Medical Unit 5 exam Question and Answers with Great Explanation 2021/2022

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Results for item 1. I I I


1
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The nurse is caring for a client who had skin traction applied 30
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minutes ago to the left leg. Which of the following actions would bea
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priority for the nurse to take?
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Check the clients peripheral pulses and temperature of the toes.
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Inspect the client's skin under the traction.
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Incor
rectans wer :

Reposition the client frequently. I I I


Correct Answer:
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Check the clients peripheral pulses and temperature of the toes.
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Monitor the client's pain level. I I I I


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General
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Rationale:
Monitoring the client's circulation by checking skin temperature and
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peripheral pulses should be the priority intervention 30 minutes after
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skin traction application. The other actions should be completed but
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would not be a priority over circulation.
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deWit 2017, pg. 742-746 I I I


Results for item 2. I I I


2
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The nurse is to administer prescribed estradiol 0.45 mg, po, daily to
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a client in menopause. The nurse has 0.9 mg tablets. How many tablets
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should the nurse administer with each dose? Do not roundyour answer.
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Enter numeric value only.
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Cor rectans wer:
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Results for item 3. I I I

,3
1/1poi nt
The nurse is caring for a client who takes medication for
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hypothyroidism and type I diabetes mellitus. The client had a I I I I I I I I I


cholecystectomy 24-hours ago and is now diaphoretic and acting
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rude and demanding. The client’s vital signs are normal. Which ofthe
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following actions should the nurse take first?
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Confirm that the client received prescribed levothyroxine this
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morning.
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Administer a prescribed PRN analgesic for postoperative pain. I I I I I I I


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Inspect the surgical incision for signs of infection.
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Correctans wer:

Measure the client’s blood glucose level. I I I I I




Feedback

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Rationale:
Diaphoresis, irritability, and “temper tantrums” are signs of I I I I I I I


hypoglycemia, which is life-threatening if it is not promptly corrected.
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The client with type I diabetes might have unstable blood glucose
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levels in the perioperative period because of physiologic stress as well
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as changes to the insulin regimen in attempt to prevent or manage
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hyperglycemia. The nurse should first check the client’s blood
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glucose level with a glucometer and be prepared to give the client a
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fast source of oral glucose if the level is low. The nursing actions in the
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distractors are appropriate but not as time- sensitive. A client with
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hypothyroidism must receive life-long daily levothyroxine therapy, but
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the client’s behavior is not characteristic of hypothyroidism, and even
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if the client missed a dose of levothyroxine, it would not be acutely
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threatening. The nurse must monitor for signs of infection at the
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surgical site, but the client’s vital signs, which would probably be
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altered if infection were causingthe cause for the client’s behavior,
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are normal. Pain can cause
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,diaphoresis and personality changes, and postoperative pain must I I I I I I I


be managed, but it is not as critical as identifying and treating
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hypoglycemia because hypoglycemia immediately threatens the
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client’s life.
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DeWit 2017, pp. 868-879, pp. 696-698, pp. 847-848
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Results for item 4. I I I


4
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The nurse in an outpatient clinic is reinforcing teaching with the
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parents of an infant regarding introduction of solid foods. Which of the
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following information should the nurse recommend including inthe
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teaching?
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“Begin solid foods while the extrusion reflex is still present to
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prevent choking.”
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Correctans wer:

“Introduce solid foods one at a time, for 4 to 7 day intervals.” I I I I I I I I I I I I




“Solid foods can be mixed in an infant feeder to make feedingeasier.”
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“Solid foods should begin with fruits and vegetables.”
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Rationale:
Solid foods should be added to the diet one at a time, for 4 to 7 day
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intervals between new foods. The extrusion reflex completely
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disappears around 4 to 6 months of age which would be the
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appropriate time to start solid foods. Solids should not be added to the
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bottle and the use of infant feeders is discouraged. The first foodadded
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to the infant’s diet should be rice cereal.
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Leifer, p. 401 I I

Results for item
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5.5
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, 1/1point
The nurse received change of shift report about assigned clients.
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Which of the following clients should the nurse assess first?
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The client with a serum potassium level of 5.0 mEq/L who isreporting
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abdominal cramping.
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The client with a serum sodium level of 145 mEq/L who reports dry
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mouth and is asking for water.
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Correctans wer:

The client with a serum magnesium level of 1.1 mEq/L who has tremors
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and hyperactive deep tendon reflexes.
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The client with a serum phosphorus level of 4.5 mg/dL who has multiple
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soft tissue calcium-phosphate precipitates.
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I Feedback

General
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Rationale:
The client with low magnesium needs to be seen first because
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hypomagnesemia can lead to cardiac dysrhythmias. The client with
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a high phosphorus is just barely high and has manifestations that
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are expected and not life threatening. The client with a high normal
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potassium level is experiencing expected symptoms of abdominal
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cramping and also does not have life-threatening symptoms. Finally,
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the client whose sodium is 145 is within normal limits and so would
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not be the priority.
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DeWitt 2017, p. 40-42 I I I


Results for item 6. I I I


6
1/1poi nt
The nurse is administering prescribed heparin 4,000 units,
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subcutaneous to an assigned client after surgery. Using the labelshown I I I I I I I I I I


below, how many mL should the nurse administer to the client? Do not
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round your answer. Enter numeric value only.
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