinal fluid glucose level

2. to determine the causative agent

Which assessment finding indicated that a client has had a stroke? SATA 1. lopsided smile 2. unilateral vision 3. incoherent speech 4. unable to raise right arm 5. symptoms started 2 hours ago

1. lopsided smile 2. unilateral vision 3. incoherent speech 4. unable to raise right arm 5. symptoms started 2 hours ago

Which nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke? 1. place objects within the visual field 2. Teach passive range-of-motion exercises 3. instill artificial teardrops into the affected eye 4. reduce time client is positioned on the left side

1. place objects within the visual field

The nurse is caring for a client with a tracheostomy. Which action would the nurse implement when performing tracheal suctioning? 1. pre oxygenate the client before suctioning 2. employ gentle suctioning as the catheter is being inserted 3. loosen the client's secretions before suctioning by instilling saline 4. ensure that the cuff of the tracheostomy is inflated during suctioning.

1. pre oxygenate the client before suctioning

Which nursing action would the nurse implement immediately when providing care to a trauma client whose primary survey indicates a Glasgow Coma Scale (GCS) score of 7? 1. prepare for intubation 2. observe for chest wall trauma 3. cover the client with a blanket 4. apply direct pressure to the client's wound

1. prepare for intubation

Which type of impairment does the nurse expect the client who has expressive aphasia to exhibit? 1. speaking or writing 2. following instructions 3. understanding speech or writing 4. recognizing words for familiar objects

1. speaking or writing

A post-operative client with a tracheostomy tube in place suddenly develops noisy, increased respirations and an elevated heart rate. The nurse would take which action IMMEDIATELY? 1. suction the tracheostomy 2. change the tracheostomy tube 3. Readjust the tracheostomy tube and tighten the ties 4. perform a complete respiratory assessment

1. suction the tracheostomy

Which Glascow Coma Scale score indicated that the client is in a coma? 1. 6 2. 9 3. 12 4. 15

1. 6

Which statement about the care of clients who have neurological changes associated with aging indicates a need for further instruction? 1. "Clients with decreased sensory perception of touch should be carefully monitored for infection." 2. "Clients with recent memory loss should be taught by repetition and use memory aids that provide recurrent alerts." 3. "Clients with slower processing time should be provided with sufficient time to respond to questions or directions." 4. "Clients with decreased coordination should be instructed to hold handrails when ambulating."

1. "Clients with decreased sensory perception of touch should be carefully monitored for infection."

Which would the nurse include when teaching a client about the use of an incentive spirometer? 1. "inhale completely and exhale in short, rapid breaths" 2. "inhale deeply through the spirometer, hold it as long as possible, and slowly exhale" 3. "exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale" 4. "Exhale halfway, the inhale a rapid, small breath; repeat several times"

3. "exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale"

When a client develops bacterial meningitis, which action is the nurses's PRIORITY? 1. monitoring for signs of intracranial pressure 2. adding pads to the side of the bed 3. administering prescribed antibiotics 4. administering glucocorticoids

3. administering prescribed antibiotics

A client reports neck stiffness, severe headache, and a decreased level of consciousness. Which condition would the nurse suspect? 1. Encephalitis 2. Brain abscess 3. Viral Meningitis 4. Bacterial Meningitis

4. Bacterial Meningitis

Which laboratory result of a client with chronic bronchitis would be MOST important for the nurse to communicate to the health care provider? 1. PaO2 75 mmHg 2. PaCO2 48 mmHg 3. Hematocrit 52% (0.52) 4. Leukocytes 16,000

4. Leukocytes 16,000 elevated white blood cell = infection

Which nursing action is appropriate for a patient during the tonic-clonic stage of a seizure? 1. Go for additional help 2. Establish a patent airway 3. Restrain the client to prevent injury 4. Protect the client's head from injury

4. Protect the client's head from injury

Which nursing assessment supports a diagnosis of atelectasis in a postoperative client? 1. productive cough 2. clubbing of the fingertips 3. low-pitched expiratory rhonchi 4. diminished breath sounds on auscultation

4. diminished breath sounds on auscultation

Which clinical finding is consistent with an increase in intracranial pressure? 1. Thready, weak pulse 2. Narrowing pulse pressure 3. Regular, shallow breathing 4. Lowered level of consciousness

4. lowered level of consciousness

Which assessment finding would be MOST important for the nurse to communicate to the health care provider after assessing a client with chronic bronchitis? 1. rhonchi with expiration 2. prolonged expiratory phase 3. heart rate 96 beats per minute 4. temperature 101.8

