Med Surg Nursing 5410 Final Exam Study Guide

Med Surg Nursing 5410 Final Exam Study Guide (Chapters used in this Review- 6, 8, 11-16, 23, 26, 31-38, 40-51, 56-72, 74) (Chapters Before Midterm 11-40, 54-60/After Midterm 6, 41-48,50-51, 53-60, 62-74) Coronary Artery Bypass Graft Surgery- Ch6, Ch33, Ch34, Ch38 1. A nurse assesses a client recovering from coronary artery bypass graft surgery. Which assessment should the nurse complete to evaluate the clients activity tolerance? a. Vital signs before, during, and after activity b. Body image and self-care abilities c. Ability to use assistive or adaptive devices d. Clients electrocardiography readings ANS: A To see whether a client is tolerating activity, vital signs are measured before, during, and after the activity. If the client is not tolerating activity, heart rate may increase more than 20 beats/min, blood pressure may increase over 20 mm Hg, and vital signs will not return to baseline within 5 minutes after the activity. A body image assessment is not necessary before basic activities are performed. Self-care abilities and ability to use assistive or adaptive devices is an important assessment when planning rehabilitation activities, but will not provide essential information about the clients activity tolerance. Electrocardiography is not used to monitor clients in a rehabilitation setting. 2. A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond? a. This is a routine surgery and the risk of death is very low. b. Would you like to speak with a chaplain prior to surgery? c. Tell me more about your concerns about the surgery. d. What support systems do you have to assist you? ANS: C The nurse should discuss the clients feelings and concerns related to the surgery. The nurse should not provide false hope or push the clients concerns off on the chaplain. The nurse should address support systems after addressing the clients current issue. 3. A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily b. A 50-year-old who is post coronary artery bypass graft surgery c. A 78-year-old who had a carotid endarterectomy d. An 80-year-old with chronic obstructive pulmonary disease ANS: B Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these clients at higher risk for atrial fibrillation. 4. A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg c. Client who is 1 day post percutaneous coronary intervention, going home this morning d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking ANS: B Hypertension after coronary artery bypass graft surgery can be dangerous because it puts too much pressure on the suture lines and can cause bleeding. The charge nurse should see this client first. The client who became dizzy earlier should be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for. Activity Tolerance/Angina- Ch6 5. A nurse teaches a client with a past history of angina who has had a total knee replacement. Which statement should the nurse include in this clients teaching prior to beginning rehabilitation activities? a. Use analgesics before and after activity, even if you are not experiencing pain. b. Let me know if you start to experience shortness of breath, chest pain, or fatigue. c. Do not take your prescribed beta blocker until after you exercise with physical therapy. d. If you experience knee pain, ask the physical therapist to reschedule your therapy. ANS: B Participation in exercise may increase myocardial oxygen demand beyond the ability of the coronary circulation to deliver enough oxygen to meet the increased need. The nurse must determine the clients ability to tolerate different activity levels. Asking the client to notify the nurse if symptoms of shortness of breath, chest pain, or fatigue occur will assist the nurse in developing an appropriate cardiac rehabilitation plan. Ambulation/Older Adult- Ch6 6. A nurse delegates the ambulation of an older adult client to an unlicensed nursing assistant (UAP). Which statement should the nurse include when delegating this task? a. The client has skid-proof socks, so there is no need to use your gait belt. b. Teach the client how to use the walker while you are ambulating up the hall. c. Sit the client on the edge of the bed with legs dangling before ambulating. d. Ask the client if pain medication is needed before you walk the client in the hall. ANS: C Before the client gets out of bed, have the client sit on the bed with legs dangling on the side. This will enhance safety for the client. A gait belt should be used for all clients. The UAP cannot teach the client to use a walker or assess the clients pain. 7. A nurse assists a client with left-sided weakness to walk with a cane. What is the correct order of steps for gait training with a cane? 1. Apply a transfer belt around the clients waist. 2. Move the cane and left leg forward at the same time. 3. Guide the client to a standing position. 4. Move the right leg one step forward. 