Medsurg Final

Question 1

Right ankle: Red, swollen, decreased ROM

Answer 1

Inflammation w/o infection

Question 2

Anaphylactic reaction priority assessment

Answer 2

maintaining patent airway

Question 3

Warmth around injured area

Answer 3

“the warmth indicated increased blood flow”

Question 4

Wrist: red, warm, edematous

Answer 4

assess circulation + evaluate extremity

Question 5

Kidney transplant

Answer 5

the immune system will try to destroy the new kidney if we do not suppress it

Question 6

the nurse receives a report that a client with purulent wound drainage has lab results that shows a left shift. whats the next action?

Answer 6

obtain a wound culture

Question 7

a nurse is caring for a client in the ED who has an allergy to bee venom. what action should the nurse take first?

Answer 7

administer epinephrine

Question 8

the nurse is assisting planning care for a client with a diagnosis of immunodeficiency. whats the priority action?

Answer 8

protecting the client from infection

Question 9

which client is at highest risk of compromised immunity?

Answer 9

client who just had surgery

Question 10

client is scheduled to receive a flu vaccination. pt. asks “how do these work?” best response:

Answer 10

immunizations work by sensitizing your body to prepare antibodies against this virus if exposed in the future to the same antigen

Question 11

the charge nurse observes the primary nurse interacting with a client. which action by the primary nurse warrants immediate intervention by the charge nurse?

Answer 11

administering a med without checking allergies

Question 12

the client diagnosed with anaphylaxis to bee venom is now stable and being discharged from the ED. which priority discharge instruction should be taught to the client?

Answer 12

demonstrate how to use an epipen

Question 13

the client comes into the ED complaining for dyspnea and wheezing after eating at a seafood restaurant. the pt can’t speak and has bluish color around the mouth. what intervention?

Answer 13

administer oxygen at 100% via nonrebreather

Question 14

which statement is true about pathologic conditions of the immune system?

Answer 14

in autoimmune disease the bodys immune system treats some of the body’s own tissues as foreign invaders

Question 15

For years after seroconversion, an HIV-infected client has a CD4+ cell count of 800 ul and low viral load. the nurse teaches the client that:

Answer 15

the body currently is able to produce an adequate number of CD4+ cells to replace those destroyed by viral activity

Question 16

the client is taking spironolactone. what complication would you assess for?

Answer 16

hyperkalemia

Question 17

greatest risk for dehydration?

Answer 17

older adult with cognitive impairment

Question 18

a client is found unresponsive and their ABGs are: pH 7.12, PCO2 90mm Hg, and HCO3-22. whats the condition?

Answer 18

respiratory acidosis wo/o compensation

Question 19

a client has the following ABG results: pH 7.12, HCO2-22, PCO2 65. The nurse correlates with what clinical situation?

Answer 19

tracheal obstruction related to aspiration

Question 20

the client has the following ABGs: pH 7.19, PaCO2 35, PAO2 95, HCO3 19. What med would you administer?

Answer 20

IV sodium bicarb

Question 21

Partially compensated metabolic acidosis?

Answer 21

ph 7.32, HCO2 17, PCO2 25, PO2 98

Question 22

The nurse correlates which condition with the following ABGs? pH 7.48, HCO2 22, PCO2 28, PO2 98

Answer 22

anxiety-induced hyperventilation

Question 23

a nurse is caring for a client with an NG tube that is attached to low suction. What disorder could they develop?

Answer 23

metabolic alkalosis

Question 24

a client who is intubated has the following ABGs: pH 7.30, HCO3 22, PCO2 55, PO2 86. what is priority intervention?

Answer 24

assessing the airway

Question 25

a nurse is caring for a pt. who is receiving IV diuretics suspects that the pt. is experiencing a fluid volume deficit. what assessment finding would she note?

Answer 25

increased hematocrit

Question 26

the nurse is caring for a pt. with heart failure. on assessment, the nurse notes that the client is dyspneic and that crackles are audible with auscultation. what additional assessment would show excess fluid volume?

Answer 26

high blood pressure

Question 27

the client is admitted to the nursing unit from a long term care facility with a hematocrit of 56% and a serum sodium level of 152. which condition is a cause for these findings?

