Med surge Exam 1
The nurse is evaluating a client in skeletal traction. When evaluating the pin sites the nurse would be MOST concerned with which findings?
Thick yellow drainage from the pin sites
The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?
Twitching
The nurse is caring for a client with a diagnosis of gout. Which lab value would the nurse expect to note in the client
Uric acid level of 9.0 meq
The nurse has just reassessed the condition of a post op client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?
Urinary output of 20ml/hr
The low pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm the nurse should take what INITIAL action
Ventilate the client manually
A client with MI is developing cardiogenic shock. Because of the risk of myocardial ischemia what ondition should the nurse carefully assess the client for?
Ventricular dysrhythmias
The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The clients rhythm suddenly changes to one with no P waves. No definable QRS complex and coarse wavy lines of varying amplitude . How should the nurse correctly interpret this rhythm
Ventricular fibrillation
The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves , the QRS complexes are wide and the ventricular rate is regular but more than 140 b/m . The nurse determines that the client is experiencing which dysthymia?
Ventricular tachycardia
A oxygen delivery system is prescribed for a client with COPD to deliver a precise o2 concentration. Which oxygen delivery system would the ruse prepare
Venturi Mask
The nurse is caring for a client who has been receiving IV diuretics suspects that the client is Experiencing a fluid volume deficit . Which assessment finding would the nurse note in a client with this condition.
Weight loss and poor skin turgor
A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. the nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain?
impaired tissue perfusion
A client with a gastric ulcer is scheduled for surgery . The client cannot sign the operative consent form because of sedation from the opioid s that have been administered. The nurse should take which most appropriate action in the care of this client?
obtain telephone consent from a family member following agency policy
what techniques will the nurse use to help loosen secretions?
percussion and vibration
The nurse performs an admission assessment on a client with a diagnosis of TB.. the nurse should check the results of which diagnostic test that will confirm this diagnosis.
sputum culture
The nurse is teaching a client about coughing and deep breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques?
"Use of a incentive spirometer will help prevent pneumonia
The nurse is preparing to suction a client via tracheostomy tube. The nurse should plan to limit the suctioning time to a max of
10 seconds
A client has developed uncontrolled atrial fibrillation with a ventricular rate of 150 beats/min. What manifestation should the nurse observe for when performing the client's focused assessment? 1.Flat neck veins 2.Nausea and vomiting 3.Hypotension and dizziness 4.Clubbed fingertips and headache
3.Hypotension and dizziness
The nurse is assigned to care for a group of clients . On review of the clients medical records the nurse determines that which client is most likely at risk for a fluid volume deficit.
A client with an ileostomy. ( others include vomiting, diarrhea, increased urinary output , draining fistula"
the nurse is evaluating the condition of a client after pericardiocentesis preformed to treat cardiac tamponade. Which observation would indicate that the procedure was effective?
A rise in BP
The nurse is conducting heath screening for osteoporosis. Which client is at greatest risk of developing this disorder?
A sedentary 65 year old woman who smokes cigaretts
The nurse is caring for a patient who has just had implantation of an automatic internal cardioverter defibrillator . The nurse should assess which item based on priority?
Activation status of the device, HR cutoff, and number of shocks it is programmed to deliver
Home care instructions for a patient with TB should include....
Activities should resume gradually A sputum culture is needed ever 2 to 4 weeks Respiratory isolation is not necesssary because family members already have been exposed Cover mouth and nose when coughing or sneezing and put used tissues in plastic bag
A client who had cardiac surgery 24 hours ago has had a Urine OP averaging 20 ml/hr for 2 hours. The client received a single bonus of 500ml of IV fluid. Urine OP for the subsequent hour was 25 ml. Daily lab results intimate that the blood urea nitrogen level is 45 mg and the serum creatinine level is 2.2 mg. On the basis of these findings the nurse would anticipate that the client is at risk for which problem?
Acute kidney injury
A nurse in a medical unit is caring for a pt with HF. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the HCP and prepares to implement which priority interventions
Administering o2 inserting a Foley catheter to accurately track output Administer furosemide ( diuretic) Admin morphine surfactant IV
The nurse is caring for a client with heart failure. On assessment the nurse notes that the client is dysgenic and crackles are audible on auscultation. What additional manifestation would the nurse expect to note in this client if excess fluid volume is present?
An increase in blood pressure and increased respirations
A client with a 3 day history of N/V presents to the emergency department . The client is hypovenelating and has a respiratory rate of 10 breaths/min.the ECG monitor displays tachycardia with a heart rate of 120 beats/min. Arterial blood gasses are drawn and the nurse reviews the results expecting to note which finding?
An increased PH and an increased HC03
The nurse receives a telephone call from the post anesthesia care unit stating that a client is being transferred to the surgical unit . The nurse plans to take which action FIRST on arrival of the client?
Assess the latency of the airway
The nurse is watching the cardiac monitor and a clients rhythm suddenly changes. There are no P waves , instead there are fibrillatory waves before the QRS complex. How should the nurse correctly interpret the clients Heart rhythm?
Atrial fibrillation
A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor?
Bending or lifting
A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item?
