VATI Med-Surg pre-assessment

A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? A. Continue to monitor the client. B. Immediately notify the provider. C. Reposition the client toward the left side. D. Clamp the chest tube near the water seal.

A. Continue to monitor the client. The fluid in the water seal chamber rises 2 to 4 inches during inhalation and falls during exhalation. This is a process called tidaling. An absence of tidaling might indicate a fully expanded lung or an obstruction in the chest tube. The nurse does not need to contact the provider at this time. The fluid in the water seal chamber is expected to rise during inhalation and fall during exhalation.

A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply) A. Count your pulse for 1 min each morning. B. Resume activities that can cause jolting, such as horseback riding, after 4 weeks. C. Do not wear tight clothing over the insertion area. D. Request to be scanned with a handheld metal detector when in the airport. E. Do not have a microwave oven in the home.

A. Count your pulse for 1 min each morning. C. Do not wear tight clothing over the insertion area.

A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload? (Select all that apply.) A. Dyspnea B. Gastrointestinal bloating C. Jugular vein distention D. Confusion E. Hypotension

A. Dyspnea C. Jugular vein distention D. Confusion Dyspnea is a clinical manifestation of fluid volume overload. Jugular vein distention is a clinical manifestation of fluid volume overload. Confusion is a clinical manifestation of fluid volume overload.

A nurse is assessing a client who has type 1 diabetes mellitus and finds the client lying in bed, sweating, and reporting feeling anxious. Which of the following complications should the nurse expect? A. Hypoglycemia B. Nephropathy C. Hyperglycemia D. Ketoacidosis

A. Hypoglycemia Manifestations of hypoglycemia include sweating, tachycardia, tremors, palpitations, hunger, and anxiety. Manifestations of nephropathy include hypertension, microalbuminuria, and elevated uric acid levels. Manifestations of hyperglycemia include warm skin, rapid respirations, and changes in mental status. Manifestations of ketoacidosis include tachycardia, Kussmaul respirations, nausea, and lethargy.

A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the early stage of the disease? A. Intermittent claudication B. Dependent rubor C. Rest pain D. Foot ulcers

A. Intermittent claudication Intermittent claudication is ischemic pain that is precipitated by exercise, resolves with rest, and is reproducible. The pain associated with claudication arises when cellular oxygen demand exceeds supply. It occurs early in the disease course, and is typically the initial reason clients who have PAD seek medical attention. Dependent rubor is a dark red color to the feet and lower legs when the leg is in a dependent position. It is the result of dilation of the arteries as a compensatory response to poor arterial blood flow and is a manifestation that occurs in later stages of PAD. Rest pain, or a numbness or burning sensation to various areas of the foot, is a manifestation that occurs in later stages of PAD and can result in the loss of a limb. The discomfort, which is worse when the foot is in a horizontal or elevated position, is the result of increasing arterial insufficiency. Foot ulcers are a manifestation that occurs in later stages of PAD. Arterial ulcers form on or between the toes and are painful. The wound has a round, "punched out" appearance and is usually small and can develop gangrene.

A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply.) A. Poor nutritional state B. Altered mental status C. Obesity D. Pain medication administration E. Wound infection

A. Poor nutritional state C. Obesity E. Wound infection

A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply) A. Troponin I B. Troponin T C. Plasma low-density lipoproteins (LDL) D. CPK E. Myoglobin

A. Troponin I B. Troponin T D. CPK E. Myoglobin Troponin I is a myocardial muscle protein that is released when there is injury to cardiac muscle. Levels are elevated as early as 2 to 3 hr following a myocardial infarction. Troponin T is a myocardial muscle protein that is released when there is injury to cardiac muscle. Levels are elevated as early as 2 to 3 hr following a myocardial infarction. CPK, or creatine phosphokinase, is an enzyme that is elevated in the presence of muscle injury. Although CPK is not specific for myocardial damage, it is used in conjunction with other diagnostic tests to support a diagnosis of myocardial infarction. A CPK isoenzyme, CK-MB, is specific to cardiac muscle and a significant elevation in this isoenzyme indicates a myocardial infarction has occurred. Elevation of myoglobin indicates myocardial injury. Myoglobin levels will significantly increase within approximately 3 hours following myocardial infarction. This test is used in conjunction with other diagnostic tests to support a diagnosis of myocardial infarction.

