NURSING 250 Proctored Med Surg Exam 1 with Solutions and Rationale

NURSING 250 Proctored Med Surg Exam 1 with Solutions 1. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? a. Bradycardia- more tachycardia cuz of a failing ventricle , SNS is activated to compensate . b. Flushed skin- duskly it wIll look like c. Frothy sputum-Left sided- can be blood tinged d. Jugular vein distention→ Right Rationale: ATI MS: pg. 198 ch 32 pdf Left side: dyspnea, orthopnea, fatigue, pulmonary congestion, frothy sputum, organ failure such as oliguria. Right Side: Jugular vein distention, ascending dependent edema, abdominal distention, polyuria ar rest, liver enlargement, 2. A nurse is assessing a client who is experiencing renal colic from a calculus in left renal pelvis. Identify the area where the nurse should expect the client to have referred pain. ( Find “hot spots” in the artwork) Pain travels downward to the inguinal area and lower back Renal colic occurs in the kidney area. Referred pain is somewhere that happens in another place other than where the pain should be felt. 2. A nurse is caring for a client who is receiving peritoneal dialysis and notes a decrease in the dialysate flow rate. Which of the following actions should the nurse take? (Select all the apply?). Check answer i read pg 644-647 med surg it’s not so specific p. 370 ch 57 pdf a. monitor the access site for drainage.- to check for sxs of infection. b. Strip the catheter tubing c. Measure the amount of the dialysate outflow d. Raise the client to high fowlers position- they must lie supine e. Position the client to her other side. 3. A nurse is planning to insert an indwelling catheter for a female client. Which of the following actions should the nurse plan to take? Ati video tutorials foley a. Collect urine specimen from the drainage bag 1 hr after insertion b. Raise the head of the bed to 45 degrees prior to insertion c. Secure the catheter to the client's inner thigh d. Attach the bag to the rail of the bed. –under non movable area 6. A nurse is providing teaching for a client who has age-related macular degeneration which of the following information should the nurse include in the teaching a. A possible cause of this problem is long-term lack of dietary protein b. You probably have a Detachment of your retina -vision is like having curtains over eyes c. You probably have noticed a decline in your central vision d. The doctor can perform surgery to correct the start paying the folds in your retina Rationale: ATI MS: PG. 63 Macular degeneration, often called age-related macular degeneration (AMD), is the central loss of vision that affects the macula of the eye. NO cure , happens alot in old people. Sxs: distorted vision, blurred vision, caused by smoking, female, HTN, diet lacking carotene. 7. A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report? P . 357 ch 55 pdf Med surg a. Platelets 70,000/mm3- risk of bleed normal range is 150,000 - 300,00- ABCS is compromised automatically . b. Distended abdomen- expected c. Alkaline phosphatase 125 units/L -norm normal is 30 -120 D. Clay colored stools- bile not on your shit 8. A nurse is preparing to discontinue long-term total parenteral nutrition (TPN) therapy for a client for a client. The nurse should plan to discontinue the TPN gradually to reduce the risk of which of the following adverse effects? Old med surge docs we used a. Hyperglycemia b. Diarrhea c. Constipation d. Hypoglycemia (Repeat) Since your body is producing enough insulin to take on higher loads, you must taper it down to avoid hypoglycemia with lower concentrations of TPN Abruptly discontinuing TPN will cause rebound hypoglycemia 9. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse plan to take? P . 250 chapter 40 pdf p . 678 lewis a. Administer the unit of packed RBC’s over 1 hr- 2- 4 hr its must be given for 2 -4 hours. older adults b. Obtain the client’s first set of vital signs 1 hr after initiating the transfusion- you get vital signs at the initial first 15 to 30 minutes of the transfusion. c. Initiate venous access with a 21-gauge needle - no more than 19, for a regular adult it is 18 or 20 . d. Use Y tubing with 0.9% sodium chloride when administering the transfusion. Pg 249 10. TOXIC SHOCK SYNDROME- same 11. A nurse is providing discharge teaching to an older adult client who had an exacerbation of COPD. The client is to start fluticasone by metered-dose inhaler. WHich of the following instructions should the nurse include? ( C) p . 132 ch 22 a. Use fluticasone as needed for shortness of breath.- fluticasone used to treat inflammation. b. Limit fluid intake to 1 L per day. - drink plenty to avoid dehydration. 2-3 liters. c. Obtain a yearly influenza immunization. - reduce risk of infection. d. Assist use of pursed-lip breathing.