Blood pressure and Oxygen saturation
The nurse is caring for a client with a bronchoscope and biopsy. Which finding if noticed in the client should be reported IMMEDIATELY to the HCP.
Bronchospasm
The nurse is caring for a patient who had a resection of an abdominal aortic aneurysm yesterday. The client has an IV infusion at a rate of 150 ml/hr unchanged for the last 10 hours. The urine OP for the last 3 hours is 90,50 and 28 being the most recent. Blood urea nitro level is 35 mg, and serum creatinine level is 1.8 mg measured this morning. Which nursing action is the priority?
Call the health care provider ( may be sign of kidney failure)
A preoperative client expresses ancient to the nurse about the upcoming surgery . Which response from the nurse would stimulate further discussion between the client and the nurse?
Can you share with me what you've been told about your surgery?
A client is wearing a continuous cardiac monitor which begins to count its alarm. The nurse sees no electrocardiographic complexes on the screen. which is the priority nursing action
Check the clients status and lead placement
A client has experienced pulmonary embolism. The nurse should assess for which symptom , which is most commonly reported.
Chest pain that occurs suddenly
The nurse is caring for a client being treated for fat embolus after multiple fractures. Which date would the nurse evaluate as the most favorable indication of resolution of the fat embolus?
Clear mentation
The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pad on the clients chest and before discharge, which intervention is a priority?
Confirm that the rhythm is actually ventricular fibrillation
The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complex's are regular . The PR interval is 0.16 seconds and QRS complexes measure 0.06 seconds. The overall heart rate is 64 b/m . Which action should the nurse take?
Continue to monitor for any rhythm change
A client with myocardial infraction suddenly becomes tachycardic, shows signs of air hunger and begins coughing frothy pink tinged sputum. Which finding would the nurse-anticipate when auscultation get the clients breath sounds?
Crackles
The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client?
Diminished breath sounds
A client who has had abdominal surgery complains of a feeling as though " something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protrudeing though the incision. Which interventions should the nurse take?
Document findings Contact the surgeon ( prepair pt for wound closure , instuct client to remain quite) may be other options
A client with AIDS has a histoplasmosis. The nurse should assess the client for which expected fiding
Dyspnea
The community health nurse is conducting an educational session with communit members regarding s&s associated with TB. The nurse informs the participant that TB is considered as a diagnosis if which S&S are present?
Dyspnea Night Sweats A bloody , productive couch A cough with expectoration of mucous sputum
The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster case applied . Which position would be best for the casted leg?
Elevated on pillows continuously for 24 to 48 hours. ( this minimizes swelling and promotes venous drainage)
The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?
Have client void immediately before going into surgery.
Which lab would indicate needing the surgery to be postponed?
Hemoglobin 8.0 g
The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment the nurse notes that the client has flat neck veins, generalized muscle weakness and diminished deep tendon reflexes. The nurse suspects hyponatremia . What additional signs would the nurse expect to note in a client with hyponatremia?
Hyperactive bowel sounds.
A client is being discharged to home after application of a plaster leg cast. Which statement indicates that the client understands proper care of the cast?
I need to avoid getting the cast wet.
The nurse has conducted preoperative teaching for a client scheduled for a surgery in 1 week. The clien has a history of arthritis and has been taking acetylaslicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement?
I need to continue to take the aspirin until the day of surgery
The nurse has given instructions to a client returning home after a knee arthroscopy. Which statement by the client indicates that the instruction are understood?
I need to report a fever or swelling to my HCP.
The nurse conducts discharge teaching to a client with TB. The nurse determines the patient understood the teaching when they state
I should not be contagious after 2-3 weeks of med therapy
The nurse has given the client instructions about crutch safety. Which statement indicates that the client understands the istructions
I should not use someone else's crutches I need to remove any scatter rugs at home I need to have spare crutches and tips available
The nurse assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress
Increased RR
The nurse is monitoring the status of a post op client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication?
Increasing restlesness
A client being measured for crutches asks the nurse why crutches cannot rest up underneath the arm for extra support. The nurse responds knowing that which would most likely result from this improper crutch measurement .
Injury to the brachial plexus nerves
The nurse is reading a health care providers progress notes in the clients record and reads that the HCP has documented "insensible fluid loss of approx 800 ml daily. The nurse makes a notation that insensible fluid loss occurs through which type of excretion?
Integumentary output.
A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia?
It can develop into ventricular fib at any time.
Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm?
Keep the cast clean and dry Allow the cast 24 to 72 hours to dry Keep the cast and extremity elevated
The nurse reviews a clients lab report and notes that the clients serum phosphorus level is 1.8 meq. Which condition most likely caused this serum phosphorus level?
Malnutrition
The nurse is taking the history of a client with occupaational lung disease . The nurse should assess whether the client wears which item during periods of exposure to Cilicia particles
Mask
The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?
Metabolic alkalosis
A client admitted to the hospital with chest pain and a hx of type 2 diabetes Mellitus is scheduled for a radial catherization. Which medication would need to be withheld for 24 hours before the procedure and 48 hours after the procedure
Metformin
A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for FURTHER teaching?