A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make? A. "It is caused by the lack of production of insulin by the pancreas.." B. "It is caused by the lack of production of aldosterone by the adrenal gland." C. "It is caused by the overproduction of growth hormone by the pituitary gland." D. "It is caused by the overproduction of parathormone by the parathyroid gland."

B. "It is caused by the lack of production of aldosterone by the adrenal gland." Addison's disease is caused by a lack of production of the adrenocorticotropic hormones (cortisol and aldosterone) by the adrenal gland. A client who does not produce insulin has type 1 diabetes mellitus. A client who has an overproduction of the growth hormone has acromegaly. A client who has hyperparathyroidism produces an excessive amount of parathormone.

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse recognize as a risk factor for this medication? A. History of bulimia B. History of NSAID use C. Drinks green tea D. Has a glass of wine with dinner each day

B. History of NSAID use The nurse should recognize that long-term use of NSAIDs is a risk factor for peptic ulcer disease. NSAIDs break down the mucosal barrier and cause production of prostaglandins to decrease, which results in local gastric mucosal injury.

A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client? A. Respiratory alkalosis B. Increased anteroposterior diameter of the chest C. Oxygen saturation level 96% D. Petechiae on chest

B. Increased anteroposterior diameter of the chest The nurse should anticipate an increased anteroposterior diameter of the chest (barrel chest) because of chronic hyperinflation of the lungs. The nurse should anticipate the client's arterial blood gasses will reveal respiratory acidosis because there is increased arterial carbon dioxide. This oxygen saturation level is within the expected reference range. The nurse should anticipate a decreased oxygen saturation level. The nurse should anticipate petechiae on the chest and the abdomen for a client who has pulmonary embolism.

A nurse is caring for a client who is postoperative and has a prescription for antiembolic stockings. Which of the following actions should the nurse take? A. Apply the stockings while the client is sitting in a chair. B. Remove the stockings once each day. C. Check the stockings for wrinkles. D. Measure the size of the client's foot.

C. Check the stockings for wrinkles. The nurse should check the stockings for wrinkles or constriction that can increase the risk for skin breakdown or reduced circulation. The nurse should apply the stockings before the client gets out of bed to reduce the risk for dependent edema. The nurse should remove the stockings once per shift to assess the client's skin integrity. The nurse should measure the circumference of the client's calf and thigh at the widest point before obtaining the antiembolic stockings for the client.

A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension? A. High-density lipoprotein (HDL) level of 70 mg/dL B. A diet high in potassium C. Obstructive sleep apnea (OSA) D. Taking benazepril

C. Obstructive sleep apnea (OSA) The nurse should include OSA as a risk factor in the development of hypertension. OSA is a condition in which the client's airway becomes blocked by the relaxation of the tongue and muscles of the oropharynx, effectively obstructing the airway. The obstructed airway results in surges in the both the systolic and diastolic pressure during sleep and, in some clients, through the waking hours even when breathing is normal.

A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first? A. Check the client for a fecal impaction. B. Examine the client for areas of skin breakdown. C. Check the client's bladder for distention. D. Place the client in a sitting position.

D. Place the client in a sitting position. The nurse should use the least invasive intervention first. Therefore, the nurse should place the client in a sitting position to decrease the manifestation of hypertension. The nurse might have to check the client for fecal impaction, which can precipitate autonomic dysreflexia. However, the nurse should use a less invasive intervention first. The nurse might have to examine the client's skin for areas of skin breakdown or pressure, which can trigger autonomic dysreflexia. However, the nurse should use a less invasive intervention first. The nurse might have to check the client for bladder distention, which can precipitate autonomic dysreflexia. However, the nurse should use a less invasive intervention first.

Day 1 0800 Temperature 101° F (38° C) Pulse 98 /min Respiratory rate 28/min Blood pressure 145/92 mm Hg Oxygen saturation 93 % room Air Pain of 8 on a scale of 0 to 10 Day 1 1030 Temperature 101° F (38° C) Pulse 99 /min Respiratory rate 24/min Blood pressure 105/72 mm Hg Oxygen saturation 93 % room Air Pain of 3 on a scale of 0 to 10 Day 1 0840 Client presents with a 3-day history of epigastric pain, nausea, and vomiting. Reports sharp epigastric pain, rated as 8 on a scale of 0 to 10, that is unrelieved with antacids. Bowel sounds hypoactive in all four quadrants. Abdominal ultrasound reveals presence of gallstones. Client has a history of hypertension and hyperlipemia. Day 1 0900 Alert and oriented but guarded. Client reports sharp epigastric pain, which they rate as an 8 on a scale of 0 to 10. Also complains of nausea. Bowel sounds are hypoactive in all quadrants. Day 1 1000 Medicated with 30 mg of ketor

The client is at risk for developing bowel obstruction as evidenced by the client's bowel sounds. Fluid volume deficit is correct. The client is at risk for developing fluid volume deficit because the client's urine specific gravity is elevated. A client with epigastric pain is less inclined to intake food and fluids which can place them at high risk for a state of fluid volume deficit. The client is elevated which puts them at risk for developing fluid volume deficit.

A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect? A. HCO3- 30 mEq/L B. PaCO2 50 mm Hg C. pH 7.45 D. Potassium 3.3 mEq/L

B. PaCO2 50 mm Hg This laboratory value is an expected finding for a client who has respiratory acidosis.

A nurse is reviewing the medication list for a client who has a new diagnosis of a small bowel obstruction. The nurse should withhold which of the following medications? A. Senna B. Ibuprofen C. Omeprazole D. Zolpidem

A. Senna Laxatives are contraindicated in clients who have fecal impaction, bowel obstruction, and acute abdominal surgery to prevent perforation. Because the bowel does not allow for any passage of stool with a complete small bowel obstruction, laxatives will cause increased abdominal cramping and discomfort. Ibuprofen is contraindicated for clients who have asthma or severe hepatic or renal disease. It should be used with caution in clients who have a bleeding disorder. Omeprazole is contraindicated in clients who are allergic to omeprazole. It should be used with caution in clients who are pregnant or breast feeding. Zolpidem is contraindicated in clients who are allergic to benzodiazepines. It should be used with caution in older adults and clients who have respiratory disease.

The nurse is caring for a client with chronic kidney disease. History of chronic kidney disease (CKD) that has recently progressed to stage 5 with an eGFR <15. Reports increased edema, shortness of breath with exertion, poor appetite, and minimal urine output. No known allergies. Discussed need for hemodialysis and placement of vascular access. Client verbalizes understanding and will be admitted for arteriovenous (AV) fistula placement and initiation of dialysis. Ultrasound completed for vein mapping in LUE. Nurses Notes Day 1 0922 Client admitted for placement of AV fistula for chronic kidney disease. Consent signed by surgeon and client. Client verbalizes understanding of procedure. Alert & oriented x 4. Up to chair with minimal assist. Denies pain. Anuric. Day 1 1202 Started IV fluid 0.45NS at 50mL/hr. Pain level is 0/10. Spouse at bedside. Laboratory TestResultsReference RangePotassium 5.2 mEq/L3.5 - 5 mEq

Anticipated: Weight client daily, Administer sodium polystyrene sulfonate, and Administer lisinopril Contraindicated: Administer Potassium chloride, and draw labs from left arm Draw labs from left arm is contraindicated. The AV fistula is being placed in the left arm. Therefore, all blood pressure readings, venipunctures, and IV lines should be in the right arm. Administer lisinopril is anticipated. ACE inhibitors such as lisinopril are the most effective to reduce the risk of cardiovascular events in clients with chronic kidney disease. ACE inhibitors help control blood pressure, which is necessary to preserve kidney function. Administer sodium polystyrene sulfonate is anticipated. Sodium polystyrene sulfonate is a cation exchange resin that is treatment for hyperkalemia. Administer potassium chloride is contraindicated. Potassium chloride is a supplement that will increase the potassium level and would negatively impact the client's status. The client is hyperkalemic and is at risk for adverse effects of this electrolyte imbalance. Weigh client daily is anticipated. Daily weights at the same time of day, on the same time of scale, wearing the same amount of clothing is important to monitor for fluid retention. Clients should also be weighed before and after dialysis for fluid management.

A nurse is providing discharge teaching to a female client who has neuropathy and a new prescription for gabapentin. Which of the following statements should the nurse include in the teaching? A. "Take this medication with an antacid to reduce gastric irritation." B. "You may experience drowsiness while taking this medication." C. "You should take this medication with meals." D. "You may continue to breastfeed while taking this medication."

B. "You may experience drowsiness while taking this medication." The nurse should instruct the client that gabapentin and antacids should be taken 2 hr apart. The nurse should instruct the client that this medication can be taken without regard to meals. The nurse should instruct the client to avoid breastfeeding while taking this medication.

