Med Surg Exam #2 Units 4,5,6, Quizzes of Nursing

Download Med Surg Exam #2 Units 4,5,6 and more Quizzes Nursing in PDF only on Docsity! Med Surg Exam #2 Units 4,5,6 1. The nurse is monitoring fluid volume status of the client who has heart failure and is at risk for clinical dehydration. Which of the following interventions is the most effective for monitoring this client? Answer: weigh the client every morning before breakfast 2. The nurse is caring for assigned clients who have fluid overload and are at risk for the development of complications. Which clients from the box below should the nurse identify at being at the greatest risk? Answer: 22 yr. old diagnosed with congenital heart failure at age 5, 62 yr. old who is recently diagnosed with hepatic cirrhosis, 36 yr. old who received hemodialysis 3 times a week for chronic kidney disease. 3. The nurse is caring for a client who is receiving prescribed 0.9% sodium chloride or normal saline IV at a rate of 200ml/hr. for treatment of dehydration. Which of the following findings requires immediate follow-up by the nurse? Answer: distended neck veins when the patient is in semi-fowlers position. 4. The nurse has attended a staff education conference about fluid and electrolyte imbalances. Which of the following statements by the nurse indicates a correct understanding of the conference? Answer: The client who has hyponatremia is likely to develop acute onset of confusion. 5. A nurse is preparing to administer 10 mEq of potassium chloride IV to a client who has a potassium level of 2.6 mEq/L. Which of the following actions should the nurse take? Answer: adequate blood return of the IV access before administration. 6. A nurse is caring for a client whose electrocardiogram demonstrates changing characteristics of hypokalemia. Which of the following assessment finding should the nurse suspect? Answer: hypoactive bowel sounds 7. The nurse is caring for a client who has a serum potassium level of 2.7 mEq/L. Which of the following medications is prescribed for the client should the nurse question? Answer: hydrochlorothiazide or HCTZ—because it is not potassium sparing. 8. The nurse is caring for a client who has been receiving prescribed furosemide and has a potassium level of 2.8 mEq/L. Which of the following assessments should the nurse perform first? Answer: Apical pulse rate and depth of respirations 9. The nurse is caring for a client who has cardiac dysrhythmias. The nurse should be concerned about which of the following laboratory values? Answer: Potassium level of 6 mEq/L 10. The nurse is assigned to four clients on a medical surgical floor. Which of the following clients should the nurse determine has the greatest risk for developing hypercalcemia? Answer: a client with hyperparathyroidism 11. The nurse is assigned to four clients who have fluid and electrolyte imbalances after receiving the change of shift report. Which of the following clients should the nurse assess first? Answer: Client who has serum magnesium level of 4.2 and is drowsy and has a pulse of 54. (This patient is more symptomatic) -other answers given are: Client who has serum potassium level of 5 mEq/L and is reporting occasional palpitations. Client who has a serum sodium level of 147mEq and has a dry mouth and pulse of 101. Client who has a serum calcium level of 11 and who has hypoactive bowels and constipation. 12. The nurse is caring for a client who has metabolic alkalosis. Which of the following clinical manifestations should the nurse monitor? Answer: Skeletal muscle weakness 13. The nurse is caring for a client who takes antacids for heartburn. The nurse should consider that this client is at risk of developing… Answer: Metabolic alkalosis 14. The nurse is reviewing the medical records of the following assigned clients who have an acid- base imbalance. Which client should the nurse recognize at being at risk for metabolic acidosis? Answer: The client who has renal failure with oliguria. 15. The nurse is reviewing the laboratory values for a client who has respiratory acidosis. Which of the following findings should the nurse expect? Answer: pH of 7.15 which indicates respiratory acidosis. 