Med Surg Adaptative Quiz

A nurse is assessing a client who has cholecystitis. Which of the following findings should the nurse expect? A. Blumberg's sign B. Ascites C. Gastrointestinal bleeding D. Kehr's sign

Correct Answer: A. Blumberg's sign The nurse should expect to find rebound tenderness (Blumberg's sign) in a client who has cholecystitis. This response can be an indication of peritoneal inflammation.

A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. How should the nurse assist the client with smoking cessation? A. Discuss ways the client can reduce the number of cigarettes smoked per day B. Suggest the client switch from smoking cigarettes to smoking a pipe C. Inform the client that treatment will be ineffective if smoking continues D. Discourage the use of nicotine gum

Correct Answer: A. Discuss ways the client can reduce the number of cigarettes smoked per day The nurse should discuss ways the client can reduce the number of cigarettes smoked per day to assist the client in creating a realistic goal to decrease smoking gradually.

A nurse is providing teaching about degenerative complications to the partner of a client who has a new diagnosis of Parkinson's disease. Which of the following manifestations is the priority? A. Dysphagia B. Emotional lability C. Impaired speech D. Self-care dependency

Correct Answer: A. Dysphagia The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and should be the nurse's priority concern. When applying the ABC priority-setting framework, the airway is the priority because it must be open for oxygen exchange to occur. Breathing is the second priority framework because adequate ventilatory effort is essential for oxygen exchange to occur. Circulation is the third priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, dysphagia is the priority manifestation because it can lead to aspiration.

A nurse is examining the ECG of a client who is having an acute myocardial infarction. The nurse should identify that the elevated ST segments on the ECG indicate which of the following alterations? A. Necrosis B. Hypokalemia C. Hypomagnesemia D. Insufficiency

Correct Answer: A. Necrosis ST-segment elevation during an acute myocardial infarction indicates necrosis. This ECG change reflects a clot at the site of injury. Therefore, the client requires immediate revascularization of the artery.

A nurse in a provider's office is assessing a client's skin lesions. The nurse notes that the lesions are 0.5 cm (0.20 in) in size, elevated, and solid with distinct borders. The nurse should document these findings as which of the following skin lesions? A. Papules B. Macules C. Wheals D. Vesicles

Correct Answer: A. Papules A papule is a small, solid, elevated lesion with distinct borders. It is usually smaller than 10 mm in diameter. Papules are common lesions of warts and elevated moles. B. A macule is a change in the color of the skin that is flat, variably shaped, discolored, and small (typically <10 mm in diameter). Freckles and the rash associated with rubella are types of macules. C. Wheals (also known as hives) are transient, elevated, irregularly shaped lesions caused by localized edema. Wheals are a common manifestation of an allergic reaction. D. A vesicle is a circumscribed, elevated lesion or blister containing serous fluid. Vesicles typically arise in herpes simplex, poison ivy, and chickenpox.

A nurse is caring for a client who had a gastric resection to treat adenocarcinoma of the stomach. The client tells the nurse in the PACU that he does not remember why the surgeon said he had to have a tube in his nose. The nurse should explain that the NG tube serves which of the following purposes? A. Prevents excessive pressure on suture lines B. Allows gastric lavage after surgery C. Allows early postoperative feeding D. Facilitates obtaining gastric specimens for testing

Correct Answer: A. Prevents excessive pressure on suture lines The NG tube remains in place after surgery to prevent excessive pressure on suture lines postoperatively. It drains the air and fluid that can cause pressure from inside the gastrointestinal (GI) tract. In doing so, it also prevents vomiting and GI distention.

A nurse is providing discharge teaching to a client who has emphysema. Which of the following instructions should the nurse include? A. "Be sure to take cough medicine to avoid coughing." B. "Try to drink at least 2 to 3 liters of fluid per day." C. "Try to reduce your smoking to 2 cigarettes per day." D. "Be sure to eat 3 full meals each day."