My spouse told me that since i have developed this problem we are going to stop walking in the mall every morning.
The nurse notes that a clients arterial blood gas results reveal a ph of 7.50 and a paco2 of 30mm . The nurse monitors the client for which clinical manifestations associated with these ABG results.
Nessus, confusion, Tachycardia, Hyperkalemia
The nurse has conducted teaching with a client in an arm cast about the S&S of compartment syndrome. The nurse determines that the client understands the info if the client stated that he/she should report which early symptom of compartment syndrome?
Numbness and tingling in the fingers
The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurses findings?
PH 7.25 Paco2 50mm
The nurse is assessing the respiratory status of a client who has suffered a freactured rib. The nurse should expect
Pain, especially on incpiration
A client with a chest injury has suffered fail chest. The nurse assesses the client for which most distinctive sign of fail chest
Paradoxical chest movement
The nurse is preparing to give a bed bath to an immobilized client with TB. The nurse should wear which items when performing this care.
Particulate respirator, gown, and gloves
The nurse is reviewing lab results and notes that a clients serum sodium level is 150 meq . Which dietary food items would the HCP have the nurse instruct the client to consume?
Peas, Nuts, cauliflower
A client who is HIV positive has had a TB test. The nurse notes a 7mm area of induration at the site of the skin test and interpreted the result and which finding
Positive since it Its over 5mm
The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a ph of 7.50 and Paco2 of 30mm . the nurse has determined that the client is experiencing respiratory alkalosis. Which lab value would most likely be noticed in this condition?
Potassium level of 3.0 ( hypokalemia can cause confusion tachycardia and dysrythmea
The nurse is reviewing a surgeons prescription sheet for a preoperative client that states that the client must be nothing by mouth after midnight. The nurse should call the surgeon to clarity that which med should be given to the client ad not withheld?
Prednisone
A client in sinus bradycardia with a HR of 45 b/m complains of dizziness and has a BP of 82/60mm . Which prescription should the nurse anticipate will be prescribed?
Prepare for transcutaneous pacing
The nurse is assessing the casted extremity of a client. Which sign is indicative of infection?
Presence of a "hot spot" on the cast.
The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states .....
Promotes carbon dioxide elimination
A client with a hip fracture asks the nurse about bucks traction that is being applied before surgery and what is involved . The nurse should provide which information to the client
Provides comfort by reducing muscle spasms , provides fracture immobilization and involves pulleys and wheels.
The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods?
Raisins, potatoes, cantaloupe, strawberries
The nurse is preparing to care for a client with potassium deficit. The nurse reviews the clients record and determines that the client is as risk for developing the potassium deficit because of which situation?
Requires nasogastric suction
The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid based imbalance?
Respiratory acidosis from inadequate ventilation
The nurse reviews the arterial blood gas results of a client and notes the foll owing PH 7.45, paco2 of 30mm and HCO3 of 20 meq. The nurse analyzes these results as indicating which condition?
Respiratory alkalosis
The nurse is caring for a client who had an above knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage which has come off. Which Immediate action should the nurse take?
Rewrap the residual limb with an elastic compression bandage
A client has been admitted for chest trauma after a motor vehicle crash and has undergone subsequent intubation. The High pressure alarm sounds and the nurse sees the client has absence of breath sounds in the right upper lobe of the lung. The nurse immeadiately assesses for other signs of which condition
Right Pneumothorax
A client with diabetes mellitus has had a right below knee amputation. Given the clients history of DM which complication is the client at most risk for after surgery?
Separation of the wound edges ( patients with DM increases the risk of infection)
The nurse assesses a clients surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding?
Serous drainage
The nurse is giving discharge instructions to a client with pulmonary carcoidosis. The nurse concludes that the client understands the info if the client indicates to report which early sign of exacerbation
Shortness of breath
The nurse is instructing a hospital client with a diagnosis of emphysema about measures. That will enhance he effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume
Sitting up and leaning on an over bed table.
The nurse is evaluating a clients response to cardio version. Which assessment would be priority?
Status of airway
The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention should the nurse take?
Stay with the victim and encourage him/ her to stay still.
The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure the nurse notes on the monitor that the HR is decreasing. The nursing intervention would be
Stop the procedure and deoxygenate the client
The nurse is caring for a client who had a spinal fusion with insertion of hardware. The nurse would be most concerned with which assessment finding?
Temperature of 101.6 (38.7 )orally
The nurse conducting preoperative teaching with a client about the use of an incentive spirometer . The nurse should include which piece of information in discussion with the client?
The best results are achieved when sitting up for with the head of the bed elevated 45 to 90 degrees
Which client is at risk for the development of potassium level of 5.5 meq.
The client who has sustained a traumatic burn.
Which client is at risk for the development of a sodium level at 130 meq.
The client who is taking diuretics
On review of the clients medical records, the nurse determines that which client is at risk for fluid vol. excess?
The client with kidney disease and a 12 year history of diabetes mellitus.
the nurse is assessing the neuro vascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the clients neurovascular status.
The neurovascular status is normal because of increased blood flow through the leg.
