Exam (elaborations) MED SURG LEVEL 4 Fundamentals Prepu Alt; South Texas College

MED SURG LEVEL 4 Fundamentals Prepu Alt; South Texas College Question 1 See full question A physician orders hourly urine output measurement for a postoperative client with an indwelling catheter. The nurse records the following amounts of output for 2 consecutive hours: 8 a.m. (0800): 50 ml; 9 a.m. (0900): 60 ml. Based on these amounts, which action should the nurse take? You Selected:  Irrigate the indwelling urinary catheter. Correct response:  Continue to monitor and record hourly urine output. Explanation: Remediation: Question 2 See full question A nurse is performing a sterile dressing change. Which action contaminates the sterile field? You Selected:  Holding sterile objects above the waist Correct response:  Pouring solution onto a sterile field cloth Explanation: Remediation: Question 3 See full question When bandaging a client's ankle, the nurse should use which technique? You Selected:  Spiral reverse Correct response:  Figure-eight Explanation: Remediation: Question 4 See full question A client who's scheduled for open-heart surgery in 2 days has been having circulation problems in the feet and legs. The physician orders antiembolism stockings. The nurse is teaching the client about this treatment. What is the purpose of antiembolism stockings? MED SURG LEVEL 4 Fundamentals Prepu Alt; South Texas College You Selected:  To decrease arterial blood circulation to the legs and feet Correct response:  To reduce or prevent edema of the legs and feet Explanation: Remediation: Question 5 See full question A primary unit nurse tells the nurse-manager that a newly hired registered nurse needs an additional week of orientation in order to function effectively on the staff. Which action is most appropriate for the nurse-manager to take? You Selected:  Tell the primary nurse that the new nurse must finish orientation within 6 weeks because of a staffing shortage. Correct response:  Meet with the new nurse and the primary nurse and help set up an additional week of orientation. Explanation: Question 6 See full question For a client with a nursing diagnosis of Insomnia, the nurse should use which measure to promote sleep? You Selected:  Serving the client a cup of coffee and a snack in the evening Correct response:  Playing soft or soothing music Explanation: Remediation: Question 7 See full question During the termination phase of a nurse-client relationship, which intervention may lead to client confusion? You Selected:  Having the client express sadness that the relationship is ending Correct response:  Introducing new issues to the client Explanation: Remediation: Question 8 See full question A nurse notes that a client's I.V. insertion site is red, swollen, and warm to the touch. Which action should the nurse take first? You Selected:  Discontinue the I.V. infusion. Correct response:  Discontinue the I.V. infusion. Explanation: Remediation: Question 9 See full question A client is to receive a glycerin suppository. Which nursing action is appropriate when administering a suppository? You Selected:  Instructing the client to bear down during insertion Correct response:  Applying a lubricant to the suppository Explanation: Remediation: Question 10 See full question A client is to be discharged on daily medication delivered by a transdermal disk. Which statement indicates the need for further medication teaching? You Selected:  "I'll avoid touching the gel in the disk." Correct response:  "I'll place the disk on the same spot each day." Explanation: Remediation: Question 11 See full question Which moral principle is a nurse applying when she decides what is best for a client and acting without consulting the individual? You Selected:  Autonomy Correct response:  Paternalism Explanation: Question 12 See full question Which description about crackles are true? You Selected:  They may be fine or coarse. Correct response:  They may be fine or coarse. Explanation: Remediation: Question 13 See full question A nurse must assess skin turgor in an elderly client. When evaluating skin turgor, the nurse should remember that: You Selected:  normal skin turgor is moist and boggy. Correct response:  inelastic skin turgor is a normal part of aging. Explanation: Remediation: Question 14 See full question A nurse is reviewing a client's arterial blood gas (ABG) report. Which ABG value reflects the acid concentration in the client's blood? You Selected:  HCO3 – Correct response:  pH Explanation: Remediation: Question 15 See full question The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. The nurse should: You Selected:  indicate to the caller that the nurse cannot receive verbal results from laboratory tests for neonates, and ask the laboratory to bring the written results to the nursery. Correct response:  write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller that the nurse understands the results. Explanation: Question 16 See full question The nurse is planning care for a group of pregnant clients. Which client should be referred to a health care provider (HCP) immediately? You Selected:  a woman who is at 37 weeks' gestation and has insulin-dependent