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? A. Defibrillation B. Elective cardioversion C. CPR D. Radiofrequency catheter ablation

B. Elective cardioversion Elective cardioversion is the priority intervention when the client is awake and responsive. Ventricular tachycardia might not be an immediate threat to the client, but it does require intervention to prevent long-term cardiac impairment. Defibrillation is performed to correct life-threatening cardiac arrhythmias including VT. In cardiac emergencies, defibrillation should be performed immediately after identifying the client is experiencing an arrhythmia. The client in the question is awake and reporting sudden heart palpitations. There is no indication the client is unstable. The nurse should assess the client's airway, breathing, circulation, level of consciousness, and oxygenation level prior to beginning CPR. Because this client is awake and in a stable VT rhythm, the nurse should not initiate CPR. Radiofrequency catheter ablation is a procedure used to destroy the area of the heart (irritable focus) that causes the VT. It is used to treat clients who have repeated episodes of stable VT, but it is not used in initial treatment.

A nurse is planning care for a client who has terminal cancer and has a prescription for morphine. Which of the following interventions should the nurse include in the plan of care? A. Instruct the client to take diphenoxylate/atropine 5 mg PO twice a day. B. Instruct the client to actively cough to prevent a buildup of secretions in the airway. C. Instruct the client to stop taking the morphine if itching develops. D. Instruct the client to keep room lights dim during waking hours.

B. Instruct the client to actively cough to prevent a buildup of secretions in the airway. Morphine acts on the medulla to suppress cough. The nurse should teach the client to actively cough to prevent a buildup of secretions in the airway. Constipation is an adverse effect of morphine. Diphenoxylate/atropine is administered to treat diarrhea. The nurse should instruct the client to take a stool softener, not an antidiarrheal daily. Itching is an expected finding for clients who take morphine. The client should not stop taking morphine if itching develops. Morphine causes miosis which can impair vision. The client should keep the room lights bright during waking hours.

A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the plan to take? A. Instruct the client to perform range-of-motion exercises to his lower extremities. B. Perform neurovascular checks with vital signs. C. Ambulate the client 1 hr following the procedure. D. Restrict the client's fluid intake.

B. Perform neurovascular checks with vital signs. The nurse should assess color, temperature, and pulse in the affected extremity and monitor the client for neurovascular changes that can indicate a stroke, such as slurred speech and visual disturbances. The client should keep the extremity of the insertion site straight to reduce the risk for bleeding. A knee brace might be used to restrict movement. The client should remain on bed rest for 2 to 6 hr following the procedure to reduce the risk for bleeding. The nurse should increase fluid intake following a cardiac catheterization to promote excretion of the contrast medium and reduce the risk for dehydration.

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse take to reduce the risk for ventilator-associated pneumonia? A. Position the head of the client's bed in the flat position. B. Turn the client every 4 hr. C. Rinse the client's mouth with an antimicrobial solution every 4 hr. D. Perform hand hygiene prior to suctioning the client's endotracheal tube.

C. Rinse the client's mouth with an antimicrobial solution every 4 hr. The nurse should brush the client's teeth every 8 hr and rinse the client's mouth with an antimicrobial rinse every 2 hr to reduce the growth of bacteria. The nurse should elevate the head of the client's bed 30° to reduce the risk for aspiration and pneumonia. The nurse should turn the client every 2 hr to promote lung expansion and reduce the risk for pneumonia. The nurse should perform hand hygiene prior to suctioning the client's endotracheal tube to reduce the risk of introducing bacteria.

A nurse is assessing a client who has diabetes insipidus. Which of the following findings is a manifestation of this diagnosis? A. Hypertension B. Bounding peripheral pulses C. Tachycardia D. Hyperglycemia

C. Tachycardia Tachycardia is a manifestation of diabetes insipidus due to dehydration from fluid loss. Hypotension is a manifestation of diabetes insipidus. Weak peripheral pulses are a manifestation of diabetes insipidus.

A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment? A. Sodium 165 mEq/L B. Potassium 5.2 mEq/L C. Urine specific gravity 1.020 D. Hct 62%

C. Urine specific gravity 1.020 In cases of dehydration or fluid volume deficit, the kidney reabsorbs all available water, making the urine more concentrated and increasing the urine specific gravity. A level of 1.020 is within the expected reference range of 1.005 to 1.030, which indicates that the treatment is effective.