5. Place the cane in the clients right hand. 6. Check balance and repeat the sequence. a. 3, 1, 5, 4, 2, 6 b. 1, 3, 5, 2, 4, 6 c. 5, 3, 1, 2, 4, 6 d. 3, 5, 1, 4, 2, 6 ANS: B To ambulate a client with a cane, the nurse should first apply a transfer belt around the clients waist, then guide the client to a standing position and place the cane in the clients strong hand. Next the nurse should assist the client to move the cane and weaker leg forward together. Then move the stronger leg forward and check balance before repeating the sequence. Spinal Cord Injury/Cred Bladder- Ch6 8. A nurse is caring for a client who has a spinal cord injury at level T3. Which intervention should the nurse implement to assist with bladder dysfunction? a. Insert an indwelling urinary catheter. b. Stroke the medial aspect of the thigh. c. Use the Cred maneuver every 3 hours. d. Apply a Texas catheter with a leg bag. ANS: C Two techniques are used to facilitate voiding in a client with a flaccid bladder: the Valsalva maneuver and the Cred maneuver. Indwelling urinary catheters generally are not used because of the increased incidence of urinary tract infection. Stroking the medial aspect of the thigh facilitates voiding in clients with upper motor neuron problems. If the spinal cord injury is above T12, the client is unaware of a full bladder and does not void or is incontinent. Therefore, the client would not benefit from a Texas catheter with a leg bag. Airborne Precautions/TB-Ch8, Ch23 9. While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action should the nurse take first? a. Apply oxygen via nasal cannula. b. Administer intravenous 0.9% saline solution. c. Transfer the client to a negative-pressure room. d. Obtain a sputum culture and sensitivity. ANS: C A client with signs and symptoms of tuberculosis or other airborne pathogens should be placed in a negative- pressure room to prevent contamination of staff, clients, and family members in the crowded emergency department. 10. A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are best? (Select all that apply.) a. Admit the client to a negative-airflow room. b. Maintain a distance of 3 feet from the client at all times. c. Order specialized masks/respirators for caregiving. d. Other than wearing gloves, no special actions are needed. e. Wash hands with chlorhexidine after providing care. ANS: A, C A client with suspected TB is admitted to Airborne Precautions, which includes a negative-airflow room and special N95 or PAPR masks to be worn when providing care. A 3-foot distance is required for Droplet Precautions. Chlorhexidine is used for clients with a high risk of infection. Vascular Access Device-Ch13 11. A nurse delegates care to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene for a client who has a vascular access device? a. Provide a bed bath instead of letting the client take a shower. b. Use sterile technique when changing the dressing. c. Disconnect the intravenous fluid tubing prior to the clients bath. d. Use a plastic bag to cover the extremity with the device. ANS: D The nurse should ask the UAP to cover the extremity with the vascular access device with a plastic bag or wrap to keep the dressing and site dry. The client may take a shower with a vascular device. The nurse should disconnect IV fluid tubing prior to the bath and change the dressing using sterile technique if necessary. These options are not appropriate to delegate to the UAP. A. nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this clients teaching? a. You will need to wear a sling on your arm while the device is in place. b. There is no risk of infection because sterile technique will be used during insertion. c. Ask all providers to vigorously clean the connections prior to accessing the device. d. You will not be able to take a bath with this vascular access device. ANS: C Clients should be actively engaged in the prevention of catheter-related bloodstream infections and taught to remind all providers to perform hand hygiene and vigorously clean connections prior to accessing the device. The other statements are incorrect. 13.A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain? a. Administer topical lidocaine to the site. b. Place warm compresses on the site. c. Administer prescribed oral pain medication. d. Massage the site with scented oils. ANS: B At the first sign of phlebitis, the catheter should be removed and warm compresses used to relieve pain. The other options are not appropriate for this type of pain. 14.A nurse assists with the insertion of a central vascular access device. Which actions should the nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that apply.) a. Include a review for the need of the device each day in the clients plan of care. b. Remind the provider to perform hand hygiene prior to starting the procedure. c. Cleanse the preferred site with alcohol and let it dry completely before insertion. d. Ask everyone in the room to wear a surgical mask during the procedure. e. Plan to complete a sterile dressing change on the device every day. ANS: A, B, D The central vascular access device bundle to prevent catheter-related bloodstream infections includes using a checklist during insertion, performing hand hygiene before inserting the catheter and anytime someone touches the catheter, using chlorhexidine to disinfect the skin at the site of insertion, using preferred sites, and reviewing the need for the catheter every day. The practitioner who inserts the device should wear sterile