NURS 2137 MedSurg Exam 1 | Questions, Answers and Rationales

NURS 2137 MedSurg Exam 1 | Questions, Answers and Rationales A nurse is developing a plan of care for the nutritional needs of a client who has stage IV Parkinson's disease. Which of the following actions should the nurse include? Select all that apply. A. Provide three large balanced meals a day B. Record diet and fluid intake daily C. Document weight every other week D. Offer cold fluids such as milkshake E. Offer nutritional supplements between meals. Rationale: Plan to provide small frequent meals throughout the day. Record the client's diet and fluid intake daily to assess for dietary needs and to maintain adequate nutrition and hydration. Document the client's weight weekly to identify weight loss. Provide cold fluids such as a milkshake because thicker cold fluids are better tolerated by the client. Offer nutritional supplements between the meals to maintain the clients weight A nurse is monitoring a client who is receiving opioid analgesia. Which of the following findings should the nurse identify as adverse effect of opioid analgesics? a. urinary incontinence b. diarrhea c. Bradypnea D. orthostatic hypotension E. Nausea Rationale: Urinary retention not urinary incontinence is a common adverse effect of opioids. Constipation not diarrhea is a common adverse effect of the opioid. Respiratory depression is a common effect of opioid medications, it can drop respiratory rates to dangerously low levels. Dizziness or lightheadedness when changing positions is a common adverse effect of opioid medications. Nausea and vomiting are common adverse effects of opioid analgesia. A nurse is caring for a client who is receiving morphine via patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following client statements indicates the client understands how to use the device? A. "I'll wait to use the device until it's absolutely necessary" B. Ill be careful about pushing the button so I don't get an overdose C. I should tell the nurse if the pain doesn't stop after I use the device D. I will ask my son to push the dose button when I am sleeping. Rationale: The client may use the device when the first begin to fell the pain. It will help prevent unnecessary worsening of the pain and more doses of analgesia to prevent the pain. A feature of the PCA is the lockout mechanism which enforces a preset minimum interval between medication doses, this safety feature is one means of preventing an overdose because the client cannot self-administer another dose of medication until that interval has passed even if they push the button. If the patient is not achieving adequate pain control, he should le the nurse know so that she can initiate a reevaluation of the client's pain management plan. The client is the only one who should operate the PCA pump. In situations where the client is not able to do so the provider may authorize a nurse or a family member to operate the pump. A nurse is caring for a patient who is post procedure following a lumbar puncture and reports a throbbing headache when sitting up right. Which of the following actions should the nurse take? (Select all that apply) a. uses the Glasgow coma scale when assessing the patient b. assists the client to a supine position c. administers and opioid medication d. encourages the client to increase fluid intake e. instructs the client to perform deep breathing and coughing exercises Rationale: GCS is used to assess level of consciousness and is not needed after this procedure. Assist the client to a supine position will help alleviate the headache post lumbar puncture. Administration of analgesic for the pain is indicated post lumbar puncture. The nurse should encourage increased fluid intake to maintain a positive fluid balance which can relieve a headache post lumbar puncture. Coughing can increase ICP which can result in an increased amount of pain Which normal physiologic process contributes most to the need for acid-base balance? A. Continuous organ production of bicarbonate from carbonic acid B. Continuous alveolar exchange of oxygen and carbon dioxide C. Continuous metabolic production of free hydrogen ions D. Continuous kidney formation of urine from blood Rationale: All normal metabolism results in the removal of hydrogen ions from more complex compounds to use in the generation of cellular energy. Normal alveolar exchange of oxygen and carbon dioxide actually are part of acid-base balance mechanisms and do not contribute to imbalance. No normal or pathologic condition causes the excess formation of bicarbonate. Normal kidney formation of urine from blood is part of the