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Download Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest do and more Exams Nursing in PDF only on Docsity! Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download GRADED A+ lOMoARcPSD| 10446529 An ER nurse is completing an assessment on a patient that is alert but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened. What additional clinical manifestation does the nurse expect to find if nacy's sysmptoms have been caused by a brain attack (stroke)? A. A carotid B. A hypotensive blood pressure C. hyperreflexic deep tendon relexes. D. Decreased bowel sounds A) A carotid bruit. Rationale: the carotid artery (artery to the brain) is narrowed in clients with a brain attack. A bruit is an abnormal sound heard on auscultation resulting from interference with normal blood flow. Usually the blood pressure is hypertensive. Initially flaccid paralysis occurs, resulting in hyporefkexic deep tendon reflexes. Bowel sounds are not indicative of a Nursing MED SURG guide Questions & Answers best exam solution guaranteed B) Explain that the client will not be able to move her head Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 should the nurse implement? A) Determine if the client has any allergies to iodine scan. C) Premedicate the client to decrease pain prior to having the procedure. D) Provide an explanation of relaxation exercises prior to the procedure. B)Explain that the client will not be able to move her head throughout the CT scan. Rationale: Because head motion will distort the images, Nancy will have to remain still throughout the procedure. Allergies to iodine is important if contrast dye is being used for the CT scan. Premedicating the client to decrease pain prior to the procedure is unnecessary because CT scanning is a noninvasive and painless procedure. Providing an explanation of relaxation exercises prior to the procedure is a worthwhile intervention to decrease anxiety but is not of highest priority. Nursing MED SURG guide Questions & Answers best exam solution guaranteed Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 informed decisions. The nurse has the knowledge, and the responsibility, to explain Nancy's condition to Gail. The nurse should give facts first, and then address her feelings after the information is provided. ⒸⒸ What is the normal range for cardiac output? The normal range for cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to 8 L/min. A client was admitted with the diagnosis of a brain attack. Their symptoms began 24 hours before being admitted. Why would this client not be a candidate for for thrombolytic therapy? Thrombolytic therapy is contraindicated in clients with symptom onset longer than 3 hours prior to admission. This client had symptoms for 24 hours before being brought to the medical center ⒸⒸ What are plate guards? Plate guards prevent food from being pushed off the Nursing MED SURG guide Questions & Answers best Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 exam solution guaranteed success latest download B) PT reported client complained of Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 performing active range of motion exercises would address the client's risk for immobility due to paralysis. ⒸⒸ A physical therapist (PT) places a gait belt on a client and is assisting them with ambulation from the bed to the chair. As they get up out of the bed, they report being dizzy and begin to fall. The PT carefully allows them to fall back to the bed and notifies the primary nurse. Which written documentation should the nurse put in the client's record? A) Client experienced orthostatic hypotension when getting out of bed. getting out of bed, and gait belt was used to allow client to fall back onto the bed. C) PT notified the primary nurse that the client could not ambulate at this time because of dizziness. D) Client had difficulty ambulating from the bed to Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 the chair when accompanied by the PT, variance report completed. B) PT reported client complained of dizziness when getting out of bed, and gait belt was used to allow client to fall back onto the bed. Rationale: This documentation provides the factual data of the events that occurred. A)The nurse is making an assumption that the dizziness was caused by orthostatic hypotension. C) Not all the pertinent facts are included in this documentation. D) A variance report should never be documented in the client's record. ⒸⒸ A new nurse graduate is caring for a postoperative client with the following arterial blood gases (ABGs): pH, 7.30; PCO2, 60 mm Hg; PO2, 80 mm Hg; bicarbonate, 24 mEq/L; and O2 saturation, 96%. Which of these actions by the new graduate is indicated? A) Encourage the client to use the incentive spirometer and to cough. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s A) Encourage the client to use the incentive spirometer and to cough. Rationale: Respiratory acidosis is caused by CO2 retention and impaired chest expansion secondary to anesthesia. The nurse takes steps to promote CO2 elimination, including maintaining a patent airway and expanding the lungs through breathing techniques. O2 is not indicated because Po2 and oxygen saturation are within the normal range. Sodium bicarbonate is not indicated because the bicarbonate level is in the normal range; promoting excretion of respiratory acids is the priority in respiratory acidosis. Post anesthesia, the client will need interventions as described in A above or may progress to a state of somnolence and unresponsiveness. The nurse is providing dietary instructions to a 68-year- old client who is at high risk for development of coronary heart disease (CHD). Which information should the nurse include? A) Limit dietary selection of cholesterol to 300 mg per day Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s Rationale: Splints may be used at night by clients with rheumatoid arthritis to prevent deformities (A) caused by muscle spasms and contractures. Splints are not used for (B). (C) is usually treated with medications, particularly those classified as non- steroidal antiinflammatory drugs (NSAIDs). For (D), a prescribed exercise program is indicated. A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints? A) Frequent urinary tract infections. B) Inability to get pregnant. C) Premenstrual syndrome. D) Chronic use of laxatives. B) Inability to get pregnant. Rationale: Dysmenorrhea, dyspareunia, and difficulty or painful defecation are common symptoms of Nursing MED SURG guide Questions & Answers best exam solution guaranteed Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s endometriosis, which is the abnormal displacement of endometrial tissue in the dependent areas of the pelvic peritoneum. A history of infertility (B) is another common finding associated with endometriosis. Although (A, C, and D) are common, nonspecific gynecological complaints, the most common complaints of the client with endometriosis are pain and infertility. A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? A) Dyspnea. B) Nocturia. C) Confusion. D) Stomatitis. B) Nocturia. Rationale: As the glomerular filtration rate decreases in early renal insufficiency, metabolic waste products, Nursing MED SURG guide Questions & Answers best Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s loop diuretic, causes bradycardia. (D) is a sympathomimetic, direct acting cardiac stimulant, which would increase the heart rate. A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse? A) White blood count of 10,000 mm3. B) Serum glucose of 115 mg/dl. C) Purulent sputum. D) Excessive hunger. C) Purulent sputum. Rationale: Steroids cause immunosuppression, and a purulent sputum (C) is an indication of infection, so this symptom is of greatest concern. Oral steroids may increase (A) and often cause (D). (B) may remain normal, borderline, or increase while taking oral steroids. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s A female client receiving IV vasopressin (Pitressin) for esophageal varice rupture reports to the nurse that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse initiate? A) Start an IV nitroglycerin infusion. B) Nasogastric lavage with cool saline. C) Increase the vasopressin infusion. D) Prepare for endotracheal intubation. A) Start an IV nitroglycerin infusion. Rationale: Vasopressin is used to promote vasoconstriction, thereby reducing bleeding. Vasoconstriction of the coronary arteries can lead to angina and myocardial infarction, and should be counteracted by IV nitroglycerin per prescribed protocol (A). (B) will not resolve the cardiac problem. (C) will worsen the problem. Endotracheal intubation may be needed if respiratory distress occurs (D). A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which Nursing MED SURG guide Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s C) Polydipsia, polyuria. D) Hypernatremia, tachypnea. A) Loss of thirst, weight gain. Rationale: SIADH occurs when the posterior pituitary gland releases too much ADH, causing water retention, a urine output of less than 20 ml/hour, and dilutional hyponatremia. Other indications of SIADH are loss of thirst, weight gain (A), irritability, muscle weakness, and decreased level of consciousness. (B) is not associated with SIADH. (C) is a finding associated with diabetes insipidus (a water metabolism problem caused by an ADH deficiency), not SIADH. The increase in plasma volume causes an increase in the glomerular filtration rate that inhibits the release of rennin and aldosterone, which results in an increased sodium loss in urine, leading to greater hyponatremia, not (D). The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning Nursing MED SURG guide Questions & Answers best Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s the teaching session? A) Present knowledge related to the skill of injection. B) Intelligence and developmental level of the client. C) Willingness of the client to learn the injection sites. D) Financial resources available for the equipment. C) Willingness of the client to learn the injection sites. Rationale: If a client is incapable or does not want to learn, it is unlikely that learning will occur, so motivation is the first factor the nurse should assess before teaching (C). To determine learning needs, the nurse should assess (A), but this is not the most important factor for the nurse to assess. (B and D) are factors to consider, but not as vital as (C). The nurse is caring for a client who has taken a large quantity of furosemide (Lasix) to promote weight loss. The nurse anticipates the finding of which acid-base imbalance? Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s system and manifests as a flight-or-fight response, which includes an increase in heart rate (B). (A, C, and D) are responses of the parasympathetic nervous system. Which client should the nurse recognize as most likely to experience sleep apnea? A) Middle-aged female who takes a diuretic nightly. B) Obese older male client with a short, thick neck. C) Adolescent female with a history of tonsillectomy. D) School-aged male with a history of hyperactivity disorder. B) Obese older male client with a short, thick neck. Rationale: Sleep apnea is characterized by lack of respirations for 10 seconds or more during sleep and is due to the loss of pharyngeal tone which allows the pharynx to collapse during inspiration and obstructs air flow through the nose and mouth. With obstructive sleep apnea, the client is often obese or has a short, thick neck as in (B). (A, C, and D) are not typically prone to sleep apnea. To decrease the risk of acid-base imbalance, what goal Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s must the client with diabetes mellitus strive for? A) Checking blood glucose levels once daily B) Drinking 3 L of fluid per day C) Eating regularly, every 4 to 8 hours D) Maintaining blood glucose level within normal limits D) Maintaining blood glucose level within normal limits Rationale: Maintaining blood glucose levels within normal limits is the best way to decrease the risk of acid- base imbalance. A) Blood glucose levels must be checked several times a day. B) Drinking 3 L of fluid per day is not necessary to maintain acid-base balance. C) Eating regularly is a way to achieve acid-base balance but is not the goal itself. After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to determine peak and trough levels. When are the best times to draw these samples? A) 15 minutes before and 15 minutes after the next dose. B) One hour before and one hour after the next dose. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s C) 5 minutes before and 30 minutes after the next dose. D) 30 minutes before and 30 minutes after the next dose. C) 5 minutes before and 30 minutes after the next dose. Rationale: Peak drug serum levels are achieved 30 minutes after IV administration of aminoglycosides. The best time to draw a trough is the closest time to the next administration (C). (A, B, and D) are not as good a time to draw the trough as (C). (B and D) are not the best times to draw the peak of an aminoglycoside that has been administered IV. The nurse is caring for a client with an oxygen saturation of 88% and accessory muscle use. The nurse provides oxygen and anticipates which of these physician orders? A) Administration of IV sodium bicarbonate B) Computed tomography (CT) of the chest, stat C) Intubation and mechanical ventilation D) Administration of concentrated potassium chloride solution C) Intubation and mechanical ventilation Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s D) Elimination of hazards to home safety. Rationale: Discussion about fall prevention strategies is imperative for the discharged client with osteoporosis so that advice about safety measures can be given (D). A low phosphorus diet is not recommended in the treatment of osteoporosis (A). Bruising (B) is not a related symptom to osteoporosis. Weight-bearing exercise is most beneficial for clients with osteoporosis. Swimming (C) is not a weight- bearing exercise. During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. What should be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope? A) This is a normal auscultatory finding. B) May indicate pneumothorax. C) May indicate pneumonia. D) May indicate severe emphysema. Nursing MED SURG guide Questions & Answers best exam solution guaranteed Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s C) May indicate pneumonia. Rationale: This test (whispered pectoriloquy) demonstrates hyperresonance and helps determine the clarity with which spoken words are heard upon auscultation. Normally, the spoken word is not well transmitted through lung tissue, and is heard as a muffled or unclear transmission of the spoken word. Increased clarity of a spoken word is indicative of some sort of consolidation process (e.g., tumor, pneumonia) (C), and is not a normal finding (A). When lung tissue is filled with more air than normal, the voice sounds are absent or very diminished (e.g., pneumothorax, severe emphysema) (B and D). The nurse is caring for a group of clients with acidosis. The nurse recognizes that Kussmaul respirations are consistent with which situation? A) Client receiving mechanical ventilation B) Use of hydrochlorothiazide C) Aspirin overdose Nursing MED SURG guide Questions & Answers best exam solution guaranteed Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s A) Long-term relationships with healthcare providers are more likely. B) There are fewer healthcare providers to choose from than in an HMO plan. C) Insurance coverage of employees is less expensive to employers. D) An individual can become a member of a PPO without belonging to a group. C) Insurance coverage of employees is less expensive to employers. Rationale: The financial advantage of (C) is the feature of a PPO that is most relevant to the average consumer. The nurse must have knowledge about PPOs, which provide discounted rates to large employers who provide insurance coverage for their employees. In return, the insurance company receives a large pool of clients for their facilities. (A, B, and D) are not accurate representations of the PPO. A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing function is of greatest importance to this client? Assess the client's Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s A) pulse rate, both apically and radially. B) blood pressure, both standing and sitting. C) temperature. D) skin color and turgor. C) temperature. Rationale: It is very important to check the client's temperature (C). Infection is the most common factor precipitating respiratory distress. Clients with COPD who are on maintenance doses of corticosteroids are particularly predisposed to infection. (A and B) are important data for baseline and ongoing assessment, but they are not as important as temperature measurement for this client who is taking steroids. Assessment of skin color and turgor is less important (D). The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply.) 