gloves, gown and mask, and anyone in the room should wear a mask. A sterile dressing change should be completed per organizational policy, usually every 7 days and as needed. Chest Injury-Ch32 15.A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? a. Apply oxygen at 100%. b. Assess the respiratory rate. c. Ensure a patent airway. d. Start two large-bore IV lines. ANS: C The priority for any chest trauma client is airway, breathing, circulation. The nurse first ensures the client has a patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs. 16. A client is brought to the emergency department after sustaining injuries in a severe car crash. The clients chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority? a. Administer oxygen and reassess. b. Auscultate the clients lung sounds. c. Facilitate a portable chest x-ray. d. Prepare to assist with intubation. ANS: D This client has manifestations of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is intubated. Cardiac Murmur/Aortic Regurgitation- Ch33 17. A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below should the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation? a. Location A b. Location B c. Location C d. Location D ANS: A The aortic valve is auscultated in the second intercostal space just to the right of the sternum. Ventricular Tachycardia-Ch34 18. A nurse assesses a clients electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. FIG. 34-7 Normal sinus rhythm. Both atrial and ventricular rhythms are essentially regular (a slight variation in rhythm is normal). Atrial and ventricular rates are both 87 beats/min. There is one P wave before each QRS complex, and all the P waves are of a consistent morphology, or shape. The PR interval measures 0.18 second and is constant; the QRS complex measures 0.06 second and is constant. How should the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The clients chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites. ANS: D Normal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization. This finding on an electrocardiograph tracing is not an indication of hyperkalemia, ventricular tachycardia, or disconnection of leads. 19. A nurse assesses a clients electrocardiogram (ECG) and observes the reading shown below: FIG. 34-12 Premature ventricular contractions. A, Normal sinus rhythm with unifocal premature ventricular complexes (PVCs). B,Normal sinus rhythm with multifocal PVCs (one negative and the other positive). How should the nurse document this clients ECG strip? a. Ventricular tachycardia b. Ventricular fibrillation c. Sinus rhythm with premature atrial contractions (PACs) d. Sinus rhythm with premature ventricular contractions (PVCs) ANS: D Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometimes precede atrial depolarization. Ventricular tachycardia and ventricular fibrillation rhythms would not have sinus beats present. Premature atrial contractions are atrial contractions initiated from another region of the atria before the sinus node initiates atrial depolarization. 20. A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: FIG. 34-13 Sustained ventricular tachycardia at a rate of 166 beats/min. Which action should the nurse take first? a. Assess airway, breathing, and level of consciousness. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR). ANS: A Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a lethal dysrhythmia. The nurse should first assess if the client is alert and breathing. Then the nurse should call a Code Blue and begin CPR. If this client is pulseless, the treatment of choice is defibrillation. Amiodarone is the antidysrhythmic of choice, but it is not the first action. 21. After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: Vital Signs Nursing Assessment Time: 0800 Temperature: 98 F Heart rate: 68 beats/min Blood pressure: 135/60 mm Hg Respiratory rate: 14 breaths/min Oxygen saturation: 96% Oxygen therapy: 2 L nasal cannula Time: 1000 Temperature: 98.2 F Heart rate: 50 beats/min Blood pressure: 132/57 mm Hg Respiratory rate: 16 breaths/min Oxygen saturation: 95% Oxygen therapy: 2 L nasal cannula Time: 0800 Client alert and oriented. Cardiac rhythm: normal sinus rhythm. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Time: 1000 Client alert and oriented. Cardiac rhythm: sinus bradycardia. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Client voids 420 mL of clear yellow urine. Based on the assessments, which action should the nurse take? a. Stop the infusion and flush the IV. b. Slow the amiodarone infusion rate. c. Administer IV normal saline. d. Ask the client to cough and deep breathe. ANS: B IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly ceasing the medication could allow fatal dysrhythmias to occur. The administration of IV fluids and encouragement of coughing and deep breathing exercises are not indicated, and will not increase the clients heart rate. Tachycardia/Bradycardia EKG-Ch34 FIG. 34-8 Sinus rhythms. A, Sinus tachycardia (heart rate, 115 beats/min; PR interval, 0.12 second; QRS complex, 0.08 second). B,Sinus bradycardia (heart rate, 52 beats/min; PR interval, 0.18 second; QRS complex, 0.08 second). Bradycardia-Ch34 