balance mechanisms and does not contribute to the need for balance. Which set of client arterial blood gas (ABG) values indicates to the nurse that some mechanisms are working to partially compensate for an acid-base imbalance? A. pH 7.42; PaO2 92 mm Hg; CO2 41 mm Hg; HCO3− 28 mEq/L (mmol/L) B. pH 7.46; PaO2 98 mm Hg; CO2 38 mm Hg; HCO3− 30 mEq/L (mmol/L) C. pH 7.22; PaO2 60 mm Hg; CO2 80 mm Hg; HCO3− 22 mEq/L (mmol/L) D. pH 7.29; PaO2 78 mm Hg; CO2 82 mm Hg; HCO3− 36 mEq/L (mmol/L) Rationale: The ABG values listed for D indicate chronic respiratory acidosis with partial compensation. The PaO2 is low and the PaCO2 is quite high, which would lower the pH. However, the pH is not as low as would be expected by these values because the HCO3− level is elevated to compensate. This compensation is only partial because the pH is still below normal, indicating acidosis is still present. The values listed in C indicate an acute respiratory acidosis (low pH, low PaO2 and high PaCO2 coupled with a normal bicarbonate level) in which no compensation has occurred. The values listed in A are all totally normal showing no imbalance and no compensation. The values listed in B show a slight metabolic alkalosis (elevated pH) with normal oxygen and carbon dioxide values accompanied by a slightly elevated bicarbonate level. With which clients does the nurse remain alert for the possibility of metabolic alkalosis? Select all that apply. A. Client who has been NPO for 36 hours without fluid replacement B. Client receiving a rapid infusion of normal saline C. Client who has been self-managing indigestion with chronic ingestion of bicarbonate D. Client who has had continuous gastric suction for 48 hours E. Client having a sudden and severe asthma attack F. Client with uncontrolled diabetes mellitus Rationale: Metabolic alkalosis is caused by a loss of hydrogen ions and/or excessive bicarbonate ions. With continuous gastric suction, hydrochloric acid is removed, and the concentration of free hydrogen ions can get too low. Clients who ingest sodium bicarbonate daily are at risk for having metabolic alkalosis from excess bicarbonate. Being NPO for 36 hours can lead to ketoacidosis, as can uncontrolled diabetes mellitus rather than alkalosis. A severe asthma attack would result in respiratory acidosis, not alkalosis. Receiving a rapid infusion of normal saline could cause fluid overload but not alkalosis. How does the corresponding increase in carbon dioxide levels that occurs when arterial pH drops assist in maintaining acid-base balance? A. Carbon dioxide loss through exhalation can raise arterial pH levels. B. Carbon dioxide retention during exhalation can lower arterial pH levels. C. Carbon dioxide is a base that can convert free hydrogen ions into a neutral substance. Carbon dioxide is a buffer that can bind free hydrogen ions and form a neutral substance Rationale: Carbon dioxide is a gas that can be eliminated during exhalation, and this action is important for acid-base balance. When any condition causes the blood free hydrogen ion concentration to increase, extra CO2 is produced in the same proportion. This extra CO2 is eliminated during exhalation, helping to bring the hydrogen ion concentration down to normal and raising the pH, indicating that fewer free hydrogen ions are present. Whenever the CO2 level changes, the pH changes to the same degree, in the opposite direction. The hand grasp strength of a client with metabolic acidosis has diminished since the previous assessment one hour ago. What is the nurse's best first action? A. Measure the client's pulse and blood pressure B. Apply humidified oxygen by nasal cannula C. Assess the client's oxygen saturation D. Notify the Rapid Response Team Rationale: Progressive skeletal muscle weakness is associated with increasing severity of the acidosis. Muscle weakness can lead to severe respiratory insufficiency. Measuring pulse and blood pressure are appropriate but do not need to be done first. Applying oxygen is not going to help reduce a metabolic acidosis. Calling the rapid response team is needed if the client's gas exchange status is impaired The nurse performs an initial neurologic assessment on an older client. Which assessment findings would the nurse expect to be the result of normal physiologic aging? Select all that apply. A. Decreased coordination B. Hearing loss C. Long term memory loss D. Recent memory loss E. Decreased balance control Rationale: All of the choices can occur as a result of normal aging except for long term memory. Many older adults often reminisce about their earlier years and life events but often cannot recall what occurred