A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.) A. Color B. Temperature C. Ecchymosis D. Skin integrity E. Sensation

Clients who have sustained trauma to an extremity, such as a fracture, are at increased risk for neurovascular compromise. The nurse should check the color of the client's affected extremity as part of this assessment. The nurse should identify pallor or cyanosis of the extremity as an indication of peripheral neurovascular dysfunction and should notify the provider.

A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect? A. Bradycardia B. Bradypnea C. Lethargy D. Intercostal retrations

D. Intercostal retrations Hypoxia is a condition in which the tissues of the body are oxygen-starved. It follows hypoxemia (low oxygen in the blood) and is manifested as substernal or intercostal retractions as the body works harder to draw more oxygen into the lungs. A client who is hypoxic is more likely to have tachycardia than bradycardia.

A nurse is providing instruction to a new nurse about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia? A. Furosemide B. Hydrochlorothiazide C. Metolazone D. Spironolactone

D. Spironolactone Spironolactone is a potassium-sparing diuretic. It blocks the effects of aldosterone in the renal tubules, causing a loss of sodium and water and the retention of potassium. The possible adverse reactions include hyperkalemia and hyponatremia. Furosemide is a high-ceiling (loop) diuretic that increases the risk of hyponatremia and hypokalemia, not hyperkalemia. Hydrochlorothiazide is a thiazide diuretic that increases the risk of hypokalemia, not hyperkalemia. Metolazone is a thiazide diuretic that increases the risk of hyponatremia and hypokalemia, not hyperkalemia.

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take? A. Instruct the client to cough and deep breathe. B. Place the client in a supine position. C. Place a warming blanket on the client. D. Use log rolling to reposition the client.

D. Use log rolling to reposition the client. Treatment of increased ICP focuses on decreasing the pressure. An important intervention includes positioning the client in a neutral position and avoiding flexion of the neck and hips. In order to avoid hip flexion, the client should be log rolled when repositioned. A client who has increased ICP is at risk for brain herniation, a potentially life-threatening condition. Actions, such as deep breathing, coughing, and blowing the nose, can increase ICP. The nurse should take measures to maintain or reduce the client's ICP. An important intervention for ICP is positioning the client in a neutral position with the head of the bed elevated to 30° to 45°. This placement allows the cerebral spinal fluid to flow freely through the brain and spinal cord, minimizes pressure within the central nervous system, and prevents aspiration. A client who has increased ICP can develop a fever in response to systemic trauma, the presence of blood in the cranium, infection, or as a generalized inflammatory response to the brain injury. Therapeutic cooling is often initiated, even in the absence of fever, in order to slow the brain's metabolism and prevent secondary brain injury.

A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia? A. Decreased heart rate B. Dyspnea C. Increased blood pressure D. Weak pulse

D. Weak pulse A decreased volume of circulating blood and less pressure within the vessels results in weak peripheral pulses (rated as +1), which can be described as thready. The heart rate of a client who has hypovolemia will be increased to compensate for the decreased blood volume. Dyspnea is characteristic of respiratory conditions, and is not usually associated with hypovolemia. The client's blood pressure will be lower due to the decreased blood volume.

A nurse is caring for a client following a below-the-knee amputation Day 1 0930 Client had all pre-operative steps completed in preparation for a right below the knee amputation. Consent signed. Client has a history of peripheral vascular disease. Client lives with their spouse and has a past medical history of diabetes mellitus, peripheral neuropathy, and osteomyelitis in the right lower leg. Alert and oriented. 1330 Client is drowsy, awake with stimulation. General anesthesia is wearing off. Oriented x 3 in post-anesthesia unit. Procedure went as expected. Right popliteal pulse was weak, 1+. Left popliteal pulse 2+. Right lower limb is warm. Skin turgor +2, cap refill < 2 sec bilaterally. Current pain level described by client as 8 on a scale of 0 to 10. Transfer to surgical unit. Day 1 1400 Client is awake and oriented. Client reports pain in right leg at the incision site, which they rate as an 8 on a scale o

The nurse should address the client's pain, followed by the client's dressing. Pain is correct. The nurse should first address the client's pain of 8 on a scale of to 10. The description of the pain could be an indication of phantom limb pain. Interventions for phantom limb pain includes administering an antiepileptic, an antispasmodic, or a beta blocker. Other interventions include massage, exercises, TENS and distraction therapy. The nurse will first address the pain and then reapply the dressing that has become loose and unsupportive to the affected extremity.