Nursing Care and Patient Management Scenarios, Exams of Nursing

Download Nursing Care and Patient Management Scenarios and more Exams Nursing in PDF only on Docsity! NURSING CLINICALS Med Surg Unit Review Exam Q & A 2024 1. A patient with chronic obstructive pulmonary disease (COPD) is admitted to the Med Surg Unit with acute respiratory failure. The nurse is preparing to administer oxygen therapy as prescribed by the physician. Which of the following actions should the nurse take first? A) Assess the patient's oxygen saturation level and respiratory rate. B) Apply a nasal cannula or a face mask to deliver oxygen. C) Adjust the oxygen flow rate to achieve the desired oxygen saturation level. D) Monitor the patient for signs of oxygen toxicity or carbon dioxide retention. Answer: A Rationale: The nurse should assess the patient's oxygen saturation level and respiratory rate before initiating oxygen therapy to determine the baseline status and the need for oxygen. Oxygen therapy can have adverse effects such as oxygen toxicity or carbon dioxide retention, so the nurse should monitor the patient closely and adjust the oxygen flow rate accordingly. Applying a nasal cannula or a face mask is an appropriate action, but not the first one. 2. A patient with type 2 diabetes mellitus is scheduled for a coronary artery bypass graft (CABG) surgery. The nurse is reviewing the patient's preoperative orders and notes that the patient is prescribed metformin, a biguanide antidiabetic agent. Which of the following actions should the nurse take? A) Administer the metformin as ordered on the day of surgery. B) Hold the metformin on the day of surgery and resume it after surgery. C) Hold the metformin for 48 hours before and after surgery. D) Discontinue the metformin permanently and switch to insulin therapy. Answer: C Rationale: Metformin can cause lactic acidosis, a potentially fatal complication, especially in patients with renal impairment or hypoxia. CABG surgery can increase the risk of these conditions, so the nurse should hold the metformin for 48 hours before and after surgery to prevent lactic acidosis. The nurse should resume the metformin after ensuring normal renal function and adequate tissue perfusion. Administering, holding, or discontinuing the metformin on the day of surgery are not appropriate actions. A) Monitoring for signs of bleeding B) Encouraging the patient to ambulate C) Administering the anticoagulant as prescribed D) Applying warm compresses to the affected area Answer: A) Monitoring for signs of bleeding Rationale: Anticoagulant therapy increases the risk of bleeding, so regular monitoring for signs of bleeding is essential to prevent complications. 6. A nursing student is caring for a patient with chronic kidney disease who is receiving hemodialysis. What is the priority nursing intervention to ensure the patient's safety during dialysis? A) Monitoring for signs of infection B) Assessing for signs of fluid overload C) Monitoring vital signs every 15 minutes D) Administering IV medications as prescribed Answer: C) Monitoring vital signs every 15 minutes Rationale: Regular monitoring of vital signs during hemodialysis is essential to detect any changes in the patient's condition and prevent complications. 7. A nursing student is caring for a patient with a fractured hip who is scheduled for surgery. What is the priority nursing intervention in the preoperative period? A) Administering pain medication B) Applying a warm blanket C) Ensuring NPO status D) Encouraging deep breathing exercises Answer: C) Ensuring NPO status Rationale: NPO status is essential prior to surgery to reduce the risk of aspiration during anesthesia. 8. A nursing student is caring for a patient with pancreatitis who is experiencing severe abdominal pain. What is the priority nursing intervention to manage the patient's pain? A) Administering antacids B) Providing a heating pad C) Administering IV pain medication D) Encouraging the patient to drink water Answer: C) Administering IV pain medication Rationale: Severe abdominal pain in pancreatitis requires prompt and aggressive pain management with IV medications. 9. A nursing student is caring for a patient with a pulmonary embolism who is receiving oxygen therapy. What is the priority nursing intervention to improve oxygenation? A) Administering bronchodilators B) Assisting the patient to cough and deep breathe C) Applying oxygen via nasal cannula D) Elevating the head of the bed Answer: B) Assisting the patient to cough and deep breathe Rationale: Coughing and deep breathing exercises help improve oxygenation by clearing secretions and increasing lung expansion. 10. A nursing student is caring for a patient with cirrhosis who is experiencing ascites. What is the priority nursing intervention to manage the patient's fluid balance? A) Administering diuretics B) Monitoring daily weights C) Restricting fluid intake D) Encouraging the patient to ambulate Answer: A) Administering diuretics Rationale: Diuretics are commonly used to manage ascites in patients with cirrhosis by promoting fluid excretion. 11. A nursing student is caring for a patient with a urinary tract infection (UTI) who is experiencing dysuria and frequency. What is the priority nursing intervention? A) Encouraging the patient to drink cranberry juice B) Administering antibiotics as prescribed C) Applying a warm compress to the abdomen D) Monitoring intake and output Answer: B) Administering antibiotics as prescribed Rationale: UTIs are commonly treated with antibiotics to eradicate the infection and relieve symptoms. 12. A nursing student is caring for a patient with a traumatic brain injury who is at risk for increased intracranial pressure (ICP). What is the priority nursing intervention to prevent complications? A) Monitoring neurologic status B) Administering antiseizure medications C) Elevating the head of the bed D) Administering IV fluids Answer: A) Monitoring neurologic status Rationale: Regular assessment of neurologic status helps detect early signs of increased ICP and prevent complications in patients with traumatic brain injury. 