MED SURGE VATI ASSESSMENT
180 QUESTIONS AND ANSWER
TESTBANK WITH CORRECT
ANSWERS AND EXPLANATION
GIVEN
A nurse is caring for a client who has deep-vein thrombosis and is receiving
heparin via continuous IV infusion. The client's weight is 80 kg (176.4 lb).
Using the client information provided, which of the following actions should
the nurse take?
STOP THE HEPARIN INFUSION FOR 1 HOUR.
- According to the titration table, when the aPTT is greater than 95, the nurse
should stop the infusion for 1 hr, then restart the infusion with a decrease of
3 units/kg/hr, which is a decrease of 240 units/hr for a client who weighs 80
kg (176.4 lb).
A nurse is caring for a client who is intubated and receiving mechanical
ventilation for heroin toxicity. Which of the following assessments is the
nurse's priority?
ABGS.
- When using the airway, breathing, and circulation (ABC) approach to client
care, the nurse's priority assessment is to monitor the client's ABGs,
including respiratory status.
,A nurse is assessing a client who has a new diagnosis of PERICARDITIS.
Which of the following findings should the nurse identify as a manifestation
of cardiac tamponade?
PARADOXICAL PULSE.
- Cardiac tamponade results from an excess of fluid in the pericardial cavity
and causes a sudden drop in cardiac output. Paradoxical pulse is a systolic
blood pressure of 10 mm Hg or more on expiration and is a manifestation of
cardiac tamponade. The nurse should report manifestations of cardiac
tamponade to the provider immediately.
A nurse is assessing a client who is undergoing radiation therapy for breast
cancer. Which of the following findings is an indication to the nurse that the
client is experiencing an adverse effect of the therapy?
SKIN CHANGES.
A client who is receiving radiation therapy to the breast will have localized
adverse effects of the treatment, such as skin changes, esophagitis, and
lymphedema.
A nurse is caring for a group of clients. In which of the following scenarios is
the nurse acting as a client advocate?
The nurse refers a client who has chronic obstructive pulmonary disease for
palliative care services.
- Palliative care is an interdisciplinary approach to client care that works
toward optimizing the quality of life for a client who has a chronic illness.
,Nurses advocate for their clients when they promote the health, safety, and
rights of the client, such as providing a referral for needed services to relieve
suffering and promote a client's quality of life.
A nurse is assessing a client who recently had a myocardial infarction. Which
of the following findings indicates that the client might be developing
PULMONARY EDEMA?
- Pink, frothy sputum
- Tachypnea
- Wheezing
A nurse is teaching a client about preventing the transmission of HIV. Which
of the following information should the nurse include?
MEDICATION IS AVALIABLE THAT WILL REDUCE THE RISK OF HIV
TRANSMISSION.
- Tenofovir/emtricitabine is an oral medication that can be used
prophylactically by a client who does not have an HIV infection to reduce the
risk for HIV transmission. Pre-exposure prophylaxis is recommended for men
who have sexual relationships with men, clients who are heterosexual and
sexually active, noninfected partners who have a sexual relationship with a
partner who has HIV, and clients who use intravenous drugs.
A nurse is caring for a client who has multiple leg fractures and is 24 hr
postoperative following placement of skeletal traction. Which of the following
actions should the nurse take?
INSPECT THE PIN SITES AT LEAST EVERY 8 HOURS.
, - The nurse should inspect the pin sites at least every 8 hr, noting any
inflammation or evidence of infection. Expected findings after the insertion of
pins include redness, warmth, and serosanguineous drainage, which should
subside after 72 hr.
Pin site interventions
- Do not apply any ointment to pin sites
- Prophylactic broad spectrum IV antibiotic 24-48 hours after insertion
- Sterile, absorbent, nonadherent dressing
- Inspect pin sites every 8 hours
- Cleanse with chlorhexidine solution
A nurse in a long-term care facility is caring for a client who has dementia.
Which of the following actions should the nurse take?
PROVIDE FINER FOOD AT MEALTIME.
- The nurse should provide the client who has dementia with fingers foods.
Clients who have dementia can have difficulty sitting still and tend to
wander, which makes weight loss and malnutrition a concern. Therefore,
foods that the client can hold while ambulating are ideal.
A nurse is completing an admission assessment for a client who has bacterial
meningitis. Which of the following personal protective equipment should the
nurse use while caring for the client?