Correct Answer: B. "Try to drink at least 2 to 3 liters of fluid per day." Although adequate hydration is essential for all clients, clients who have emphysema should drink 2 to 3 L per day to help liquefy secretions.

A nurse is providing postoperative discharge teaching to a client following a panhysterectomy for uterine cancer. Which of the following pieces of information should the nurse include in the teaching? A. "You will need to continue to use some form of birth control for 6 months." B. "You might experience manifestations of menopause." C. "Do not lift anything heavier than 15 lb." D. "Pain or burning with urination is an expected outcome of this surgery."

Correct Answer: B. "You might experience manifestations of menopause." The nurse should inform the client that a panhysterectomy includes the removal of the uterus and the ovaries, which might cause manifestations of menopause (e.g. hot flashes, night sweats, and vaginal dryness).

A nurse is caring for a client who is experiencing an acute exacerbation of rheumatoid arthritis. The nurse should anticipate that the client's affected joints will require which of the following treatments? A. An assistive device when the client is ambulating B. Heat paraffin therapy applied to the client's joints C. Gentle massage of the client's hands D. Active range-of-motion exercises on the client's affected joints

Correct Answer: B. Heat paraffin therapy applied to the client's joints The nurse should anticipate the use of heat paraffin to be prescribed as a nonpharmacological intervention. An elevated ESR indicates an acute inflammatory process due to client's rheumatoid arthritis. The use of the warm paraffin relieves the stiffness of the client's joints and provides comfort.

A nurse is caring for a client who has a brainstem injury. Which of the following physiological functions should the nurse monitor? A. Understanding speech ✔ Correct answer BB. Respiratory effort C. Decision-making ability D. Temperature control

Correct Answer: B. Respiratory effort The nurse should monitor the respiratory effort of a client who has an injury to the brainstem. The medulla in the brainstem controls the respiratory center.

A nurse is caring for a client who is postoperative following shoulder surgery. The client has a prescription to keep the affected arm adducted. Which of the following instructions should the nurse share with the client? A. "Keep your arm bent at the elbow." B. "Use a pillow to prop your shoulder up close to your ear." C. "Hold your arm against the side of your body." D. "Position your arm with the shoulder at a 90° angle."

Correct Answer: C. "Hold your arm against the side of your body." Adduction means to position toward the midline of the body. Therefore, the nurse should provide these instructions to explain the provider's prescription.

A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first? A. Instruct the client to cough B. Administer oxygen via face mask C. Evaluate the client for stridor D. Keep the client in a semi- to high-Fowler's position

Correct Answer: C. Evaluate the client for stridor The first action the nurse should take using the nursing process is to assess the client. After extubation, the nurse should continuously evaluate the client's respiratory status. Stridor is a high-pitched sound during inspiration that indicates laryngospasm or swelling around the glottis. Stridor reflects a narrowed airway and might require emergency reintubation.

A nurse is assessing a client who is receiving hemodialysis for the first time. Which of the following findings indicates that the client is developing dialysis disequilibrium syndrome (DDS)? A. Elevated BUN B. Bradycardia C. Headache D. Temperature 39.2°C (102.5°F)

Correct Answer: C. Headache DDS is a CNS disorder that can develop in clients who are new to dialysis due to the rapid removal of solutes and changes in the blood pH. Clients beginning hemodialysis are at greatest risk, particularly if their BUN is above 175. DDS causes headaches, nausea, vomiting, a decreased level of consciousness, seizures, and restlessness. When the condition is severe, clients progress to confusion, seizures, coma, and death.

A nurse names 3 objects for the client to remember, asks the client to repeat them, and tells the client he will have to repeat them again in a few minutes. After 5 min, the nurse asks the client to name the objects. The nurse is using this strategy to test which type of memory? A. Remote B. Sensory C. Immediate D. Recall

Correct Answer: C. Immediate The nurse tests the client's immediate or new memory by following the 3-object protocol. A client without cognitive decline should be able to recall and name the 3 objects 5 minutes later.