- this is also one of the interventions the nurse does but the question ask about fluticasone. It is a steroid, and we all know steroids decresaes inflammation but also depress our immunue system. So getting a flu shot is priority. 12. A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching? a. “You can cross your legs at the ankles when sitting down.” -avoid flexion contraction b. “Clean the incision daily with hydrogen peroxide.”- soap and water c. “Install a raised toilet seat in your bathroom.” Pg 437 also use straight chairs with arms, abduction pillow between the legs, avoid low chairs, and flexion of hip greater than 90 degrees. NO crossing legs , no turing on operative side. d. “You should use an incentive spirometer every 8 hrs.”- once every hour at least 13. Missing 14. A nurse is caring for a client who is postoperative following a femur fracture. Which of the following findings should the nurse report to the provider immediately? a. The client reports shortness of breath - embolism ABCS p . 457 chapter 71 b. The client has a temperature of 38.1 C (100.5F) c. The clients incision is red and warm d. The client reports incision pain 15. A nurse is planning care for a client who Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action? P . 290 ch 46 pdf a. Place the client in a protective environment b. Obtain a stool specimen with gloves→ CONTACT ISO c. Clean surfaces with chlorhexidine-bleach D. Wash hands with alcohol-based hand rub. 16. A nurse is setting up a sterile field before performing a dressing change on client who is postoperative. Which of the following actions should the nurse plan to take to maintain the sterile field? (select all the apply) a. Grasp 2.5 cm (1 in ) of the outer edge to open the surgical wrap- 1 inch form broder is always non sterile so its ok to touch it . b. Select a work surface at the nurses waist level- body mchiancis . c. Apply sterile gloves before opening the pack- sterile package must be opened first before donning sterile gloves d. Open the first flap of the sterile package toward the nurse's body- must be AWAY first , then sides , then TOWARDS the nurse . e. Place a surgical pack with a sterile drape on the work surface. 17. A nurse is caring for a client who has acute appendicitis. Which of the findings is the priority to the provider? Ch 23 p . 143 PEDIATRICS pdf also p 944 lewis a. Nausea- has not burst b. Flank pain - normal c. Fever - has not burst d. Rigid abdomen - muscles contract because it exploded- can lead to rupture and infection also HR ELEVATED, shallow and rapid respirations, pulse is weak. . 18. A nurse is caring for a client who is receiving radiation. The client reports nauseas since the therapy was initiated. Which of the following considerations should the nurse include when planning the clients meals? P . 583 ch 91 also ch 16 p 269 of the lewis book a. Offer frequent, high-carbohydrate meals- several small meals a day is preffered. b. Offer highly seasoned foods- you want COLD , dry , foods. Cooking stimulates odors that lead to nausea. c. Offer a snack prior to radiation therapy- several small meals a day is recommended. d. Offer hot beverages with meals- hot foods can stimulate nausea. Beverage with meals leads to nausea. 19. A nurse is caring for a client who is receiving mechanical ventilation. Which of the following interventions should the nurse implement? (D) page 208-209 not sure which answer Empty water from the ventilator tubing daily. ( -INFECTION CONTROL: water that collects in the ventilator tubing can create a breeding ground for bacteria which may lead to VAP. Suction the client’s airway every 4 hr.(Suction every 2 hr and as needed. p.157) Maintain the client in supine position. (should reposition pt to help with secretions) Perform oral care every 2 hr.( you do oral care but not every 2hrs ) 20. A nurse in an emergency department is assessing a client who has cirrhosis of the liver. Which of the following is a priority finding? ( C) a. Palmar erythema b. Spider angiomas c. Mental confusion (RM 10 Ch.55 p.359 pdf - too much bilirubin in the blood went to the brain and now caused mental encephalopathy) d. Yellow Sclera 21. A nurse is preparing to administer bumetanide to a client who has heart failure. Which of the following assessment findings should indicate effectiveness of the medication a. Bowel sounds present in 4 quadrants on auscultation b. Alert and oriented to time place and person c. Lung sounds clear - it is Bumex d. Apical pulse 80 Rationale: MS RM 10 Ch.32 p.198-9 23. A nurse is caring for a client who has hypertension and has a new prescription for lisinopril. The nurse should consult with the provider about which of the following medication in the client's medication administration record? a. Potassium chloride ** found on medscape b. evothyroxine c. Acetaminophen d. Metformin Rationale: Pharm RM 7.0 Ch.20 p.151; Hyperkalemia is a complication for Lisinopril; avoid any salt substitutes containing K+. 