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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! lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download GRADED A+ 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 bruit 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. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download GRADED A+ Usually the blood pressure is hypertensive. Initially flaccid paralysis occurs, resulting in hyporefkexic deep tendon reflexes. Bowel sounds are not indicative of a brain attack. Which clinical manifestation further supports an assessment of a left-sided brain attack? A)Visual field deficit on the left side. B)Spatial-perceptual deficits. C)Paresthesia of the left side. D)Global aphasia. D) Global aphasia. Rationale: Global aphasia refers to difficulty speaking, listening, and understanding, as well as difficulty reading and writing. Symptoms vary from person to person. Aphasia may occur secondary to any brain injury involving the left hemisphere. Visual field deficits, spatial- Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download  lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download GRADED A+ D)History of atrial fibrillation. C) Right hip replacement. The magnetic field generated by the MRI is so strong that metal-containing items are strongly attracted to the magnet. Because the hip joint is made of metal, a lead shield must be used during the procedure. Elevated blood pressure, an allergy to shell fish, and a history of atrial fibrillation would not affect the MRI. A client's daughter is sitting by her mother's bedside who was recently transferred to the Intermediate Care Unit. She states "I don't understand what a brain attack is. The healthcare provider told me my mother is in serious condition and they are going to run several tests. I just don't know what is going on. What happened to my mother?" What is the best Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download  lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download GRADED A+ response by the nurse? A)"I am sorry, but according to the Health Insurance Portability and Accounting Act (HIPAA), I cannot give you any information." B)"Your mother has had a stroke, and the blood supply to the brain has been blocked." C)"How do you feel about what the healthcare provider said?" D)"I will call the healthcare provider so he/she can talk to you about your mother's serious condition." B) "Your mother has had a stroke, and the blood supply to the brain has been blocked." Rationale: The nurse can discuss what a diagnosis means. Nancy is unable to make decisions, so the next of kin, her daughter, Gail, needs sufficient information to make informed decisions. The nurse has the knowledge, and the Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download GRADED A+ 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 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download   lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download GRADED A+ paralyzed side. This results in the client neglecting that side of the body, so it is beneficial to place objects on that side. Nancy had a left-hemisphere brain attack so her right side is the weak side. Speaking slowly and clearly would address the client's verbal deficits due to aphasia. Requesting all liquids to be thickened would address dysphagia. Turning the client every 2 hours and 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 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download  lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download GRADED A+ 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. 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. 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 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. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download GRADED A+ 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. B)Administer oxygen by nasal cannula. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download  lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download GRADED A+ Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download GRADED A+ Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download 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 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download A) Prevention of deformities. 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. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download B) Inability to get pregnant. Rationale: Dysmenorrhea, dyspareunia, and difficulty or painful defecation are common symptoms of 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. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download B)Nocturia. C)Confusion. D)Stomatitis. B) Nocturia. Rationale: As the glomerular filtration rate decreases in early renal insufficiency, metabolic waste products, including urea, creatinine, and other substances, such phenols, hormones, electrolytes, accumulate in the blood. In the early stage of renal insufficiency, polyuria results from the inability of the kidneys to concentrate urine and contribute to nocturia (B). (A, C, and D) are more common in the later stages of renal failure.  A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's medication record. Which medication is most likely the cause of the bradycardia? Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download 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 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download occurs (D).  A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client? A)Losing weight. B)Decreasing caffeine intake. C)Avoiding large meals. D)Raising the head of the bed on blocks. D) Raising the head of the bed on blocks. Rationale: Raising the head of the bed on blocks (D) (reverse Trendelenburg position) to reduce reflux and subsequent aspiration is the most effective recommendation for a client experiencing severe gastroesophageal reflux during sleep. (A, B and C) may be effective recommendations but raising the head of the bed is more effective for relief during sleep.  Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH), which is manifested by which symptoms? A)Loss of thirst, weight gain. B)Dependent edema, fever. 