Answer 27

dehydration

Question 28

the client is admitted with serum sodium level of 110, what nursing intervention should be implemented?

Answer 28

encourage fluids orally

Question 29

the client's arterial blood gasses confirm metabolic acidosis for a client diagnosed with DKA. which statement best explains the scientific rationale for irregular respirations?

Answer 29

lungs speed up to release carbon dioxide and increase the pH

Question 30

the client diagnosed with an exacerbation of COPD in respiratory distress. which intervention should the nurse implement first?

Answer 30

assist the client into a sitting position at 90 degrees

Question 31

the nurse is assessing the client diagnosed with COPD. which data requires immediate intervention?

Answer 31

O2 flowmeter set at 8 liters

Question 32

Which outcome is appropriate for the client problem: ineffective gas exchange for a pt. with COPD?

Answer 32

demonstrate the correct way to pursed-lip breathe

Question 33

health maintenance strategies of COPD?

Answer 33

yearly flu immunizations

Question 34

medication for mild intermittent asthma?

Answer 34

use of a rescue inhaler

Question 35

acute exacerbation COPD expected finding?

Answer 35

hyper-inflated chest noted on xray

Question 36

purpose of pursed-lip breathing?

Answer 36

promote CO2 elimination

Question 37

COPD teaching?

Answer 37

"i may experience palpitations or a fast heart rate after taking my albuterol nebulizer"

Question 38

generalized rash + urticaria after a dose of salmeterol inhaler?

Answer 38

call the HCP immediately

Question 39

assessments before administering albuterol?

Answer 39

lung sounds and presence of dyspnea

Question 40

inappropriate diagnosis for a client with COPD?

Answer 40

effective airway clearance with decreased mucous production

Question 41

jugular vein distention and pedal edema?

Answer 41

fluid volume excess secondary to right-sided HF

Question 42

fluticasone/salmeterol inhaler

Answer 42

one drug decreases inflammation and the other drug helps open the airways

Question 43

respiratory distress?

Answer 43

absent breath sounds

Question 44

fever of 101.4, nonproductive cough, O2 SAT 88%, highest priority?

Answer 44

impaired gas exchange r/t respiratory congestion

Question 45

chest tube is pulled out. primary action?

Answer 45

instruct the pt. to take slow, shallow breaths until the chest tube is reinserted

Question 46

which if the following is a priority patient?

Answer 46

lung cancer and tracheal deviation

Question 47

patient with chest tube- which nursing action can the nurse delegate to an unlicensed AP?

Answer 47

check the water-seal chamber for the correct fluid level

Question 48

viral pneumonia and history of COPD- which findings should be reported?

Answer 48

left shift in WBC count

Question 49

client at greatest risk for pneumonia?

Answer 49

older adult transferred from a long-term care facility who has dysphagia

Question 50

most accurate way for the nurse to monitor fluid balance?

Answer 50

weight daily

Question 51

A nurse notes bilateral +2 edema in the lower extremities of a client with a myocardial infarction was admitted 2 days ago. The nurse would plan to do which of the following next?

Answer 51

review I&O records for the last 2 days

Question 52

A client with an MI suddenly becomes tachycardia, shows signs of air hunger, and begins coughing frothy, pink tinged sputum. Which of the following would the nurse anticipate when auscultating the client's breath sounds?

Answer 52

crackles

Question 53

A client with HF on diuretic therapy is prescribed furosemide and digoxin. which lab result should be reviewed?

Answer 53

potassium

Question 54

no electrocardiographic complexes on screen?

Answer 54

check client status and lead placement

Question 55

client with angina- electrocardiographic change caused by an MI?

Answer 55

ST segment elevation or depression

Question 56

a-fib and HR of 140bpm + signs of decreased cardiac output?

Answer 56

administer metoprolol

Question 57

medication-- greatest risk for hyperkalemia?

Answer 57

spironolactone

Question 58

whats a serious complication for atenolol?

Answer 58

development of audible expiratory wheezes

Question 59

seek emergent care for adverse effect of?

Answer 59

swelling of the tongue

Question 60

therapeutic effect hydrochlorothiazide?

Answer 60

decrease in BP

Question 61

administering furosemide-- assess the clients?

Answer 61

serum potassium level

Question 62

acute exacerbation of HF-- clinical findings?