A nurse is caring for a client who has an impairment of cranial nerve II. Which of the following actions should the nurse perform to promote the client's safety? A. Initiate seizure precautions. B. Ensure the client receives a soft diet. C. Provide an obstacle-free path for ambulation. D. Instruct the client to use lukewarm water when showering.

Correct Answer: C. Provide an obstacle-free path for ambulation. Although providing an obstacle-free path is a safety precaution for all clients, it is especially crucial for this client. Cranial nerve II is the optic nerve; therefore, the client has at least some visual challenges and will need an obstacle-free path for ambulation.

An emergency room nurse is assessing a client who has a new traumatic brain injury. The nurse observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. Which of the following actions is the nurse's priority? A. Monitor urinary output B. Administer an osmotic diuretic C. Provide supplemental oxygen D. Initiate seizure precautions

Correct Answer: C. Provide supplemental oxygen The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to provide supplemental oxygen. The client might require an artificial airway and mechanical ventilation because these findings indicate decerebrate positioning, which is associated with brainstem injury and can lead to brain herniation and death.

A nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care? A. Clamp the chest tube if there is continuous bubbling in the water seal chamber B. Keep the chest tube drainage system at the level of the right atrium C. Tape all connections between the chest tube and drainage system D. Empty the collection chamber and record the amount of drainage every 8 hr

Correct Answer: C. Tape all connections between the chest tube and drainage system The nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidentally disconnecting.

A nurse is assessing a 66-year-old client during a routine physical examination. This is the client's first clinic visit, and she does not have her medical records. When the nurse asks if she has received the pneumococcal immunization, the client replies, "I am not sure, but it's been at least 5 years since I've had any immunizations." Which of the following responses should the nurse provide? A. "In case you had the immunization before, we can't give you another one." B. "You'll need a series of 3 injections." C. "This immunization is unsafe for people over the age of 65 years old." D. "Let's go ahead and give you this immunization."

Correct Answer: D. "Let's go ahead and give you this immunization." The Centers for Disease Control and Prevention recommend this immunization for people who are 65 years of age and older. If the client did receive this immunization more than 5 years ago, the nurse should administer another because the client is over 65.

A nurse is admitting a client who is in sickle cell crisis. Besides pain management, which of the following interventions should the nurse include in the client's plan of care? A. Flexion of the extremities B. Therapeutic hypothermia C. Upright positioning ✔ Correct answer DD. Ample hydration

Correct Answer: D. Ample hydration A client who is in sickle cell crisis needs ample hydration (either IV, oral, or both) to shorten the duration of painful episodes. The nurse should plan to offer the client water, juice, or a favorite beverage that does not contain caffeine.

A nurse is preparing a client for discharge following a bronchoscopy. Which of the following assessments is the nurse's monitoring priority? A. Measuring heart rate B. Palpating peripheral pulses C. Observing sputum for blood D. Confirming the gag reflex

Correct Answer: D. Confirming the gag reflex The greatest risk to the client's safety is aspiration resulting from a depressed gag reflex. The nurse's priority is to make sure the client's gag reflex has returned before discharge so that the client can maintain hydration and nutrition without risk.

A nurse is providing postoperative care for a client who has 2 chest tubes in place following a lobectomy. The client asks the nurse the reason for having 2 chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons? A. Removing air from the pleural space B. Creating access for irrigating the chest cavity C. Evacuating secretions from the bronchioles and alveoli D. Draining blood and fluid from the pleural space

Correct Answer: D. Draining blood and fluid from the pleural space The nurse should inform the client that blood and fluids tend to accumulate in the bases and posterior areas of the pleural cavity following a lobectomy. For this reason, the lower chest tube primarily drains blood and fluid from the pleural space.

A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should the nurse include in the client's plan of care? A. Maintain the client's knees and hips in a flexed position B. Apply cold compresses to painful joints C. Withhold opioids until the crisis is resolved D. Encourage increased fluid intake

Correct Answer: D. Encourage increased fluid intake The nurse should encourage increased fluid intake to promote hydration because dehydration increases the viscosity of the blood, which can aggravate sickling and client discomfort.