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 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download not consistent with diuretic use. D) pH of 7.31: This pH is acidotic; diuretics promote metabolic alkalosis.  The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus. Which signs and symptoms should the nurse describe when teaching the client about hypoglycemia? A)Sweating, trembling, tachycardia. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download B)Polyuria, polydipsia, polyphagia. C)Nausea, vomiting, anorexia. D)Fruity breath, tachypnea, chest pain. A) Sweating, trembling, tachycardia. Rationale: Sweating, dizziness, and trembling are signs of hypoglycemic reactions related to the release of epinephrine as a compensatory response to the low blood sugar (A). (B, C, and D) do not describe common symptoms of hypoglycemia.  Which reaction should the nurse identify in a client who is responding to stimulation of the sympathetic nervous system? A)Pupil constriction. B)Increased heart rate. C)Bronchial constriction. D)Decreased blood pressure. B) Increased heart rate. Rationale: Any stressor that is perceived as Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download threatening to homeostasis acts to stimulate the sympathetic nervous 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 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download 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 Rationale: Support with mechanical ventilation may be needed for clients who cannot keep their oxygen saturation at 90% or who have respiratory muscle fatigue. A) Sodium bicarbonate is used to treat metabolic acidosis; this client displays hypoxemia. B) Although the underlying reason for this client's hypoxemia may eventually require a diagnostic study, the priority is to restore oxygenation. D)No indication suggests that this client has hypokalemia. Signs of hypoxemia and work Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download of breathing are present, requiring correction with intubation and mechanical ventilation.  A male client receives a local anesthetic during surgery. During the post-operative assessment, the nurse notices the client is slurring his speech. Which action should the nurse take? A)Determine the client is anxious and allow him to sleep. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download B)Evaluate his blood pressure, pulse, and respiratory status. C)Review the client's pre-operative history for alcohol abuse. D)Continue to monitor the client for reactivity to anesthesia. B) Evaluate his blood pressure, pulse, and respiratory status. Rationale: Slurred speech in the post-operative client who received a local anesthetic is an atypical finding and may indicate neurological deficits that require further assessment, so obtaining the client's vital signs (B) will provide information about possible cardiovascular complications, such as stroke. The client's anxiety (A), a history of alcohol abuse (D), or local anesthesia (D) are unrelated to the client's sudden onset of slurred speech.  When providing discharge teaching for a client with osteoporosis, the nurse should reinforce which home care activity? A)A diet low in phosphates. B)Skin inspection for bruising. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download 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 D)Administration of sodium bicarbonate C) Aspirin overdose Rationale: If acidosis is metabolic in origin, the rate and depth of breathing increase as the hydrogen ion level rises; this is known as Kussmaul respirations. Metabolic acidosis is caused by alcoholic beverages, methyl alcohol, and acetylsalicylic acid (aspirin). A) Mechanical ventilation is used to correct hypoxemia and hypercapnia (elevated Pco2). B) Hydrochlorothiazide causes metabolic alkalosis; clients who display metabolic acidosis compensate with Kussmaul respirations. D) Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download Sodium bicarbonate is used in the treatment of metabolic acidosis; administration of this buffer may cause metabolic alkalosis.  During an interview with a client planning elective surgery, the client asks the nurse, "What is the advantage of having a preferred provider organization insurance plan?" Which response is best for the nurse to provide? 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 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download 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 lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download but neither prevents the risk of TSS. The diaphragm should not be used during menses (C) because it obstructs the menstrual flow and is not indicated because conception does not occur during this time. (F) is not necessary.  A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet? A)He visits his diabetic brother who just had surgery to amputate an infected foot. B)He is provided with the most current information about the dangers of untreated diabetes. C)He comments on the community service announcements about preventing complications associated with diabetes. D)His wife expresses a sincere willingness to prepare meals that Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download 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).  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 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download 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 thrombophlebitis is present. By not seeking immediate attention, (D) is potentially dangerous to the client.  A female client requests information about using the calendar method of contraception. Which assessment is most important for the nurse to obtain? A)Amount of weight gain or weight loss during the previous year. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download C)Increased protein in the urine, slightly increased serum glucose levels. D)Decreased serum sodium, an increased urine specific gravity. C) Increased protein in the urine, slightly increased serum glucose levels. Rationale: In older adults, the protein found in urine slightly rises probably as a result of kidney changes or subclinical urinary tract infections. The serum glucose increases slightly due to changes in the kidney. The specific gravity declines by age 80 from 1.032 to 1.024.  