16. The nurse is collecting data from a client who has pneumonia and is experiencing acute respiratory acidosis and hypokalemia. Which of the following manifestations should the nurse expect to find? Answer: weak decreased pulses 17. The nurse is caring for a client who has acidosis and is awake, alert, and oriented. Which of the following actions should the nurse perform next? Answer: Take the clients vital signs and analyze the electrocardiogram ecg strip 18. The nurse is in the post anesthesia care unit (PACU) and is caring for a client who had abdominal surgery under general anesthesia. The client is receiving oxygen at 40% by a face mask and respirations are shallow at a rate of 8. Which of the following arterial blood gas results are consistent with the client’s respiratory assessment? Answer: pH of 7.31 (go with the low pH) Other answer given are pao2 of 73, paco2 of 50, Hco3 of 22, Sao2 of 85. pH of 7.35, 7.45, and 7.50. 33. The nurse has been made aware of the following client situations; the nurse should first assess the patient who has - patient with diabetic neuropathy with a serum potassium level of 6meq/l 34. The nurse is caring for the client who has a nephrostomy preformed and has returned to the nursing unit over the last 6 hours drainage in the tube has gone from 40mL/hr to 12mL/hr which of the following interventions should be performed by the nurse? -assess the client’s abdomen and vital signs 35. The nurse is reviewing assessment data for a clint who has acute glomerular nephritis which of the following findings is consistent with this diagnosis? -hematuria & proteinuria 36. The nurse is performing an assessment on a clint who has PKD which of the following findings is the greatest concern for the nurse? -persistent headache 37. The nurse is teaching the client with PKD and HTN who has been prescribed and angiotensin converting enzyme inhibitor for BP control which of the following statements made by the client indicate the need for further teaching? - I will eat plenty of potassium rich foods 38. The nurse is teaching a female client about ways to prevent the development of a UTI, which of the following client statements indicate the correct teaching of the information given below? -I should drink 2-3 L of sugar free fluid a day 39. The nurse is admitting a client who is experiencing renal colic with n/v and diaphoresis due to hetorothiasis?? Which of the following actions should the nurse take first? -administer prescribed caralac Intravenously to the client (treat the pain first) 40. The nurse has attended a continued education session on a client who has urolithiasis. Which of the following statements by the nurse indicate need for further teaching? -Stone formation most associated with fluid volume excess 41. The nurse is teaching the client who has urinary incontinence about lifestyle modifications to reduce incontinence which of the following client statements indicates the need for additional teaching? -I will restrict my fluid intake so I will not need to void as often. 42. The nurse has been made aware of the following client situations; The nurse should first assess the client who. - has a TURP trans ureteral resection of the prostate 1 day ago and who has a pulse rate of 52 43. The nurse who is working in the ED department is caring for a client who has been involved in a M.V.A which of the following should the nurse correlate to possible kidney trauma. -flank bruising, UA positive for RBC, abdominal pain 44. The nurse had provided discharge teaching to the client who had open prostatectomy 3 days ago and has an indwelling Foley catheter. Which of the following statements indicates the need for further teaching? - I will was my catheter every 2 days with soap and water 45. The nurse is providing health teaching to a client who was diagnosed with nephrosclerosis which of the following client statements indicates correct understanding of the teaching? -If patient states he needs to keep his BP under 160/110 46. The nurse is caring for a client who has had a transurethral resection of the prostate 4 days ago and has continuous bladder irrigation infusing at 100ml/hr. it is necessary for the nurse to contact the primary health provider if -the nurse observes burgundy colored urine in the client’s drainage bag 47. The nurse is caring for a client who has Benign prostate hyperplasia which of the following findings should the nurse expect to find. -straining to urinate 48. The nurse is providing medication instruction to a male client who has been prescribed PDE5 inhibitor to treat erectile dysfunction -I should avoid drinking apple juice. 49. the nurse is teaching a client with diabetes type 2 about disease management, which statement by the client displays correct understanding of the teaching? -If I have surgery of get very ill, I may have to receive insulin injections for a short time. 50. the nurse is reviewing the chart of a client who is scheduled to have a CT with contrast, which of the following should the nurse question before the procedure? -Serum creatine level of 1.8