Answer 62

apical pulse rate of 110 and 4+ pedal edema

Question 63

short term goal for heart failure?

Answer 63

urine output of at least 30 ml/hour

Question 64

MI signs and symptoms?

Answer 64

diaphoresis and cool clammy skin

Question 65

"Why do i get chest pain?"

Answer 65

chest pain is caused by decreased O2 to heart muscle

Question 66

patient experiencing chest pain?

Answer 66

have client sit down immediately

Question 67

client is lying in bed gasping for breath, cool+clammy, and has cyanosis. Priority?

Answer 67

assist client to the sitting position

Question 68

what indicates effective treatment of HF?

Answer 68

client is able to preform ADLs w/o dyspnea

Question 69

Which client should be assisted first?

Answer 69

myocardial infarction with newly elevated BNP

Question 70

intervention for increased activity intolerance in client w/ CHF?

Answer 70

plan for frequent rest periods

Question 71

Which assessment data would cause the nurse to question administration of diltizem to a client with MI?

Answer 71

blood pressure 89/62

Question 72

which assessment data would cause the nurse to question administration of metroprolol to a client with hypertension?

Answer 72

apical pulse of 56

Question 73

priority action when experiencing angina?

Answer 73

stop activity + rest

Question 74

which assessment data would cause nurse to question administration of furosemide for client w/ hypertension?

Answer 74

mucous membranes are dry and has tented skin turgor

Question 75

client w/ systolic dysfunction has ejection fraction of 38%. nurse assesses for which physiologic change?

Answer 75

decrease in tissue perfusion

Question 76

possible right sided heart failure?

Answer 76

"my shoes fit really tight lately"

Question 77

why is it important to be weighed everyday if he has right sided HF?

Answer 77

"weight is the best indication that you are gaining and loosing fluid"

Question 78

Priority nursing interventions for a client prescribed IV nitro and furosemide?

Answer 78

monitor clients blood pressure

Question 79

factors responsible for atherosclerosis?

Answer 79

combination of platelets and fats accumulates, narrowing the artery and redirecting blood flow

Question 80

priority nursing intervention to promote vasodilation for a client with peripheral arterial disease?

Answer 80

abstain from smoking

Question 81

pain after arterial revascularization priority action?

Answer 81

assess the peripheral pulses in the limb

Question 82

venous ulcer on the clients left ankle. additional findings?

Answer 82

brownish discoloration of lower extremities

Question 83

sustained ventricular tachycardia priority action?

Answer 83

assess airway, breathing and LOC

Question 84

lab values that correlate with cirrhosis?

Answer 84

serum albumin, 2.1

Question 85

medication for end-stage cirrhosis

Answer 85

lactulose

Question 86

lab value correlated with cirrhosis?

Answer 86

elevated serum ammonia level

Question 87

most effective nursing intervention in controlling ascites?

Answer 87

providing a low sodium diet

Question 88

decreased protein diet for pt. with hepatic encealopathy?

Answer 88

less protein in the diet will help with confusion

Question 89

client refusing to take lactulose because of diarrhea?

Answer 89

diarrhea is expected, that's how your body gets rid of ammonia

Question 90

itchy skin w/ jaundice?

Answer 90

bile salts accumulate in the skin and causes the itching

Question 91

primary intervention to reduce discomfort with pancreatitis?

Answer 91

maintaining NPO status

Question 92

hand spasm with acute pancreatitis associated finding?

Answer 92

serum calcium 5.8 mg/dL

Question 93

what type of pain is consistent with acute pancreatitis?

Answer 93

severe and unrelenting pain, located in the epigastric area and radiating to the back

Question 94

acceptable food items in diet for a client with cholecystitis?

Answer 94

baked fish

Question 95

lab values for client with exacerbation of ulcerative colitis?

Answer 95

erythrocyte sedmientaton rate of 55 mm/hr

Question 96

highest priority for client with ulcerative colitis and sever diarrhea?

Answer 96

heart rhythm and rate

Question 97

contact HCP for which assessment with chrons disease?

Answer 97

distended, firm abdomen

Question 98

chrons disease with draining fistula: which finding leads the nurse to intervene?

Answer 98

serum potassium of a 2.6