24. A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan or care? a. Avoid use of anticoagulants - use it b. Place pillow under client knees - stasis danger c. Discourage leg exercises while in bed - you need it d. Apply compression stocking in lower extremities Rationale: It’s common post-op, also, resume regular activity after 4-6 wks. 25. What interferes with warfarin therapy a. Potatoes (Potassium) Oranges (Vit C) b. Bananas (Potassium) c. Cauliflower - Huge Vitamin K remember veggies Rationale: Avoid any interaction with Vitamin K when on anticoagulant therapy, and dark, leafy veggies (or just any veggies) are THE source for it. 26. A nurse is administering furosemide 80 to a client with pulmonary edema. Which of the following assessment findings indicates the nurse that the medication is effective? P , 144 ch 19 pharm pdf a. Elevation in BP b. Adventitious breath sounds c. Weight loss of 1.8 kg (4lb) in the past 24 hr d. Respiratory rate of 24/min 27. A nurse is caring for a client who has Cushing’s disease. Which of the following findings should the nurse expect? Ch 80 page 518 a. Weight loss b. Hyponatremia- increased c. Hyperglycemia d. Hypercalcemia- DECREASED ERRYTHANG is UP except K+/Ca+, both HYPO 28. A nurse is monitoring a client who has receiving 2 units packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction? (MS RM 10.0 Ch.40 p.250: chills, fever, low-back pain, tachycardia, flushing, hypotension, chest tightening or pain, tachypnea, nausea, anxiety, hemoglobinuria, and an impending sense of doom) a. Back pain b. Bradycardia- should be tachycardia c. Hypertension- hypotension it will cause. d. Chills 29. A PACU nurse is monitoring the drainage from a client’s NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider? a. 75 mL of greenish yellow drainage (Purulent) b. 100 mL of red drainage (Sanguineous/fresh bleeding) c. 200 mL of brown drainage (Purulent) d. 150 mL of serosanguineous drainage 30. A nurse is performing an admission assessment on a client who has severe chronic kidney disease. Which of the following findings should the nurse expect? MS RM 10.0 Ch.59 p.382 pdf a. Lethargy b. Potassium 4.0 mEq/L c. Hypotension- HTN due to fluid overload d. Serum creatinine 0.9 mg/dL- should be increased . Rationale: Expected findings include nausea, fatigue, lethargy, involuntary movement of legs, depression, and intractable hiccups. In most cases of chronic CKD, findings are r/t fluid overload, including both HTN and orthostatic hypotension. 31. Missing 32. A nurse is teaching a client who has hypothyroidism. Which of the following information should the nurse include in the teaching? (select all the apply) pg. 886 med srg a. You will take medication for this condition for several months b. You will need to eat a high-fiber diet to prevent complications of this condition c. You might notice that you perspire more with this condition d. We will perform laboratory tests to monitor the effect of your medication e. This condition can cause you to gain weight. 33. A nurse is caring for a client who is receiving mechanical ventilation when the low pressure alarm sounds on the ventilator. Which of the following actions should the nurse take? P 113 ms ati pdf a. Empty water from the client’s ventilator tubing b. Evaluate the client for a cuff leak - check this first for cause of low pressure c. Suction the client’s airway d. Increase the client’s ventilator flow rate. 34. A nurse is reviewing laboratory results for four clients who are scheduled for surgery. Which of the following laboratory values should the nurse report to the surgeon? a. INR of 1.6 (Normal 1.0-2.0) b. Platelets 95,000/mm3 (low 150,000-350,000) c. Hct 42% (Normal 42%-52% men; 37%-47% women) d. WBC 8,000/mm3 (Normal 5,000-10,000/mm3) Rationale: MS RM 10.0 Ch.39 p.245; Normal labs 35. A nurse is assessing a client who is receiving valsartan to treat heart failure. Which of the following findings should the nurse identify as an indication that the medication is effective? a. Increased potassium level b. Decreased blood pressure ?? ** c. Increased heart rate ( pg 365 md srg valsartan is a afterload reducing agent, angiotensin receptor blocker ) d. Decreased urinary output 36. A nurse is providing teaching to a client following a liver biopsy 1 hour ago. Which of the following positions should the nurse instruct the client to maintain after the procedure??? P. 882 lewis medsurg a. Prone b. Supine c. Right lateral - with minimum 2 hours, with patient bed flat. d. Left lateral Rationale: ATI Capstone question; “Following a liver biopsy, the nurse should instruct the client to lie on the affected side for hemostasis to occur. The liver sits just under the rib cage on the right side of the abdomen.” 