the day before. The nurse is preparing to conduct a focused neurologic assessment for a client who had a traumatic brain injury. Which assessment finding is the immediate concern of the nurse? A. Disorientation B. Numbness in both arms C. Decreased level of consciousness D. Report of headache Rationale: A decreased level of consciousness is the first sign of neurologic deterioration and can be life-threatening more than the other changes in the client's condition. Disorientation and headache are expected findings for a brain injury (Choices A and D). Numbness in the arms is not life-threatening Choice B). The nurse is preparing to teach a client who has been prescribed a levodopa-carbidopa preparation for Parkinson's disease. What health teaching will the nurse include for the client and family? Select all that apply. A. "Move slowly when changing positions from sitting to standing." B. "Take your medication after meals to help prevent nausea." C. "Report any hallucinations that the client may have." D. "Note any changes in mental or emotional status." E. "Pay attention to whether your tremors improve or worsen." Rationales: Choice B is an incorrect response because levodopa drugs should be taken with meals to help with absorption. The other choices are all correct. The nurse is preparing a teaching plan for a client with migraine headaches. Which of these foods or food additives that may trigger a migraine and should be avoided will the nurse include in the teaching? Select all that apply. A. Sugar B. Beer C. Smoked sausage D. Pickles E. Caffeine F. Wine Rationales: Clients who have migraines should avoid food and beverages that contain tyramine. Choices B, C, and D contain tyramine. However, caffeine and wine do not contain tyramine but can cause headaches in many patients (Choices E and F). Artificial sweeteners, not sugar, can cause a migraine headache, so Choice A is an incorrect response. A nurse is assessing a client with a suspected diagnosis of multiple sclerosis. Which assessment findings will the nurse expect? Select all the apply. A. Resting tremors B. Memory loss C. Muscle spasticity D. Fatigue E. Diplopia F. Dysarthria Rationales: The client with MS often has intention tremors rather than tremors at rest. Therefore, Choice A is an incorrect response. The remaining choices are very typical findings that result from loss of myelin (white matter) and the presence of a chronic disease. A client who sustained a recent cervical spinal cord injury reports having a throbbing headache and feeling flushed. The client's blood pressure is 190/110. What is the nurse's priority action at this time? A. Perform a bladder assessment. B. Insert an indwelling urinary catheter. C. Place the patient in a sitting position. D. Turn on a fan to cool the patient. Rationales: The patient's high blood pressure (BP) is causing the headache and flushing. If the BP continues to remain elevated, the patient is at risk for stroke. Therefore, sitting the patient up will help to lower the blood pressure and is the first priority action for the nurse. The other choices would be the next actions to determine and relieve the cause of the autonomic dysreflexia. A nurse is caring for a client who has a halo fixator device with vest for a complete cervical spinal cord injury. Which assessment finding will the nurse report to the primary health care provider? A. Purulent drainage from the pin sites on the client's forehead B. Painful pressure injury under the collar C. Inability to move legs or feet D. Oxygen saturation of 95% on room air Rationales: The client wearing a halo device for a complete spinal cord injury cannot move his or her legs of feet which makes Choice C an incorrect response. An oxygen saturation of 95% on room air is normal and does not require a report to the primary health care provider. Choice B is incorrect because a halo device is not the same as a hard cervical collar. Instead, Choice A is correct because the halo is put in place with four pins into the skull which can become infected. This change needs to be reported to the primary health care provider The primary health care provider started a client with multiple sclerosis on mitoxantrone therapy. Which statement will the nurse include in teaching the client about this drug? A. "Report changes in urinary and bowel elimination immediately." B. "Follow up for annual lab testing to monitor for liver toxicity." C. "Rotate the sites for your self-administered injections." D. "Avoid crowded places such as malls and large public gatherings." Rationales: Mitoxantrone is administered by IV infusion and therefore Choice C is not the correct