SURGICAL MASK.
180 QUESTIONS AND ANSWER
TESTBANK WITH CORRECT
ANSWERS AND EXPLANATION
GIVEN
A nurse is caring for a client who has deep-vein thrombosis and is receiving
heparin via continuous IV infusion. The client's weight is 80 kg (176.4 lb).
Using the client information provided, which of the following actions should
the nurse take?
STOP THE HEPARIN INFUSION FOR 1 HOUR.
- According to the titration table, when the aPTT is greater than 95, the nurse
should stop the infusion for 1 hr, then restart the infusion with a decrease of
3 units/kg/hr, which is a decrease of 240 units/hr for a client who weighs 80
kg (176.4 lb).
A nurse is caring for a client who is intubated and receiving mechanical
ventilation for heroin toxicity. Which of the following assessments is the
nurse's priority?
ABGS.
- When using the airway, breathing, and circulation (ABC) approach to client
care, the nurse's priority assessment is to monitor the client's ABGs,
including respiratory status.
,A nurse is assessing a client who has a new diagnosis of PERICARDITIS.
Which of the following findings should the nurse identify as a manifestation
of cardiac tamponade?
PARADOXICAL PULSE.
- Cardiac tamponade results from an excess of fluid in the pericardial cavity
and causes a sudden drop in cardiac output. Paradoxical pulse is a systolic
blood pressure of 10 mm Hg or more on expiration and is a manifestation of
cardiac tamponade. The nurse should report manifestations of cardiac
tamponade to the provider immediately.
A nurse is assessing a client who is undergoing radiation therapy for breast
cancer. Which of the following findings is an indication to the nurse that the
client is experiencing an adverse effect of the therapy?
SKIN CHANGES.
A client who is receiving radiation therapy to the breast will have localized
adverse effects of the treatment, such as skin changes, esophagitis, and
lymphedema.
A nurse is caring for a group of clients. In which of the following scenarios is
the nurse acting as a client advocate?
The nurse refers a client who has chronic obstructive pulmonary disease for
palliative care services.
- Palliative care is an interdisciplinary approach to client care that works
toward optimizing the quality of life for a client who has a chronic illness.
,Nurses advocate for their clients when they promote the health, safety, and
rights of the client, such as providing a referral for needed services to relieve
suffering and promote a client's quality of life.
A nurse is assessing a client who recently had a myocardial infarction. Which
of the following findings indicates that the client might be developing
PULMONARY EDEMA?
- Pink, frothy sputum
- Tachypnea
- Wheezing
A nurse is teaching a client about preventing the transmission of HIV. Which
of the following information should the nurse include?
MEDICATION IS AVALIABLE THAT WILL REDUCE THE RISK OF HIV
TRANSMISSION.
- Tenofovir/emtricitabine is an oral medication that can be used
prophylactically by a client who does not have an HIV infection to reduce the
risk for HIV transmission. Pre-exposure prophylaxis is recommended for men
who have sexual relationships with men, clients who are heterosexual and
sexually active, noninfected partners who have a sexual relationship with a
partner who has HIV, and clients who use intravenous drugs.
A nurse is caring for a client who has multiple leg fractures and is 24 hr
postoperative following placement of skeletal traction. Which of the following
actions should the nurse take?
INSPECT THE PIN SITES AT LEAST EVERY 8 HOURS.
, - The nurse should inspect the pin sites at least every 8 hr, noting any
inflammation or evidence of infection. Expected findings after the insertion of
pins include redness, warmth, and serosanguineous drainage, which should
subside after 72 hr.
Pin site interventions
- Do not apply any ointment to pin sites
- Prophylactic broad spectrum IV antibiotic 24-48 hours after insertion
- Sterile, absorbent, nonadherent dressing
- Inspect pin sites every 8 hours
- Cleanse with chlorhexidine solution
A nurse in a long-term care facility is caring for a client who has dementia.
Which of the following actions should the nurse take?
PROVIDE FINER FOOD AT MEALTIME.
- The nurse should provide the client who has dementia with fingers foods.
Clients who have dementia can have difficulty sitting still and tend to
wander, which makes weight loss and malnutrition a concern. Therefore,
foods that the client can hold while ambulating are ideal.
A nurse is completing an admission assessment for a client who has bacterial
meningitis. Which of the following personal protective equipment should the
nurse use while caring for the client?
SURGICAL MASK.
