Med Surg Proctored EXAM 2024.pdf, Exams of Nursing

Download Med Surg Proctored EXAM 2024.pdf and more Exams Nursing in PDF only on Docsity! Med Surg Proctored EXAM 2024-2025 QUESTIONS AND ANSWERS 100 % PASS SOLUTION A+ GRADE The nurse in a cardiac stepdown unit has received a hand-off shift report for these clients. Which client should be assess first? A. a client who has just returned from a coronary artierogram with placement of an intracoronary stent. B. A client who is in heart failure and has gained 2 pnds in the last 24 hours. C. a client with endocarditis who has temperature elevation of 100F and P 100 beats/min D. A client who was cardioverted from atrial fib 24 hours ago and has had 3 atrial premature - answer>>A. a client who has just returned from a coronary artierogram with placement of an intracoronary stent. What ECG changes would reflect myocardial ischemia in a client who has been admitted for observation after experiencing an episode of chest pain? A. Prolonged PR interval B. Wide QRS complex C. ST- Segment elevation or depression D. Tall, peak T-waves - answer>>C. ST- Segment elevation or depression A new employee at a facility needs a hepatitis vaccine. Which statement reflects accurate understanding of the immunization? A. I need to get 6 shots of hep C B. Once I receive the Hep vaccine I will always been immune C. I will receive 3 injections over a period of months, which should protect me from hep B D. Hep vaccine is an oral vaccine with live attenuated Virus - answer>>C. I will receive 3 injections over a period of months, which should protect me from hep B ) While talking with a client with a diagnosis of end stage liver disease. The nurse notices the client is unable to stay awake and seems to fall asleep in the middle of a sentence. The nurse recognizes these symptoms to be indicative of what condition? A. Hyperglycemia B. Increased Bile production C. Increased blood ammonia levels D. Hypocalcaemia - answer>>C. Increased blood ammonia levels The nurse is caring for a client with chronic hep B. What will the teaching plan for this client include? A. use a condom for sexual intercourse B. Report any clay- colored stools. C. Eat a high protein diet D. Perform daily urine bilirubin checks - answer>>A. use a condom for sexual intercourse A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock? a. cool clammy skin b. inspiratory crackles c. apical heart rate of 48 beats/min d. temperature 101.2* F - answer>>c. apical heart rate of 48 beats/min c. Pale, cool, and dry extremities d. New onset of confusion and agitation - answer>>New onset of confusion and agitation A patient is admitted to the burn unit with burns the upper body and head after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are decreased ad no wheezes are audible. What is the best action for the nurse to take? a. encourage the patient to cough and auscultate the lungs again b. Notify the HCP and prepare for endotracheal intubation c. Document the results and continue to monitor the patient's resp. rate d. Reposition pt in high-Fowler's position and reassess breath sounds - answer>>b. Notify the HCP and prepare for endotracheal intubation During the emergent phase of burn care, which nursing action will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor b. Monitor daily weight c. Assess mucous membranes d. Measures hourly urine output - answer>>d. Measures hourly urine output After receiving change-of-shift report, which of these patients should the nurse assess first? a.A patient with smoke inhalation who has wheezes and altered mental status b. A patient with full-thickness leg burns who has a dressing change scheduled c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain. d. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hr - answer>>a.A patient with smoke inhalation who has wheezes and altered mental status . The RN observes all of the following actions begin taken by a staff nurse who has floated to the unit. Which action requires that the RN intervene? a.The nurse uses latex gloves when applying antibacterial cream to a burn wound b. The float nurse obtains burn cultures when the patient has a temp of 101* F c. The float nurse administers PRN fentanyl (Sublimaze) IV to a pt 5 minutes before a dressing change d. The float nurse calls the health care provider for an insulin order when a nondiabetic pt has an elevated serum glucose - answer>>The nurse uses latex gloves when applying antibacterial cream to a burn wound A client with cervical neck fracture is admitted to the intensive care unit. Which findings would the nurse recognize as indicative of spinal shock? A. Spastically, neuromuscular irritability, hyperreflexia B. Flaccidity and lack of sensation below the level of spinal cord lesion. C. Automatic dysreflexia with neurogenic bladder symptoms D. Muscular spasticity and loss of motor reflexes in all parts of the body below the level of spinal cord lesion. - answer>>Flaccidity and lack of sensation below the level of spinal cord lesion. A client with T6 spinal cord injury is being discharged. The PT is concerned about autonomic dysreflexia. S/S include the following: A. Dialited pupils B. Sudden vomiting and diarrhea C. drop in BP and pulse D. Diaphoresis above the level of the lesion - answer>>D. Diaphoresis above the level of the lesion A woman has been recently diagnosed with systemic lupus and shares with the nurse, I want to get pregnant, but I don't know how I will tolerate pregnancy because I have lupus. Which response is best? A. Most women find that they feel better when they are pregnant B. How long have you been in remission? C. Women with lupus frequently have slightly longer gestation D. Its best to become pregnant within the first 6 months of diagnosis - answer>>B. How