22. A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the clients electrocardiogram. Which action should the nurse take next? a. Administer intravenous diltiazem (Cardizem). b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature. ANS: B In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and contraction. The nurse should assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture. 23. A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The clients blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 liters per nasal cannula. The nurse assesses the clients rhythm on the cardiac monitor and observes the reading shown below: Which action should the nurse take first? a. Begin external temporary pacing. b. Assess peripheral pulse strength. c. Ask the client what medications he or she takes. d. Administer 1 mg of atropine. ANS: C This client is stable and therefore does not require any intervention except to determine the cause of the bradycardia. Bradycardia is often caused by medications. Clients who have multiple chronic diseases are often on multiple medications that can interact with each other. The nurse should assess the clients current medications first. Headaches/Nitrates-Ch35 25. A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take? a. Initiate oxygen therapy. b. Hold the next dose of Imdur. c. Instruct the client to drink water. d. Administer PRN acetaminophen. ANS: D The vasodilating effects of isosorbide mononitrate frequently cause clients to have headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen. The clients headache is not related to hypoxia or dehydration; therefore, these interventions would not help. The client needs to take the medication as prescribed to prevent angina; the medication should not be held. Digoxin (Lanoxin) therapy-Ch35 26. A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this clients teaching? a. Avoid taking aspirin or aspirin-containing products. b. Increase your intake of foods that are high in potassium. c. Hold this medication if your pulse rate is below 80 beats/min. d. Do not take this medication within 1 hour of taking an antacid. ANS: D Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 beats/min is too high for this cutoff. Potassium and aspirin have no impact on digoxin absorption, nor do these statements decrease complications of digoxin therapy. Ventricular Fibrillation-Ch34 27. A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a. Make sure the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 joules. d. Ensure that everyone is clear of contact with the client and the bed. ANS: D To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation. 28. The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, which action should the nurse take next? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d. Ask the clients family about code status. ANS: B The clients rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The clients code status should already be known by the nurse prior to this event. Atrial fibrillation-EKG- Ch34 FIG. 34-11 Atrial fibrillation. Note wavy baseline with atrial electrical activity and irregular ventricular rhythm. Acute Pericarditis/Nonpharmacological treatment- Ch35 29. A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure should the nurse implement? a. Apply an ice pack to the clients chest. b. Provide a neck rub, especially on the left side. c. Allow the client to lie in bed with the lights down. d. Sit the client up with a pillow to lean forward on. ANS: D Pain from acute pericarditis may worsen when the client lays supine. The nurse should position the client in a comfortable position, which usually is upright and leaning slightly forward. Pain is decreased by using gravity to take pressure off the heart muscle. An ice pack and neck rub will not relieve this pain. African Americans/Screening on Antihypertensives-Ch36, Ch67 30. A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service? a. African-American churches b. Asian-American groceries c. High school sports camps d. Womens health clinics ANS: A African Americans in the United States have one of the highest rates of hypertension in the world. The nurse has the potential to reach this priority population by providing services at African-American churches. Although hypertension education and screening are important for all groups, African Americans are the priority population for this intervention. 31. A nurse provides health screening for a community health center with a large population of African- American clients. Which priority assessment should the nurse include when working with this population? a. Measure height and weight. b. Assess blood pressure. c. Observe for any signs of abuse. d. Ask about medications. ANS: B All interventions are important for the visiting nurse to accomplish. However, African Americans have a high rate of hypertension leading to end-stage renal disease. Each encounter that the nurse has with an African- American client provides a chance to detect hypertension and treat it. If the client is already on antihypertensive medication, assessing blood pressure monitors therapy. High Risk Factors/Coronary problems- Ch35, Ch38 32. A nurse assesses clients on a car