37. A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching? MS RM 10.0 Ch.92 p.614 a. “I will have to wait 2 months before additional saline can be added to my breast expander” (tissue expanders have ports for additional injection of saline for gradual expansion & is encouraged) b. “I will perform strength building arm exercises using a 15 pound weight” (Squeeze a rubber ball, elbow flexion/extension, hand-wall climbing to promote full ROM and prevent lymphedema) c. “I should expect less than 25 ml of secretions per day in the drainage devices” d. “I will keep my left arm flexed at the elbow as much as possible” (Elbow flexion AND extension) 38. A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instructions should the nurse include? Ch 82 page 532 a. “Wash your feet twice per day with antibacterial soap and hot water” b. “Wear loose fitting slippers around the house” c. “Wear cotton rather than nylon sock” d. “Use a heating pad to keep your feet warm at night” 39. A nurse is caring for a client following the placement of a transverse colostomy. Which of the following findings indicates a possible complication? a. Client reports pain of 6 on scale from 0 to 10 b. Heart rate 110/min c. Bowel sounds hypoactive d. Stoma appears dry p. 602.. Stoma should be pink , moist , ischemia should be reported to the provider. 40. A nurse is counseling a client who has a family history of hypertension about reducing high risk for high blood pressure. Which of the following strategies should the nurse recommend? P .161 a. Engage is isometric exercises for 15 min daily b. Maintain a body mass index between 31 and 34 c. Lower total cholesterol level 200 mg/dL d. Increase dietary potassium intake 41. A nurse in the PACU is assessing a client who is postoperative following general anesthesia. Which of the following findings is the priority to address? P . 645 a. Piloerection of the skin b. Vomiting upon arousal c. Decreased body temperature- increases risk for wound infection, cardiac dysrhymias, altered absorpton of medication. d. Indistinct, rambling speech 42. A nurse is providing discharge teaching to the partner of a client who has a linear incision site following an open cholecystectomy. Which of the following wound care instructions should the nurse include? a. Change the dressing four times per day b. Use sterile gloves when performing the dressing change ??? ( they dont have to use sterile they can use clean gloves ) c. Clean from the incision to the surrounding skin d. Apply tincture of benzoin prior to removing the dressing 43. A nurse is preparing to administer vancomycin IV bolus to a client who has pneumonia. Which of the following clinical manifestations should the nurse instruct the client to monitor for and report? a. Pallor of the extremities b. Taste of metal in the mouth c. Halo of light around objects d. Ringing in the ears- ototoxic is vanco p 359 pharm ati pdf 44. A nurse is caring for a client who has pancreatitis and has been receiving total parenteral nutrition. Which of the following laboratory tests should the nurse monitor for overall nutritional status? a. Prealbumin b. C reactive protein c. Creatinine d. Lipase 45. A charge nurse is called to a client’s room after a staff nurse reports a client has had a wound evisceration. Which of the following actions should the charge nurse take? Page 650 MS ATI PDF 10.0 im stuck with c and d . its says with cover the wound with a sterile saline soaked towel or dressing a. Attempt to reinsert the protruding viscera- DO NOT ATTEMPT TO REINSERT ORGANS b. Obtain bottles of warm, sterile 0.9% sodium chloride solution = wouldn’t you want to get sterile solution for the dressing cover to put on the wound? c. Place the client in left lateral recumbent position- low fowlers hips knees bent (ati book p1111 “place in supine position with hips and knees bent”)= which is lithotomy position, not recumbent d. Apply a firm pressure dressing across the client’s abdomen - in practice A/B. confirmed (p1111 ati book “cover wound with sterile dressing”--doesn’t mean apply firm pressure) 46. A nurse is caring for four clients. Which of the following clients is at risk for developing metabolic alkalosis? Pg 283 ati a. A client who is receiving continuous gastric suctioning b. A client who has aspiration pneumonia c. A client who is experiencing an opioid overdose- respiratory acidosis. d. A client who has uncontrolled diabetes mellitus 47. A nurse is caring for a client who is taking digoxin 0.125 mg PO daily and is at risk for developing digoxin toxicity. The nurse should monitor the client for an imbalance of which of the following electrolytes because it can increase the risk for digoxin toxicity? a. Calcium b. Potassium c. Magnesium d. Phosphatase Rationale: Digoxin level and Potassium levels are inversely correlated. So if you have less K+ your digoxin levels shots up leading to digoxin toxicity and if your K+ is high=digoxin level is low. 48. A nurse is assessing the abdominal wound of a client who is 3 days postoperative following a colon resection. Which of the following findings should the nurse report to the provider? a. Erythema (redness can be indicative of infection) b. Ecchymotic skin c. Drainage (expected for 3-4 days?) d. Edema ??? 