A nurse is reviewing the medical record of a client who is experiencing tinnitus in both ears. Which of the following pieces of information in the client's medical record should the nurse identify as a risk factor for tinnitus? A. Use of hydrochlorothiazide B. Chronic use of acetaminophen C. Allergic external otitis D. Sclerosis of the ossicles

Correct Answer: D. Sclerosis of the ossicles Sclerosis of the ossicles, called otosclerosis, is an overgrowth of the tissue of the bones in the middle ear, which can cause tinnitus and conductive hearing loss. A stapedectomy is a surgical procedure that corrects otosclerosis by removing a portion of the stapes and inserting a prosthesis.

A nurse is performing a gastrointestinal assessment of a client who has liver cirrhosis with abdominal distention. Which of the following actions should the nurse take to assess for changes in the client's abdominal distention? A. Percuss the abdomen for tympanic sounds B. Inspect the contour of the abdominal wall C. Instruct the client to report increased abdominal discomfort D. Take serial measurements of the abdomen with a tape measure

Correct Answer: D. Take serial measurements of the abdomen with a tape measure Measuring the abdomen is the most effective way to assess for a change in abdominal distention because it provides concrete, objective data that can be compared at various points in time to monitor changes.

A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35 mL of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax? (Select all that apply.) A. Tracheal deviation to the left B. Temperature of 38.8°C (102°F) C. Absent breath sounds on the right side D. Neck vein distention E. Bradypnea

Correct Answers: A. Tracheal deviation to the left C. Absent breath sounds on the right side D. Neck vein distention

A nurse on an oncology unit is providing discharge teaching to an adolescent female client who received a bone marrow transplant for leukemia. Which of the following pieces of information should the nurse include in the teaching? (Select all that apply.) A. "Take your temperature twice each day." B. "You may return to school if you feel strong enough." C. "It is important to wear shoes always." D. "Clean your toothbrush weekly with isopropyl alcohol." E. "Avoid using tampons."

Correct Answers: A. "Take your temperature twice each day." C. "It is important to wear shoes always." E. "Avoid using tampons." Clients who are postoperative from bone marrow transplants are immunosuppressed and should continually monitor for manifestations of infection. A temperature that is greater than 38°C (100°F) should be reported immediately to the provider. The client should wear shoes to prevent injury and decrease the risk of infection. The use of tampons is discouraged because they can disrupt the mucosal layer of the vagina and may support the growth of bacteria if left in place for too long.

A nurse is updating the plan of care for a client who is to receive total parenteral nutrition (TPN). Which of the following actions should the nurse include in the plan? (Select all that apply.) A. Weigh the client daily B. Obtain a serum blood glucose every 4 hr C. Apply a new dressing to the client's IV site every 5 days D. Change the IV tubing every 24 hr E. Infuse the TPN through a peripheral IV site

Correct Answers: A. Weigh the client daily B. Obtain a serum blood glucose every 4 hr D. Change the IV tubing every 24 hr The nurse should weigh the client daily while receiving TPN. Clients who are receiving TPN are typically malnourished; therefore, the client's weight needs to be monitored closely. Fluid retention can also be an indication that the client is not digesting the TPN, and the rate of the transfusion might need to be decreased. The nurse should also obtain the client's serum blood glucose; insulin can be given if needed. Finally, the nurse should change the client's IV tubing every 24 hours to prevent bacteria from developing in the client's tubing.

A nurse is talking with a group of women at a community center about the current recommendations for early detection of breast cancer. The nurse should explain which of the following options? A. Begin monthly breast self-examinations at age 40 B. Have a clinical breast examination each year after age 30 C. Begin annual mammograms at age 40 D. Have breast magnetic resonance imaging every 5 years after age 50

Women should begin performing monthly breast self-examinations at 20 years of age. From 20 to 39 years of age, women should undergo a breast examination by a health care provider every 3 years. Women older than 40 years of age should have annual breast examinations by a health care provider and an annual mammogram.