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D) His wife expresses a sincere willingness to prepare meals that are within his prescribed diet. A) He visits his diabetic brother who just had surgery to amputate an infected foot. Rationale: The loss of a limb by a family member (A) will be the strongest event or "cue to action" and is most likely to increase the perceived seriousness of the disease. (B, C, and D) may influence his behavior but do not have the personal impact of (A). Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What action should the nurse implement? A) Determine if the client has also experienced breast tenderness and weight gain. B) Encourage the client to begin a regular, daily program of walking and exercise. C) Advise the client to notify the healthcare provider for immediate medical attention. D) Tell the client to stop taking the medication for a week to see if symptoms subside. C) Advise the client to notify the healthcare provider for immediate medical attention. Rationale: Calf pain is indicative of thrombophlebitis, a serious, life- threatening complication associated with the use of oral contraceptives which requires further assessment and possibly immediate medical intervention (C). (A) are symptoms of oral contraceptive use, but are of less immediacy than (C). (B) may cause an embolism if Nursing MED SURG guide Questions & Answers best exam solution guaranteed Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s demonstrate client understanding and compliancy but is not the most important aspect. The nurse knows that lab values sometimes vary for the older client. Which data should the nurse expect to find when reviewing laboratory values of an 80-year-old male? A) Increased WBC, decreased RBC. B) Increased serum bilirubin, slightly increased liver enzymes. 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C)Episodes of vaginal bleeding. Rationale: Postmenopausal vaginal bleeding (C) may be an indication of endometrial cancer, which should be reported to the healthcare provider. Compared to a new- onset of a single lump, breasts that feel lumpy (A) overall Nursing MED SURG guide Questions & Answers best exam solution guaranteed Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s does not require (A). Although (B) is information that should be considered, it does not have the priority of (D). (C) is used to drain fluid from a dead space and is not important in choosing a room. A patient admitted for a head injusry develops dry skin and urine output of 600 mL/hr. Which of the following interventions should the nurse perform first? a) Assess the patient's urine specific gravity b) Slow IV fluid infusion rate c) Assess the patient's level of conciousness d) Notify the physician a)Assess the patient's urine specific gravity Ratoinale: A urine output of 400 mL/hr after sustaining a head injury may be indictative of diabetes insipidus. The nurse should assess for low specific gravity and elevated serum osmolarity. -Diabetes insipidus is the failure to produce antidiuretic hormone due to damage to the pituitary gland from increased ICP. 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D) An electrical stimulus is discharged when no ventricular response is sensed. D) An electrical stimulus is discharged when no ventricular response is sensed. The artificial cardiac pacemaker is an electronic device used to pace the heart when the normal conduction pathway is damaged or diseased, such as a symptomatic dysrhythmias like atrial fibrillation with a slow ventricular response. Pacing modes that are Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s synchronous (impulse generated on demand or as needed according to the patient's intrinsic rhythm) send an electrical signal from the pacemaker to the wall of the myocardium stimulating it to contract when no ventricular depolarization is sensed (D). (A, B, and C) do not provide accurate information. The unlicensed assistive personnel (UAP) reports that an 87-year-old female client who is sitting in a chair at the bedside has an oral temperature of 97.2° F. Which intervention should the nurse implement? A) Document the temperature reading on the vital sign graphic sheet. B) Report the temperature to the healthcare provider immediately. C) Instruct the UAP to take the client's temperature again in 30 minutes. D) Advise the UAP to assist the client in returning to her bed. A) Document the temperature reading on the vital sign graphic sheet. A subnormal temperature of 97.2° F (orally) is a common finding in elderly clients, so the nurse should document the findings (A) and continue with the plan of care. (B, C, and D) are not indicated unless the temperature falls Nursing MED SURG guide Questions & Answers best Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s abdomen. What technique should the nurse perform next in the abdominal examination? A) Percussion. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s B) Auscultation. C) Deep palpation. D) Light palpation. B) Auscultation. Auscultation (B) of the client's abdomen is performed next because manual manipulation (A, C, and D) can stimulate the bowel and create false sounds heard during auscultation. A client who has just tested positive for human immunodeficiency virus (HIV) does not appear to hear what the nurse is saying during post- test counseling. Which information should the nurse offer to facilitate the client's adjustment to HIV infection? A) Inform the client how to protect sexual and needle-sharing partners. B) Teach the client about the medications that are available for treatment. C) Identify the need to test others who have had risky contact with the client. D) Discuss retesting to verify the results, which will ensure continuing contact. D) Discuss retesting to verify the results, which will ensure continuing Nursing MED SURG guide Questions & Answers best Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s is a continuous high-pitched squeaking or musical sound caused by rapid vibration of bronchial walls that are first evident on expiration and may be audible. Although (C) describes an adventitious lung sound, this documentation is vague. (D) is a creaking or grating sound from roughened, inflamed surfaces of the pleura rubbing together heard during inspiration, expiration, and with no change during coughing. A client asks the nurse about the purpose of beginning chemotherapy (CT) because the tumor is still very small. Which information supports the explanation that the nurse should provide? A) Side effects are less likely if therapy is started early. B) Collateral circulation increases as the tumor grows. C) Sensitivity of cancer cells to CT is based on cell cycle rate. D) The cell count of the tumor reduces by half with each dose. D) The cell count of the tumor reduces by half with each dose. Initiating chemotherapy while the tumor is small provides a better chance of eradicating all cancer cells Nursing MED SURG guide Questions & Answers best Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s assesses for infection, not risk for bleeding. The nurse is caring for a client with end stage liver disease who is being assessed for the presence of asterixis. To assess the client for asterixis, what position should the nurse ask the client to demonstrate? A) Extend the left arm laterally with the left palm upward. B) Extend the arm, dorsiflex the wrist, and extend the fingers. C) Extend the arms and hold this position for 30 seconds. D) Extend arms with both legs adducted to shoulder width. B) Extend the arm, dorsiflex the wrist, and extend the fingers. Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen frequently in hepatic encephalopathy. The tremor is induced by extending the arm and dorsiflexing the wrist causing rapid, non- rhythmic extension and flexion of the wrist while attempting to hold position (B). (A, C, and D) do not illicit axterixis. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s During the assessment of a client who is 24 hours post- hemicolectomy with a temporary colostomy, the nurse determines that the client's stoma is dry and dark red in color. What action should the nurse implement? A) Notify the surgeon. B) Document the assessment. C) Secure a colostomy pouch over the stoma. D) Place petrolatum gauze dressing over the stoma. A) Notify the surgeon. The stoma should appear reddish pink and moist, which indicates circulatory perfusion to the surgical diversion of the intestine. If the stoma becomes dry, firm, flaccid, or is dark red or purple, the stoma is ischemic, and the surgeon should be notified immediately (A). Although (B, C, and D) may be implemented, the findings require immediate medical attention. What assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is Nursing MED SURG guide Questions & Answers best exam solution guaranteed Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s exam solution guaranteed success latest download Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s Which method elicits the most accurate information during a physical assessment of an older client? A) Ask the client to recount one's health history. B) Obtain the client's information from a caregiver. C) Review the past medical record for medications. D) Use reliable assessment tools for older adults. D) Use reliable assessment tools for older adults. Specific assessment tools (D) for an older adult, such as Older Adult Resource Services Center Instrument (OARS), mini- mental assessment, fall risk, depression (Geriatric Depression Scale), or skin breakdown risk (Braden Scale), consider age-related physiologic and psychosocial changes related to aging and provide the most accurate and complete information. (A and B) are subjective and may vary in reliability based on the client's memory and caregiver's current involvement. Although (C) is a good resource to identify polypharmacy, a written record may not be available or currently accurate. 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Sexual intercourse after an MI, or acute coronary syndrome, has been found to require no more energy expenditure or cardiac stress than walking briskly up two flights of stairs (D), as long as other guidelines, such as limiting food and alcohol intake before intercourse, are followed. (A, B, and C) do not provide the best factual information to reduce the client's anxiety and misconceptions. An 85-year-old male client comes to the clinic for his annual physical exam and renewal of antihypertensive medication prescriptions. The client's radial pulse rate is 104 beats/minute. Which additional assessment should the nurse complete? A) Palpate the pedal pulse volume. B) Count the brachial pulse rate. C) Measure the blood pressure. Nursing MED SURG guide Questions & Answers best exam solution guaranteed Stuvia. - The e o Buy and Sell Study lOMoARcPSD| 10446529 Nursing MSEtuvDia.comS- ThUe MRarkeGtplace togBuyuanid dSell eyour SQtudyuMaeteriasl & Answers best tion s success latest download