49. A nurse is completing an admission assessment for a client. The nurse should expect the provider to prescribe which of the following medications for the client? EXHIBIT VITAL SIGNS: Temperature (98.3 F), HR (100/min), RR (20/min), BP (152/94mmHg) a. Atorvastatin b. Allopurinol c. Metoprolol d. levothyroxine 50. A nurse is assessing a client who is near the end of life following a head injury. The client has alternating periods of rapid breathing and apnea. The nurse should document this finding as which of the following respiratory patterns? page 75 ch 14 a. Biot’s respirations- quick shallow respirations followed by apnea. b. Hypoventilatory respirations- opoid overdose c. Kussmaul respirations- hyperglycemia d. Cheyne-Stokes respirations- occurs during INCREASED INTRACRANIAL PRESSURE 51. A nurse is administering a unit of packed RBCs to a client and notes that there are several small clots floating in the IV bag. Which of the following actions should the nurse take? a. Inject 5,000 units of heparin into the unit of packed RBCs b. Place the unit of packed RBCs in a warming unit for 5 min c. Return the unit of packed RBCs to the blood bank- return that shit d. Dilute the unit of packed RBCs using 50 mL of lactated Ringer’s 52. A nurse in a provider’s office is teaching a client about the self-management of GERD. Which of the following instructions should the nurse include? a. “Eat a light meal 1 hour before bedtime”- avoid eating before bedtime b. “Lie down for 30 minutes after each meal”- CANNOT BE SUPINE c. “Increase your caloric intake by 250 calories per day” d. “Sleep with the head of your bed elevated 6 inches”- Rationale: so your acid doesn’t hit your throat when you sleep pg 309 57. A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication? a. Generalized abdominal pain b. Cloudy effluent c. Fever d. Increased heart rate Rationale: Peritonitis Assessment Findings : Rigid, board-like abdomen(hallmark), abd distention, N&V, Rebound tenderness, tachycardia, FEVER. 58. A nurse is caring for a client who is receiving enteral nutrition. Which of the following interventions by the nurse will prevent aspiration? a. Check the gastric pH following bolus feedings ( for verifying placement) b. Place the client in supine position before initiating feedings (No; 30 degree) c. Instruct the client to perform the Valsalva maneuver after feedings (no) d. Measure residual volume prior to bolus feedings Rationale: Nursing measures to prevent aspiration include verifying tube placement, checking gastric residuals, assessing bowel function to confirm peristalsis, and elevating the head of the patient’sbed to 30 degrees or more during feeding and at least 1 hour after feeding. Monitor fluid and electrolyte balance carefully; additional water may be prescribed based on the patient’s fluid status. Providing mouth care is particularly important for patients receiving enteral feedings, as is addressing the psychosocial aspects of care. 62. Client has a pressure ulcer. Which indicates wound healing? a. Light yellow exudate (Seropurulent) b. Wound tissue firm to palpation (firm, not healing yet) stage 1. c. Dry brown eschar (dead skin?) d. Dark red granulation tissue p . 330 fundamentals Ratonale: Red: Healthy regeneration of tissue Yellow: Presence of purulent drainage and slough Black: Presence of eschar that hinders healing and requires removal 63. STEPS to use of a peak flow meter a. “Stand upright” 1 b. “Seal your lips around the mouth piece”3 c. “Fill your lungs with a deep breath”2 d. “Exhale forcefully and quickly”4 e. “Record the highest of three consecutive readings”5 Rationale: A,C,B,D,E 1. Stand up or sit up straight. 2. Make sure the indicator is at the bottom of the meter (zero). 3. Take a deep breath in, filling the lungs completely. 4. Place the mouthpiece in your mouth; lightly bite with your teeth and close your lips on it. Be sure your tongue is away from the mouthpiece. 5. Blast the air out as hard and as fast as possible in a single blow. 6. Remove the meter from your mouth. 7. Record the number that appears on the meter and then repeat steps one through seven two times. 8. Record the highest of the three readings in an asthma diary. This reading is your peak expiratory flow (PEF). 67. Client, who is 6 hr postoperative following application of an external fixator for a tibial fracture. Which of the following actions should the nurse take? a. Palpate the dorsalis pedis pulse. b. Maintain the affected extremity in a dependent position (ELEVATE) c. Wrap sterile gauze on the shart point of the pins (NOPE 8-12HRS) d. Adjust the clamps on the fixator flame (NEVER, MD DOES THIS) Rationale: Elevate extremity, Monitor neurovasc