13. A nursing student is caring for a patient with a pressure ulcer on the sacrum. What is the priority nursing intervention in wound care? A) Applying a sterile dressing B) Cleaning the wound with saline solution C) Turning the patient every 2 hours D) Applying a hydrocolloid dressing Answer: B) Cleaning the wound with saline solution Rationale: Gentle cleansing of the wound with saline solution helps promote healing by removing debris and bacteria. 14. A nursing student is caring for a patient with heart failure who is experiencing edema in the lower extremities. What is the priority nursing intervention to manage the patient's fluid balance? A) Administering IV diuretics B) Elevating the legs C) Applying compression stockings D) Monitoring daily weights d) Take the medication with a high-fat meal for better absorption Answer: b) Change positions slowly to prevent orthostatic hypotension Rationale: ACE inhibitors can cause orthostatic hypotension, and patients should be educated on the importance of changing positions slowly to prevent dizziness and falls. A patient with a lower leg cast reports severe pain, pallor, and lack of pulse in the affected extremity. The nurse's immediate action should be to: a) Elevate the affected leg b) Apply ice to the casted area c) Remove the cast to assess the extremity d) Administer an analgesic Answer: c) Remove the cast to assess the extremity Rationale: The patient's symptoms are indicative of compartment syndrome, a serious complication that requires immediate assessment and intervention to prevent tissue damage and neurovascular compromise. A patient with chronic kidney disease is prescribed a low-protein diet. The nurse should educate the patient about the importance of restricting which of the following nutrients? a) Sodium b) Potassium c) Phosphorus d) Calcium Answer: c) Phosphorus Rationale: Patients with chronic kidney disease are at risk for hyperphosphatemia, and restricting dietary phosphorus intake is essential to prevent further kidney damage and mineral imbalances. A patient with cirrhosis presents with ascites. The nurse should prioritize which of the following interventions to manage the patient's ascites? a) Administering spironolactone b) Monitoring serum albumin levels c) Initiating paracentesis d) Encouraging increased fluid intake Answer: a) Administering spironolactone Rationale: Spironolactone is a potassium-sparing diuretic commonly used to manage ascites in patients with cirrhosis by promoting diuresis and reducing fluid retention. A postoperative patient is receiving patient-controlled analgesia (PCA) with morphine for pain management. The nurse should monitor the patient for which of the following adverse effects associated with opioid analgesics? a) Hypertension b) Tachypnea c) Urinary retention d) Bradycardia Answer: c) Urinary retention Rationale: Opioid analgesics can cause urinary retention due to their effects on the central nervous system and should be closely monitored in patients receiving PCA. A patient with chronic obstructive pulmonary disease (COPD) is prescribed home oxygen therapy. The nurse should educate the patient to: a) Use oxygen during mealtimes to improve oxygenation b) Store extra oxygen tanks in a cool, dry place c) Avoid smoking while using oxygen d) Increase oxygen flow rate when experiencing shortness of breath Answer: c) Avoid smoking while using oxygen Rationale: Smoking while using oxygen can lead to a fire hazard, and patients should be educated about the importance of smoking cessation while on oxygen therapy. A patient with a history of deep vein thrombosis (DVT) is receiving warfarin (Coumadin) therapy. The nurse should monitor the patient's international normalized ratio (INR) to assess: a) Platelet function b) Coagulation status c) Fibrinolytic activity d) Red blood cell count Answer: b) Coagulation status Rationale: The INR is a measure of the patient's coagulation status and is used to monitor the effectiveness and safety of warfarin therapy in preventing thromboembolic events. A patient with chronic heart failure is prescribed digoxin. The nurse should monitor the patient for which of the following signs of digoxin toxicity? a) Hypotension b) Bradycardia c) Visual disturbances d) Hyperkalemia Answer: c) Visual disturbances Rationale: Digoxin toxicity can manifest as visual disturbances, including blurred or yellow-tinted vision, and should be promptly reported to the healthcare provider. A patient is admitted with a suspected myocardial infarction. The nurse should prioritize which of the following interventions for the patient? a) Administering aspirin b) Initiating thrombolytic therapy c) Obtaining a 12-lead electrocardiogram (ECG) d) Monitoring cardiac enzymes Answer: c) Obtaining a 12-lead electrocardiogram (ECG) Rationale: Obtaining a 12-lead ECG is a critical intervention in the early assessment of myocardial infarction to evaluate for ST-segment changes and guide further management. A patient with end-stage renal disease is receiving hemodialysis. The nurse should monitor the patient for which of the following complications during hemodialysis? a) Hypernatremia b) Hypokalemia c) Hypotension d) Hyperglycemia Answer: c) Hypotension Rationale: Hypotension is a common complication during hemodialysis due to rapid fluid removal and shifts, and patients should be closely monitored for signs of hypotension during the procedure. A patient with a history of peptic ulcer disease is prescribed pantoprazole, a proton pump inhibitor (PPI). The nurse should educate the patient about the potential adverse effect of long-term PPI use, which is: