Med Surg Test 2 Practice
A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make?
"A headache is an expected adverse effect of the medication."
A nurse is teaching a client who is taking atorvastatin daily. Which of the following statements by the client indicates an understanding of the teaching?
"I will avoid drinking grapefruit juice."
A nurse is preparing to administer 0.45% sodium chloride (NaCl) 1000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Answer the NUMBER ONLY)
125
Which statements by a 70-year-old client about elective surgery for repair of an abdominal aortic aneurysm indicate that teaching was effective? Select all that apply
"I have a greater risk of rupture because I have hypertension" "Because my aneurysm is 7 cm, the risk of rupture is greater than the risk of dying during surgery"
A nurse is providing teaching to a client who has a new prescription for lisinopril. Which of following statements by the nurse indicates an understanding of the teaching?
"I should report a cough to my provider."
A nurse is caring for an infant who weighs 12 lb and is prescribed cefuroxime sodium 15mg/kg PO every 12 hr. Available is cefuroxime sodium oral solution 125mg/5mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Give the answer in the NUMBER ONLY)
3.3
The nurse is assessing a client with a closed head injury who has received mannitol for manifestations of increased intracranial pressure (ICP). Which of the following indicates that the medication is having a therapeutic response?
Patient's glasglow coma scale changes from 9 to 11
A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?
Elevate the head of the bed
A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity?
"My vision seems yellow."
A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?
"These tests help determine the degree of damage to the heart tissues."
A nurse is preparing to administer clindamycin palmitate 225 mg PO every 8 hr to a client. The amount available is clindamycin palmitate oral suspension 75 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Give the answer in the NUMBER ONLY)
15
A nurse is preparing to administer dextrose 5% in water (D5W) IV to infuse at 100 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Give the answer in the NUMBER ONLY)
33
A nurse is preparing to administer 0. 9% sodium chloride IV infusion 1-L bag at a rate of 200 mL/hr for a client who has rhabdomyolysis. The nurse should expect the IV pump to infuse over how many hours? (Round the answer to the nearest whole number. Answer with the NUMBER ONLY)
5
The nurse is caring for a patient in a barbiturate coma for increased intracranial pressure (ICP). What should the nurse assess to determine this patient's cerebral function?
Pupillary size and reaction
The latest blood pressure reading for a patient with a spinal cord injury is 210/140 mm Hg. What action should the nurse take first?
Raising the head of the bed 45 degrees
A nurse is preparing to administer mannitol, an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?
Reduce edema of the brain.
Once ventricular fibrillation has been confirmed in a patient, which action is the priority?
Starting chest compressions
What is the cause of unstable angina?
Atherosclerosis which reduces O2 to tissue
A nurse in an emergency department is assessing a client who sustained a fall off a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? Select all that apply
Battle's sign Clear fluid coming from nares
The nurse is caring for a client with the most common type of spinal cord injury who is experiencing functional motor loss that is greater in the arms than in the legs. The nurse is aware that this type of SCI is classified as:
Central cord syndrome
A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?
Check the client's vital signs.
The nurse correlates which assessment data to unstable angina?
Chest pain that is not relieved by rest
The nurse is caring for a client who dove into a shallow pool and now has a complete spinal cord injury. The nurse knows the client most likely experienced which type of spinal trauma?
Compression
A patient is in normal sinus rhythm with prolonged PR intervals. What prescribed treatment does the nurse plan for this patient?
Continue to monitor
A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?
Defibrillation
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
Epidural hematoma
A nurse is providing teaching for a client who has a new diagnosis of stable angina pectoris. Which of the following information should the nurse include about anginal pain?
Exertion and anxiety can trigger the pain.
A patient is prescribed atorvastatin. This medication is classified as a:
HMG-CoA Reductase Inhibitor
The nurse correlates which clinical manifestations to autonomic dysreflexia in a patient with a spinal cord injury?
Hypertension with bradycardia
A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?
Hypotension
The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising?
Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
A nurse is teaching about necessary baseline examinations with a female client who is to start taking atorvastatin. Which of the following baseline examinations should the nurse include in the teaching?
Liver function tests
A client has frequent bursts of ventricular tachycardia on the cardiac monitor. Why should the nurse be most concerned about with this dysrhythmia?
It can develop into ventricular fibrillation at any time
The nurse is educating a patient with athlerosclerosis on the risks of aortic abdominal aneurysm. Which of the following risk factors for AAA does the nurse include in the education? Select all that apply
Male gender Smoking
In administering an angiotensin-converting enzyme inhibitor to a patient with cardiomyopathy, the nurse correlates which rationale for this medication?
Reduce afterload
A 65-year-old male comes to the emergency department with complaints of crushing chest pain that radiates to his left shoulder and jaw. Immediate orders include oxygen per nasal cannula at 4L/min, blood work, chest x-ray, electrocardiogram (ECG), and 2 mg of morphine given intravenously. No ED tech is available at this time. The nurse should first:
Obtain a 12-lead EKG
A nurse is planning to administer digoxin to a client who has heart failure. Which of the following laboratory results is the priority for the nurse to review prior to administering the medication?
Potassium
A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of the following indicates the AAA is expanding?
Report of sudden, severe back pain
A patient has arrived by ambulance at the emergency department after a cervical spinal cord injury. Which assessment is a priority for the nurse to perform at this time?
Respiratory pattern and airway
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?
Restlessness
The nurse notes that PR intervals are getting progressively longer before a QRS complex is dropped on a patient's cardiac rhythm strip. The nurse interprets this as which cardiac dysrhythmia?
Second-degree AV block, Mobitz I (Wenckebach)
The adaptations of a client with complete heart block would most likely include:
Syncope and low ventricular rate
In preparing a patient with atrial fibrillation for cardioversion, the nurse prepares the patient for which diagnostic before the cardioversion?
Transesophageal echocardiogram (TEE)
A nurse is caring for a client with symptomatic supraventricular tachycardia. The nurse instructs the client to do which of the following, if prescribed, during an episode of supraventricular tachycardia?
blow into an obstructed straw
A young male patient is brought to the emergency department with a diagnosis of traumatic head injury following a motor vehicle accident. Upon admission, vital signs are within normal limits, Glasgow coma scale is 6, and pupils are equal but sluggish. Based on this initial assessment, the priority nursing intervention would be:
maintain a patent airway and administer oxygen
A nurse is preparing to administer cefprozil 15 mg/kg PO every 12 hr to a child. The child weighs 45 lb. Available is cefprozil 250 mg/5mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Give the answer in the NUMBER ONLY)
6
A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Which of the following medications should the nurse plan to administer?
Mannitol 25%
A nurse is teaching a client who has coronary artery disease about the difference between angina pectoris and myocardial infarction. Which of the following should the nurse identify as indications of a myocardial infarction? Select all that apply
Nausea and vomiting Diaphoresis and dizziness Anxiety and feelings of doom
The nurse is preparing medications for a patient experiencing an acute myocardial infarction. Which medication will dilate the patient's coronary blood vessels?
Nitroglycerin
A nurse is caring for a client with a spinal cord injury sustained 8 years ago. The clients' level of injury is outlined in the image (Body image with point of injury in mid-lumbar area). Which of the following findings would the nurse NOT expect to see?
Shallow respirations