Which postmenopausal client's complaint should the nurse refer to the healthcare provider? A)Breasts feel lumpy when palpated. B)History of white nipple discharge. C)Episodes of vaginal bleeding. D)Excessive diaphoresis occurs at night. C) Episodes of vaginal bleeding. Rationale: Postmenopausal vaginal bleeding (C) Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download 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 may be a normal variant or a finding consistent with nonmalignant fibrocystic disease. Up to 80% of women experience (B), depending on sexual stimulation or hormonal levels, and is no longer recommended as a reportable symptom when discovered during breast self-exam (BSE). The client may need further teaching concerning (D), a disturbing symptom, but it is not as important as (C).  The nurse is assisting a client out of bed for the first time after surgery. What action should the nurse do first? A)Place a chair at a right angle to the bedside. B)Encourage deep breathing prior to standing. C)Help the client to sit and dangle legs on the side of the bed. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download D)Allow the client to sit with the bed in a high Fowler's position. D) Allow the client to sit with the bed in a high Fowler's position. Rationale: The first step is to raise the head of the bed to a high Fowler's position (D), which allow venous return to compensate from lying flat and vasodilating effects of perioperative drugs. (A, B, and C) are implemented after (D).  The nurse is receiving report from surgery about a client with a penrose drain who is to be admitted to the postoperative unit. Before choosing a room for this client, which information is most important for the nurse to obtain? A)If suctioning will be needed for drainage of the wound. B)If the family would prefer a private or semi-private room. C)If the client also has a Hemovac® in place. D)If the client's wound is infected. D)If the client's wound is infected. Rationale: Penrose drains provide a sinus tract Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download c)respiration rate of 12 d)Increased blood pressure a)Increased response to stimuli rationale: Dexamethasone (Decadron) is a corticosteroid that reduces inflammation in the brain. When effectivness is achieved, the patient's neurological status should improve. -Decadron has little effect on blood pressure, respiration rate, and urine output. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download  The nurse is assessing a client who is bedfast and refuses to turn or move from a supine position. How should the nurse assess the client for possible dependent edema? A)Compress the flank and upper buttocks. B)Measure the client's abdominal girth. C)Gently palpate the lower abdomen. D)Apply light pressure over the shins. A) Compress the flank and upper buttocks. Dependent edema collects in dependent areas, such as the flank and upper buttocks (A) of the client who is persistently flat in bed. (B) provides data about ascites (fluid collection in the abdomen), rather than dependent edema, and (C) provides data about abdominal distention. (D) provides data about the collection of dependent edema for a client whose lower extremities are often in a dependent position, Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download such as when sitting in a chair.  A male client with chronic atrial fibrillation and a slow ventricular response is scheduled for surgical placement of a permanent pacemaker. The client asks the nurse how this devise will help him. How should the nurse explain the action of a synchronous pacemaker? A)Ventricular irritability is prevented by the constant rate setting of pacemaker. B)Ectopic stimulus in the atria is suppressed by the device usurping depolarization. C)An impulse is fired every second to maintain a heart rate of 60 beats per minute. 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 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download D) Yellowish discoloration of the sclerae. Jaundice, a yellowish discoloration of the sclerae (D), may indicate liver damage and requires further assessment. Kyphosis and height reduction (A) due to bone loss, varicose veins (B), and external hemorrhoids with itching (C) are common findings in the elderly that do not require immediate intervention.  Which finding should the nurse report to the healthcare provider for a client with a circumferential extremity burn? A)Full thickness burns rather than partial thickness. B)Supinates extremity but unable to fully pronate the extremity. C)Slow capillary refill in the digits with absent distal pulse points. D)Inability to distinguish sharp versus dull sensations in the extremity. C) Slow capillary refill in the digits with absent distal pulse points A circumferential burn can form an eschar that results from burn exudate fluid that dries and Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download acts as a tourniquet as fluid shifts occur in the interstitial tissue. As edema increases tissue pressure, blood flow to the distal extremity is compromised, which is manifested by slow capillary refill and absent distal pulses (C), so the healthcare provider should be notified about any compromised circulation that requires escharotomy. Although eschar formation occurs more readily over full thickness burns (A), the circumferential location of the burn is most likely to constrict underlying structures. Limited movement (B) is often due to pain. (D) may be related to the depth of the burn.  The nurse completes visual inspection of a client'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 lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download 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 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download 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 because 50% of cancer cells or tumor cells are killed with each dose. (A, B, and C) vary based on the type of cancer.  The nurse is caring for a client with non- Hodgkin's lymphoma who is receiving chemotherapy. Laboratory results reveal a platelet count of 10,000/ml. What action should the nurse implement? A)Encourage fluids to 3000 ml/day. B)Check stools for occult blood. C)Provide oral hygiene every 2 hours. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download D)Check for fever every 4 hours. B) Check stools for occult blood. Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common side effect of chemotherapy. A client with thrombocytopenia should be assessed frequently for occult bleeding in the emesis, sputum, feces (B), urine, nasogastric secretions, or wounds. (A) does not minimize the risk for bleeding associated with thrombocytopenia. (C) may cause increased bleeding in a client with thromobcytopenia. (D) 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. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download 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 lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download improvement during asthma treatment. Bronchodilators do not stimulate coughing (D).  A client is admitted to the emergency department after being lost for four days while hiking in a national forest. Upon review of the laboratory results, the nurse determines the client's serum level for thyroid-stimulating hormone (TSH) is elevated. Which additional assessment should the nurse make? A)Body mass index. B)Skin elasticity and turgor. C)Thought processes and speech. D)Exposure to cold environmental temperatures. D) Exposure to cold environmental temperatures. TSH influences the amount of thyroxine secretion which increases the rate of metabolism to maintain body temperature near normal. Prolonged exposure to cold environmental temperatures (D) stimulates the hypothalamus to Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download secrete thyrotropin-releasing hormone, which increases anterior pituitary serum release of TSH. (A) may reflect weight loss from lack of food. Tenting of the skin (B) is indicative of dehydration. Slow or confused thought processes (C) or speech patterns may be related to sleep deprivation.  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 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download 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.  The nurse obtains a client's history that includes right mastectomy and radiation therapy for cancer of the breast 10 years ago. Which current health problem should the nurse consider is a consequence of the radiation therapy? A)Asthma. B)Myocardial infarction. C)Chronic esophagitis with gastroesophageal reflux. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download provider because sexual activity may be limited by your heart damage. D)Sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of stairs and may be resumed like other activities. D) Sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of stairs and may be resumed like other activities. 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.  Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download 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. D)Assess for a carotid bruit. C) Measure the blood pressure. Elderly clients who take antihypertensive medications often experience side effects, such as hypotension, which causes tachycardia, a compensatory mechanism to maintain adequate cardiac output, so the client's blood pressure (C) should be determined. (A, B, and D) are less likely to provide data related to the client's tachycardia.  Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download The nurse is preparing a teaching plan for a client with newly diagnosed glacoma and a history of allergic rhinitis. Which information is most important for the nurse to provide the client about using over-the-counter (OTC) medications for allergies? A)Notify your healthcare provider if there is an increase in heart rate. B)Increase fluid intake while taking an antihistamine or decongestant. C)Avoid allergy medications that contain pseudoephedrine or phenylephrine. D)Ophthalmic lubricating drops may be used for eye dryness due to allergy medications. C) Avoid allergy medications that contain pseudoephedrine or phenylephrine. OTC allergy medications may contain ephedrine, phenylephrine, or pseudoephedrine, which can cause adrenergic side effects, such as increased Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download healthcare provider for prescriptions to manage client to a euglycemic level.  Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download A nurse is preparing a teaching plan for a client who is post-menopausal. Which measure is most important for the nurse to include to prevent osteoporosis? A)Take a multivitamin daily. B)Use only low fat milk products. C)Perform weight resistance exercises. D)Bicycle for at least 3 miles every day. C) Perform weight resistance exercises. Weight bearing on the skeletal system stimulates bone formation, so recommending weight resistance exercises (C) is most important in the prevention of osteoporosis in post-menopausal women. Although (A, B, and D) provide common health maintenance behaviors, weight bearing exercise provides the best preventive measure in preventing calcium mobilization out of the bone.  A young adult female reports that she is Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download experiencing a lack of appetite, hypersomnia, stress incontinence, and heart palpitations. Which symptom is characteristic of premenstrual syndrome? A)Heart palpitations. B)Anorexia. C)Hypersomnia. D)Stress incontinence. A) Heart palpitations. Characteristic features of premenstrual syndrome include heart palpitations (A), sleeplessness, increased appetite and food cravings, and oliguria or enuresis. (B, C, and D) are not consistent with symptoms of premenstrual syndrome.  A nurse is preparing to insert an IV catheter after applying an eutectic mixture of lidocaine and prilocaine (EMLA), a topical anesthetic cream. What action should the nurse take to Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download B)Risk for infection. C)Disturbed body image. D)Risk for deficient fluid volume. B) Risk for infection. A wound healing by second intention is an open wound that is at risk for infection (B). Discomfort should be minimal 2 days after surgery, and acute pain (A) is not the priority. Risk for deficient fluid volume (D) requires a significant amount of wound draining, which is not evident. Although a wound may contribute to a disturbed body image (C), the client's distress may be minimal because the wound is not visible to others.  The nurse is preparing an adult client for an upper gastrointestinal (UGI) series. Which information should the nurse include in the teaching plan? A)The xray procedure may last for several hours. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download B)A nasogastric tube (NGT) is inserted to instill the barium. C)Enemas are given to empty the bowel after the procedure. D)Nothing by mouth is allowed for 6 to 8 hours before the study. D) Nothing by mouth is allowed for 6 to 8 hours before the study. The client should be NPO for at least 6 hours before the UGI (D). (A) is not typical for this procedure. A NGT is not needed to instill the barium (B) unless the client is unable to swallow. A laxative, not enemas (C), is given after the procedure to help expel the barium.  Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further? A)A scalp laceration oozing blood. B)Serosanguineous nasal drainage. C)Headache rated 10 on a 0-10 scale. D)Dizziness, nausea and transient confusion. B) Serosanguineous nasal drainage. Any nasal discharge should be evaluated (B) to determine the presence of cerebral spinal fluid which indicates a tear in the dura making the client susceptible to meningitis. The scalp is highly vascular and results in blood oozing from wounds (A). Pain is expected and can be treated after further assessment of the presence of nasal discharge (C). Dizziness, nausea, and transient confusion (D) are expected manifestations Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download room. Which items should the nurse remove from the client? (Select all that apply.) A)Nail polish. B)Hearing aid. C)Wedding band. D)Left leg brace. E)Contact lenses. F)Partial dentures. Correct Answer(s): A, B, E, F (Correct selections are A, B, E, and F). The removal of nail polish (A) provides a more accurate pulse oximetry readings and evaluation of capillary refill. Hearing aids (B), contact lenses (E), and partial dentures (F) are removed to prevent damage, loss or misplacement, or injury during surgery. (C and D) should remain with the client.  A client's prostate-specific antigen (PSA) exam result showed a PSA density of 0.13 ng/ml. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download Which conclusion regarding this lab data is accurate? A)Probable prostatitis. B)Low risk for prostate cancer. C)The presence of cancer cells. D)Biopsy of the prostate is indicated. Correct Answer(s): B Clients with a PSA density less than 0.15 ng/ml are considered at low risk for prostate cancer (B). (A, C, and D) are incorrect interpretations of the test results.  The nurse is providing postoperative instructions for a female client after a mastectomy. Which information should the nurse include in the teaching plan? (Select all that apply.) A)Empty surgical drains once a week using procedure gloves. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download B)Report inflammation of the incision site or the affected arm. C)Wear clothing with snug sleeves over the arm on the operative side. D)Avoid lifting more than 4.5 kg (10 lb) or reaching above her head. Correct Answer(s): B, D Correct answers include (B and D). Part of the client's teaching plan should include reporting evidence of inflammation at the incision or of the affected arm (B), and to avoid lifting or reaching Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download angioplasty (PTCA), a client who experiences acute chest pain may be experiencing cardiac ischemia related to restenosis, stent thrombosis, or acute coronary syndrome involving any coronary artery. The first action is to administer nitroglycerin (C) to dilate the coronary arteries and increase myocardial oxygenation. Then, (A, B, and D) are implemented.  A client is admitted to the Emergency Department with a tension pneumothorax. Which assessment should the nurse expect to identify? A)An absence of lung sounds on the affected side. B)An inability to auscultate tracheal breath sounds. C)A deviation of the trachea toward the side opposite the pneumothorax. D)A shift of the point of maximal impulse to the left, with bounding pulses. Correct Answer(s): C Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download Tension pneumothorax is caused by rapid accumulation of air in the pleural space, causing severely high intrapleural pressure. This results in collapse of the lung, and the mediastinum shifts toward the unaffected side, which is subsequently compressed (C). (A, B, and D) are not demonstrated with a tension pneumothorax.  A middle-aged male client asks the nurse what findings from his digital rectal examination (DRE) prompted the healthcare provider to prescribe a repeat serum prostatic surface antigen (PSA) level. What information should the nurse provide? A)A uniformly enlarged prostate is benign prostatic hypertrophy that occurs with aging. B)The spongy or elastic texture of the prostate is normal and requires no further testing. C)An infection is usually present when the prostate indents when a finger is pressed on it. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download lOMoARcPSD|10446529 Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download D)Stony, irregular nodules palpated on the prostate should be further evaluated. Correct Answer(s): D PSA levels are prescribed to screen for prostatic cancer which is often detected by DRE and manifested as small, hard, or stony, irregularly- shaped nodules on the surface of the prostate (D). Although PSA levels are prescribed for routine screening, the findings suggestive of BPH (A), normal texture (B) or infection (C) do not suggest cancer of the prostate, which requires further evaluation.  What is the primary nursing diagnosis for a client with asymptomatic primary syphilis? A)Acute pain. B)Risk for injury. C)Sexual dysfunction. D)Deficient knowledge. Nursing MED SURG guide Questions & Answers best exam solution guaranteed success latest download