long have you been in remission? The nurse is assessing the patency of an arteriovenous fistula and suspects clotting in the fistula if which finding are noted? Select all that apply A. presence of a thrill on palpation over the fistula *B. Absence of a bruit on auscultation over the fistula C. Presence of a pulse in the extremity below the fistula *D. Complaints of tingling or discomfort in the extremity E. Warm hand and fingers in the extremity in which the fistula is located - answer>>*B. Absence of a bruit on auscultation over the fistula *D. Complaints of tingling or discomfort in the extremity Epoetin alfa (Epogen) is prescribed for a client diagnosed with chronic renal C Nasal flaring and lung consolidation D Symmetrical chest expansion and bradypnea. - answer>>B Absent breath sounds and tachypnea A nurse is planning care for a client with a chest tube attached to a Pleur-Evac drainage system. The nurse includes which interventions in the plan? Select all that apply A. Clamping the chest tube intermittently B. Changing the client's position frequently C. Maintaining the collection chamber below the client's waist D. Adding water to the suction control chamber as it evaporates. E Taping the connection between the chest tube and the drainage system. - answer>>Changing the client's position frequently *C. Maintaining the collection chamber below the client's waist *D. Adding water to the suction control chamber as it evaporates. *E Taping the connection between the chest tube and the drainage system. A client has a total serum calcium level of 7.5 mg/dl. Which clinical manifestations would the nurse expect to note on assessment of the client? Select all A Constipation B Muscle twitches C Hypoactive bowel sounds D Hyperactive deep tendon reflexes E Positive Trousseau's sign and positive Chvostek's sign F. Prolong ST interval and QT interval on ECG - answer>>B Muscle twitches D Hyperactive deep tendon reflexes E Positive Trousseau's sign and positive Chvostek's sign F. Prolong ST interval and QT interval on ECG The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? A. Administer sublingual nitroglycerin. B Obtain a STAT electrocardiogram C Have the client sit down immediately D Assess the clien'ts vital signs. - answer>>C Have the client sit down immediately The nurse is caring for a client diagnosed with ARDS who is on a ventilator. Which interventions should the nurse implement. Select all A Assess the client's level of consciousness B Monitor clients urine output C Perform passive range of motion exercise D maintain intravenous fluids as ordered E Place the client with the HOB flat - answer>>A Assess the client's level of consciousness B Monitor clients urine output C Perform passive range of motion exercise D maintain intravenous fluids as ordered A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is pending an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? a."large incisions will be made in the eschar to improve circulation" b. " I can call the doctor back here if you want me to" c. "a piece of skin will be removed and grafted over the burned area" d. "dead tissue will be surgically removed" - answer>>a."large incisions will be made in the eschar to improve circulation" A nurse is monitoring the fluid replacement of a client who has sustained burns. Which of the following fluids is used in the first 24 hours following a burn injury? a. 5% dextrose in water b. 5% dextrose in normal saline c. normal saline d. lactated ringers - answer>>d. lactated ringers A nurse is caring for a client who has full-thickness burns all over 75% of his body. Which of the following methods is appropriate to accurately monitor the cardiovascular system? a. auscultate cuff blood pressure b. palpate pulse pressure c. obtain a central venous pressure d. monitor the pulmonary artery pressure - answer>>c. obtain a central venous pressure 4. A nurse is assessing the depth and extent of a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the first priority when assessing the severity of the burn? a. Age of the client a. Decreased WBC b. Increased serum amylase c. Decreased serum lipase d. Increased serum calcium - answer>>b. Increased serum amylase A nurse in the ICU is caring for a client who has acute respiratory distress syndrome (ARDS) and is receiving mechanical via an endotracheal tube. The provider plans to extubate her within the next 24 hour. Which of the following is an important criterion for extubating the client? a. Ability to cough effectively b. Adequate tidal volume without manually assisted breaths c. No indication of infection d. No need for supplemental oxygen - answer>>b. Adequate tidal volume without manually assisted breaths 12. A nurse is caring for a client following a CT scan with dye who suffered from an anaphylactic reaction. Which of the following conditions requires a priority nursing response? a. urticaria b. stridor c. tachypnea d. angioedema - answer>>b. stridor A nurse is caring for a female client who came in to the ED reporting SOB and pain in the lung area. Her heart rate is 110/min, resp. rate 40/min, and blood pressure 140/80 m8juiimHg. Her arterial blood gases are: pH 7.5, PaCO2 29 mmHg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority intervention? a. Prepare for mechanical ventilation b. Administer oxygen via face mask c. Prepare to administer a sedative d. Monitor for pulmonary embolism - answer>>b. Administer oxygen via face mask A nurse is monitoring a client who has just had a thoracentesis to remove pleural fluid. Which of the following clinical manifestations indicate a complication that requires notifying the provider immediately? a. Serosanguineous drainage from the puncture site b. Discomfort at the puncture site c. Increased heart rate d. Decreased temperature - answer>>c. Increased heart rate A group of college students was attending a weekend football rally when one of the students stumbled and fell into the bonfire. Although several friends quickly intervened, the client sustained partial-thickness burns to both lower legs, chest, and both forearms. Which of the following is priority nursing action when the client is brought to the ED? a. cover the burned area with sterile gauze b. inspect mouth for signs of inhalation c. administer intravenous pain medication d. draw blood for a CBC - answer>>b. inspect mouth for signs of inhalation A triage nurse in an emergency dept is caring for a client who has gunshot wound to the right side of chest. The nurse notices thick dressing on the chest and sucking noise coming from the wound. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take initially? a. Raise the foot of the bed to a 90 degree angle b. Remove the dressing to inspect the wound c. Prepare to insert a central line d. Administer oxygen via nasal cannula - answer>>d. Administer oxygen via nasal cannula A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. The nurse should know that the client requires which of the following? a. A cardiology consult b. Less frequent suctioning c. An antidysrhythmic medication d. Pre-oxygenation prior to suctioning - answer>>d. Pre-oxygenation prior to suctioning The nurse is caring for a client who is receiving a blood transfusion. The transfusion started 30 minutes ago at a rate of 100 mL/hr. The client begins to complain of low back pain and headache and is increasingly restless. What is the first nursing action? a. Stop the transfusion, disconnect the blood tubing, and begin a primary infusion of normal saline solution b. Slow the infusion and evaluate the vital signs and the client's history of 4. Norepinephrine (Levophed) has been ordered for a client in hypovolemic shock. Before administering the drug, the nurse should make sure that the client has: a. A heart rate of less than 120 beats/min b. Urine output of at least 30 mL/hr. c. Received adequate anticoagulation d. Been receiving adequate IV fluid replacement - answer>>d. Been receiving adequate IV fluid replacement . The client returns to his room after a thoracotomy. What will the nursing assessment reveal if hypovolemia from excessive blood loss is present? a. CVP of 3 cm H20 and urine output of 20 mL/hr b. Jugular vein distention with the head elevated 45 degrees c. Chest tube drainage of 50 mL/hr in the first 2 hours d. Persistent increased BP and increased pulse pressure - answer>>a. CVP of 3 cm H20 and urine output of 20 mL/hr The nurse is performing an assessment and finds the client has cold, clammy skin, pulse of 130 beats/min and weak, blood pressure of 84/56 mm Hg, and urinary of 20 mL for the past hour. The nurse would interpret these findings as suggestive of which pathophysiology? a. Reduction of circulation to the coronary arteries, this increasing the preload b. Decreased glomeruli filtration rate, resulting in volume overload c. Stimulation of the sympathetic nervous system, causing severe vasoconstriction d. Decrease in the cardiac output and inadequate tissue perfusion - answer>>d. Decrease in the cardiac output and inadequate tissue perfusion The nurse applies a Nitro-Dur patch on a client who has undergone cardiac surgery. What nursing observation indicates that a Nitro-Dur patch is achieving the desired effect? a. Chest pain is completely relieved b. Client performs activities of daily living without chest pain c. Pain is controlled with frequent changes of patch d. Client tolerates increased activity without pain - answer>>. Client performs activities of daily living without chest pain The V/S of a client with Cardiac disease are as follows: BP 102/76 mm/hg, Pulse 52, RR 16. Atropine is administered IV push. What nursing assessment indicates a therapeutic response to the medication? A. Pulse rate has increased to 70 beats/min B. systolic BP has increased by 20 C. pupils are dilated D. oral secretions have decreased - answer>>A. Pulse rate has increased to 70 beats/min An older adult client comes into ER stating that he has no appetite, is nauseated, his heart feels funny and has noticed a haziness in his vision. The client states that he has been taking an antihypertensive drug and digitalis for more than a year. Based on the presenting symptoms, what would be the priority nursing action? A. Obtain an order for an EKG and serum potassium and digitalis levels B. Perform a neurological assessment to determine whether he has one side weakness. C. Assess lungs for decreased breath sounds and/or adventitious breath sounds. d. Obtain an order for an EKG - answer>>A. Obtain an order for an EKG and serum potassium and digitalis levels the nurse is administering alteplase to a client who has been diagnosed with acute coronary syndrome. What are important nursing implications for this medication? A. Monitor the ECG for dysrthymias B. Place the client on bleeding precautions C. monitor urine output hourly D. Monitor for activity tolerance - answer>>B. Place the client on bleeding precautions The nurse is caring for a client who underwent cardiac catheterization 1 hour ago. What is an important nursing measure at this time? A. Measure urinary output hourly and maintain continuous cardiac monitoring B. Encourage client to perform slow pressure exercise of the affected side to promote circulation. C. Maintain pressure over catheter insertion site and determine distal circulation status. D. Evaluate apical pulse and determine presence of pulse deficit - answer>>C. Maintain pressure over catheter insertion site and determine distal circulation status. 65. When teaching a client about the expected outcomes after intravenous