response. This drug can cause leukemia, infection, and cardiac toxicity. Therefore, Choices A and B are incorrect. Choice D is correct because the drug can suppress the bone marrow and immunity. Clients taking this drug are therefore at risk for infection and should avoid large crowds. A client is admitted with a suspected cervical spinal cord injury. What is the nurse's priority action for this client? A. Assess cardiac sounds. B. Manage the client's airway. C. Check oxygen saturation level. D. Perform a neurologic assessment Rationale: Although all of these actions are appropriate, Choice B is the priority because the client needs a patent airway as the first desired outcome Which statement by a client who had a transient ischemic attack (TIA) and is at risk for stroke indicates a need for further health teaching by the nurse? A. "I'm glad I can keep eating protein like red meat." B. "I'll try to walk at least 20-30 minutes each day." C. "I'm going to talk to my doctor about a weight loss plan." D. "I plan to include more fruits and vegetables in my diet." Rationales: The client who has had a TIA needs to modify his or her lifestyle to promote health and prevent a stroke. Choices B, C, and D all indicate that the client realizes the need to exercise more, lose weight, and eat a healthy diet. Choice A shows that the client believes that red meat is also healthy but it contains high levels of saturated fat which can clog arteries and decrease Perfusion. The nurse is caring for a client treated with alteplase following a stroke. Which assessment finding is the highest priority for the nurse to report to the primary health care provider? A. Client has a mild headache. B. Client's blood pressure is 194/120. C. Client has left hemiparesis. D. Client continues to be drowsy. Rationales: The assessment findings in Choices C and D are not new and are likely related to the client's stroke. Having a mild headache is not unusual for clients who have a stroke but a severe headache during or after fibrinolytic therapy would be a major concern. During or after alteplase administration, the expected outcome for the client's blood pressure is to keep it below 185/110. The blood pressure in Choice B is very high and needs to be immediately reported to the primary health care provider who will likely prescribe a rapid-acting anti-hypertensive drug. A client returns from the postanesthesia care unit (PACU) after a surgical removal of a frontal lobe tumor. In what position will the nurse place the client at this time? A. Turn the client from side to side to prevent aspiration. B. Elevate the head of the bed to at least 30 degrees at all times. C. Keep the client flat in bed or up 10 degrees and reposition from side to side. D. Keep the client in a high-Fowler's position in bed at all times. Rationales: The frontal lobe tumor that was removed is considered a supratentorial tumor. Positioning for a postoperative client who has a tumor removed from the supratentorium requires the head of the bed to be elevated to a 30 degree, or semi-Fowler's position. Therefore, Choice B is the best response. Choices A and C do not imply an elevation of the head of the bed and are therefore incorrect responses. Choice D suggests a higher sitting position but if the head is too high, the client may become hypotensive. Therefore, Choice D is an incorrect response. The nurse reassesses a client who was admitted 8 hours after stroke symptoms began and documents the following findings. Which assessment findings would the nurse report immediately to the primary health care provider? Select all that apply. A. Blood pressure increase to 196/100 B. Heart rate of 88 beats per minute C. Respiratory rate of 22 breaths per minute D. New onset headache reported as 8/10 pain intensity E. Increased drowsiness and dozing frequently F. Urine output of 360 mL since admission Rationale: The client's increase in blood pressure, intense headache, and decreasing level of consciousness implies that the client is most likely experiencing either an increase in intracranial pressure or is presenting with stroke symptoms. In either case, the nurse would report these new findings (Choices A, D, E) to the primary health care provider or Rapid Response Team. The client's heart and respiratory rate are within normal limits (Choices B and C), and the client is producing an adequate amount of urine given the minimum output should be at least 30 mL/hour. A client is admitted to the hospital unit a few minutes ago with a new diagnosis of right hemiparesis and aphasia which resulted from a traumatic brain injury. Which of the following interventions is