diabetes experiencing two to three hyperglycemic episodes weekly Correct response:  a woman at 32 weeks' gestation who is preeclamptic with +3 proteinuria Explanation: Remediation: Question 17 See full question A client who has been recently diagnosed with acquired immunodeficiency syndrome (AIDS) inquires about hospice services. The nurse explains that hospice care is appropriate: You Selected:  for clients with an inevitable death within weeks to months. Correct response:  for clients with an inevitable death within weeks to months. Explanation: Remediation: Question 18 See full question A client tells the nurse on admission that she is uneasy about having to leave her children with a relative while being in the hospital for surgery. What should the nurse do? You Selected:  Contact the relative to determine their capacity to be an adequate care provider. Correct response:  Gather more information about the client's feelings about the childcare arrangements. Explanation: Remediation: Question 19 See full question A client says, “I hate the idea of being an invalid after they cut off my leg.” Which response by the nurse would be the most therapeutic? You Selected:  "You are lucky to have a wife to care for you." Correct response:  "Tell me more about how you are feeling." Explanation: Remediation: Question 20 See full question The nurse is caring for a client from Southeast Asia who has HIV-AIDS. The client does not speak or comprehend the English language. What should the nurse do? You Selected:  Contact the hospital's chaplain. Correct response:  Utilize language-appropriate interpreters. Explanation: Remediation: Question 21 See full question A client who has been scheduled to have a choledocholithotomy expresses anxiety about having surgery. Which nursing intervention would be the most appropriate to achieve the outcome of anxiety reduction? You Selected:  providing the client with information about what to expect postoperatively Correct response:  providing the client with information about what to expect postoperatively Explanation: Remediation: Question 22 See full question A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed assistive personnel (UAP) to report which clinical manifestation of this laboratory report? You Selected:  swelling around the incision Correct response:  elevated temperature Explanation: Remediation: Question 23 See full question The nurse's best explanation for why the severely neutropenic client is placed in reverse isolation is that reverse isolation helps prevent the spread of organisms: You Selected:  from the client to health care personnel, visitors, and other clients. Correct response:  to the client from sources outside the client's environment. Explanation: Remediation: Question 24 See full question Which instructions should the nurse include when developing a teaching plan for a client being discharged from the hospital on anticoagulant therapy after having deep vein thrombosis (DVT)? Select all that apply. You Selected:  Avoid surface bumps because the skin is prone to injury. Correct response:  Check urine for bright blood and a dark smoky color.  Walk daily as a good exercise.  Perform foot/leg exercises and walk around the airplane cabin on long flights.  Prevent DVT because of risk of pulmonary emboli.  Avoid surface bumps because the skin is prone to injury. Explanation: Remediation: Question 25 See full question A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, the nurse should first? You Selected:  ask the parent about medication allergies. Correct response:  institute droplet precautions. Explanation: Remediation: Question 26 See full question A client in the intensive care unit has a nursing diagnosis of Social isolation. Which action should the nurse include in the care plan? You Selected:  Providing detailed explanations of the client's conditions and treatment Correct response:  Involving the family and the client in planning care Explanation: Remediation: Question 27 See full question When performing an assessment, the nurse identifies the following signs and symptoms: discoordination, decreased muscle strength, limited range of motion, and reluctance to move. These signs and symptoms indicate which nursing diagnosis? You Selected:  Health-seeking behaviors Correct response:  Impaired physical mobility Explanation: Remediation: Question 28 See full question The nurse is assessing a 16-year-old nulligravida, who asks for information on natural family planning methods of contraception and reports that her menstrual cycle occurs every 28 days. Which information would be important to include in the teaching plan for this client? You Selected:  The ovum survives for 96 hours after ovulation, making conception possible during this time. Correct response:  Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle. Explanation: Question 29 See full question A postpartum woman who gave birth vaginally has unrelenting rectal pain despite the administration of pain medication. Which action is most indicated? You Selected:  preparing a warm sitz bath for the client Correct response:  assessing the perineum Explanation: Remediation: Question 30 See full question When