4. temperature 101.8

Which nursing intervention would the nurse consider the HIGHEST PRIORITY for a client who was in a motor bike accident and has a severe neck injury? 1. assessing for crepitus 2. assessing for bleeding 3. maintaining a patent airway 4. performing neurological assessment

3. maintaining a patent airway

The nurse instructs a client to breathe deeply to open collapsed alveoli. Which explanation could the nurse offer to explain the relationship between alveoli and improved oxygenation? 1. the alveoli need oxygen to live 2. the alveoli have no direct effect on oxygenation 3. collapsed alveoli increase oxygen demand 4. oxygen is exchanged for carbon dioxide in the alveolar membrane

4. oxygen is exchanged for carbon dioxide in the alveolar membrane

Which topic would the nurse plan to include in teaching a client with a new diagnosis of asthma? 1. home oxygen therapy 2. antibiotic treatment 3. incentive spirometer use 4. use of peak flow meter

4. use of peak flow meter

What IV medication would the nurse anticipate the health care provider WILL PRESCRIBE for a client who has a tonic-clonic seizure? 1. naloxone 2. diazepam 3. epinephrine HCl 4. atropine

2. diazepam

Which action would the nurse classify as a priority when caring for a client with tonic-clonic seizures? 1. ensuring patent airway 2. administering IV fluids 3. Monitoring level of consciousness 4. protecting the client from injury during seizures

1. ensuring patent airway

The nurse is suctioning a client's airway. Which nursing action will limit hypoxia? 1. limit suctioning with catheter to 30 seconds 2. Apply suction only after the catheter is inserted 3. Lubricate the catheter will saline before insertion 4. use a sterile suction catheter for each suctioning episode

2. Apply suction only after the catheter is inserted

Which parameters would the nurse consider for proper rapid baseline assessment using a disability mnemonic (AVPU) in a client with drug abuse? SATA 1. Level of anxiety 2. Reaction to pain 3. Response to voice 4. Body temperature 5. Evidence of assault

2. Reaction to pain 3. Response to voice

When suctioning a client with a tracheostomy, which nursing intervention is correct? 1. hyperventilate the client with room air before suctioning 2. apply suction only as the catheter is being withdrawn 3. Insert the catheter until the cough reflex is stimulated 4. remove the inner cannula before inserting

2. apply suction only as the catheter is being withdrawn

Which goal is the PRIORITY for a client with asthma who has a prescription for an inhaled bronchodilator? 1. is able to obtain pulse ox readings 2. demonstrates used of a metered-dose inhaler 3. knows the health care provider's office hours 4. can identify triggers that may cause wheezing

2. demonstrates used of a metered-dose inhaler

The nurse would utilize the Glasgow Coma Scale on a trauma client to complete which assessment? 1. patency of airway 2. level of consciousness 3. breathing abnormalities 4. circulatory abnormalities

2. level of consciousness

Which action would the nurse take FIRST when admitting a client, who has had a left-sided pneumonectomy, to the post-anesthesia care unit? 1. check incision and dressing 2. obtain oxygen saturation 3. monitor blood pressure and pulse 4. check chest drainage system for bleeding

2. obtain oxygen saturation

Which diagnostic test would be most useful in evaluating the effectiveness of treatment for asthma? 1. chest x-ray 2. pulmonary function tests 3. serum eosinophil counts 4. immunoglobulin E levels

2. pulmonary function tests

Which action would the nurse take to prevent postoperative respiratory complications after abdominal surgery? 1. implement postural drainage 2. encourage pursed-lip breathing 3. assist with incentive spirometry 4. teach sustained exhalation

3. assist with incentive spirometry

The nurse is providing care in the post-anesthesia care unit to a client who underwent a left pneumonectomy. Which nursing intervention is CRITICAL when the client regains consciousness? 1. assessing for pain 2. assessing for gag reflex 3. encouraging deep breathing 4. encouraging ankle pump exercises

3. encouraging deep breathing

Which type of acid-base imbalance would the nurse expect in a child admitted with a severe asthma exacerbation? 1. metabolic alkalosis caused by excessive production of acid metabolites 2. respiratory alkalosis caused by accelerate respirations and loss of carbon dioxide 3. respiratory acidosis caused by impaired respirations and increased formation of carbonic acid 4. metabolic acidosis caused by the kidneys' inability to compensate for increased carbonic acid formation

3. respiratory acidosis caused by impaired respirations and increased formation of carbonic acid

When inspecting the surgical site of a client who had a partial pneumonectomy, the nurse notes puffiness of the tissue, and upon palpation of the site, the tissue feels spongy and crackles can be felt. Which phrase describes the nurse's interpretation of the assessment findings? 1. respiratory stridor 2. chest distention 3. subcutaneous emphysema 4. bilateral 2+ pitting edema

3. subcutaneous emphysema