a priority for the client at this time? A. Contact the physical therapist (PT) to plan care to increase the client's mobility. B. Contact the occupational therapist (OT) to assess the client's ADL ability. C. Contact the unit social worker (SW) to talk with the family about his discharge. D. Contact the speech/language pathologist (SLP) to schedule a swallowing study. Rationale: The nurse will likely need to collaborate with all of these interprofessional health care team members. However, the priority at this time is to ensure that the client remains NPO until a bedside swallowing study can be conducted to prevent possible aspiration when the client eats food or drinks liquids. If there is a swallowing problem, the SLP makes recommendations for special swallowing precautions and communicates those interventions to the members of the health care team. The primary healthcare provider has prescribed 1 liter of D5NS to infuse at a rate of 125 ml/hour. The nurse begins the infusion at 0700 (7am). When will the nurse anticipate completion of the infusion? A. 1300 hours (1pm) B. 1500 hours (3pm) C. 1900 hours (7pm) D. 2100 hours (9pm) Rationale: The nurse will anticipate completion of the infusion at 1500 hours (or 3 pm). To calculate this the nurse will take the total volume of 1000 mls and divide by the rate 125 ml/hr which equals 8. Thus, the infusion will be complete in 8 hours. If the nurse begins the infusion at 0700, in 8 hours it will be 1500 hours (or 3 pm). 1000 ml __________ = 8 hours 125 ml/hr A client receiving gentamycin intravenously reports that the peripheral IV insertion site has become painful and reddened. What is the priority nursing action? A. Contact the primary health care provider. B. Document findings in the electronic health record. C. Change the IV site to a new location. D. Stop the infusion of the drug. Rationale: The nurse needs to stop the infusion of the drug first because the IV site is likely infiltrated. Then documentation, notifying the primary health care provider, and starting a new IV can occur. An older adult client receiving an infusion of 5% dextrose in 0.9% normal saline at 150 mL/hour has developed shortness of breath with a decrease in oxygen saturation to 86%. What is the priority nursing intervention? A. Notify the health care provider B. Place the client on oxygen C. Sit the client upright in bed D. Assess the client's lung sounds Rationale: Because the client is short of breath, the priority action that can be done immediately is to sit the client upright in bed. Assessing the lung sounds can occur after sitting the client upright. Use of oxygen and contacting the healthcare provider will follow the priority action. The rate of infusion is likely too fast for an older adult client which has created fluid build-up. The nurse will anticipate fine crackles in the lung bases and decrease in the IV flow rate and notify the health care provider. Which condition does the nurse consider as most likely to have caused a client's arterial blood gas value to show an increased pH? A. Water retention B. Partial airway obstruction C. Nasogastric suction D. Diabetic ketoacidosis Rationale: Nasogastric suction results in alkalosis from over=elimination of hydrogen ions when stomach hydrochloric acid removed by the continuous suction. Which laboratory value will the nurse check immediately to prevent harm for a client with metabolic alkalosis who now has a positive Chvostek sign? A. Serum calcium B. Serum magnesium C. Serum glucose level D. Serum sodium Rationale: A positive Chvostek sign is associated with alkalosis accompanied by a low serum calcium level. The hypocalcemia cause overexcitement of the nervous system with dizziness, agitation, confusion, and hyperreflexia, which may progress to seizures. Tingling or numbness may occur around the mouth and in the toes. If the client has hypocalcemia, the nurse must report the finding immediately to the health care provider so actions can be taken to prevent harm. Which client will the nurse observe frequently for indications of hyperkalemia? A. A 72 year old receiving total parenteral nutrition B. A 65 year old taking furosemide for chronic heart failure C. A 38 year old being managed for diabetic ketoacidosis D. A 30 year old who has anxiety-induced hyperventilation Rationale: Hyperkalemia occurs as compensation for any type of acidosis, including diabetic ketoacidosis, by having cells take up excess hydrogen ions (from the acidosis) in exchange for releasing intracellular potassium to maintain electroneutrality in both fluid compartments. The client receiving TPN is at risk for metabolic alkalosis due to an