NURSING 101-Med Surg Practice Exam

NURSING 101-Med Surg Practice Exam Medical-Surgical A 1. 1.ID: Which milestone indicates to the nurse successful achievement of young adulthood? o Demonstrates a conceptualization of death and dying. o Completes education and becomes self-supporting. Correct o Creates a new definition of self and roles with others. Incorrect o Develops a strong need for parental support and approval. Transitioning through young adulthood is characterized by establishing independence as an adult, and includes developmental tasks such as completing education, beginning a career, and becoming self-supporting (B). (A and C) are characteristic of adolescence. Although strong bonds with parents are an expected finding for this age group, the need for support and approval (D) indicates dependency, which is a developmental delay. Awarded 0.0 points out of 1.0 possible points. 2. 2.ID: The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia (VT). The client has an implanted automatic defibrillator. What action should the nurse implement? o Prepare the client for transcutaneous pacemaker. o Shock the client with 200 joules per hospital policy. Correct o Use a magnet to deactivate the implanted pacemaker. o Observe the monitor until the onset of ventricular fibrillation. The client must be externally shocked (B) to restore an effective cardiac rhythm. The automatic defibrillator is obviously malfunctioning. (A) will not be effective during ventricular tachycardia, since it is used for asystole. Since the defibrillator is not functioning, (C) is not warranted. The client should be treated immediately to restore cardiac output (D). Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring? o Positive polarity right shoulder, negative polarity left shoulder, ground left chest nipple line. o Positive polarity left shoulder, negative polarity right chest nipple line, ground left chest nipple line. o Positive polarity right chest nipple line, negative polarity left chest nipple line, ground left shoulder. o Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line. Correct In MCL I monitoring, the positive electrode is placed on the client's mid-chest to the right of the sternum, and the negative electrode is placed on the upper left part of the chest (D). The ground may be placed anywhere, but is usually placed on the lower left portion of the chest. (A, B, and C) describe incorrect placement of electrodes for telemetry monitoring. Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: Based on the analysis of the client's atrial fibrillation, the nurse should prepare the client for which treatment protocol? o Diuretic therapy. o Pacemaker implantation. o Anticoagulation therapy. Correct o Cardiac catheterization. The client is experiencing atrial fibrillation, and the nurse should prepare the client for anticoagulation therapy (C) which should be prescribed before rhythm control therapies to prevent cardioembolic events which result from blood pooling in the fibrillating atria. (A, B, and D) are not indicated. Awarded 1.0 points out of 1.0 possible points. 5. 5.ID: In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing intervention? (Select all that apply.) o Set the infusion pump to infuse the albumin within four hours. Correct o Compare the client's blood type with the label on the albumin. o Assign a UAP to monitor blood pressure q15 minutes. Incorrect o Administer through a large gauge catheter. Correct o Monitor hemoglobin and hematocrit levels. Correct o Assess for increased bleeding after administration. Correct (A, D, E, and F) are the correct selections. Albumin should be infused within four hours because it does not contain any preservatives. Any fluid remaining after four hours should be discarded (A). Albumin administration does not require blood typing (B). Vital signs should be monitored periodically to assess for fluid volume overload, but every 15 minutes is not necessary (C). This frequency is often used during the first hour of a blood transfusion. A large gauge catheter (D) allows for fast infusion rate, which may be necessary. Hemodilution may decrease hemoglobin and hematocrit levels (E), while increased blood volume and blood pressure may cause bleeding (F). Awarded 0.0 points out of 1.0 possible points. 6. 6.ID: A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement? o Give 20 mEq of potassium chloride. o Initiate continuous cardiac monitoring. Correct o Arrange a consultation with the dietician. o Teach about the side effects of diuretics. Incorrect Hypokalemia (normal 3.5 to 5 mEq/L) causes changes in myocardial irritability and ECG waveform, so it is most important for the nurse to initiate continuous cardiac monitoring (B) to identify ventricular ectopy or other life-threatening dysrhythmias. Potassium chloride (A) should be given after cardiac monitoring is initiated so that the effects of potassium replacement on the cardiac rhythm can be monitored. (C and D) should be implemented when the client is stable. Awarded 0.0 points out of 1.0 possible points. 7. 7.ID: The nurse is teaching a female client about the best time to plan sexual intercourse in order to conceive. Which information should the nurse provide? o Two weeks before menstruation. Correct o Vaginal mucous discharge is thick. o Low basal temperature. Incorrect o First thing in the morning. Ovulation typically occurs 14 days before menstruation begins (A), and sexual intercourse should occur within 24 hours of ovulation for conception to occur. High estrogen levels occur during ovulation and increase the vaginal mucous membrane characteristics, which become more "slippery" and stretchy, not (B). A rise in basal temperature, not (C), signals ovulation. The timing during the day is not as significant in determining conception as the day before and after ovulation (D). Awarded 0.0 points out of 1.0 possible points. 8. 8.ID: A 49-year-old female client arrives at the clinic for an annual exam and asks the nurse why she becomes excessively diaphoretic and feels warm during nighttime. What is the nurse’s best response? o Explain the effect of the follicle-stimulating and luteinizing hormones. o Discuss perimenopause and related comfort measures. Correct o Assess lung fields and for a cough productive of blood-tinged mucous. o Ask if a fever above 101º F has occurred in the last 24 hours. Incorrect The perimenopausal period begins about 10 years before menopause with the cessation of menstruation at the average ages of 52 to 54. Lower estrogen levels causes FSH and LH secretion in bursts (surges), which triggers vasomotor instability, night sweats, and hot flashes, so discussions about the perimenopausal body's changes, comfort measures (B), and treatment options should be provided. In-depth pathophysiology of the symptoms (A) may only confuse the client. There is no indication that the client has tuberculosis and an infection, so (C and D) are not indicated. Awarded 0.0 points out of 1.0 possible points. 9. 9.ID: Which client should the nurse recognize as most likely to experience sleep apnea? o Middle-aged female who takes a diuretic nightly. o Obese older male client with a short, thick neck. Correct o Adolescent female with a history of tonsillectomy. o School-aged male with a history of hyperactivity disorder. 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. Awarded 1.0 points out of 1.0 possible points. 10. 10.ID: The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session? o Present knowledge related to the skill of injection. o Intelligence and developmental level of the client. o Willingness of the client to learn the injection sites. Correct o Financial resources available for the equipment. 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). Awarded 1.0 points out of 1.0 possible points. 11. 11.ID: The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)? o Serum PTT of 10 seconds. o Serum calcium of 5 mg/dl. Correct o Oxygen saturation of 90%. o Hemoglobin of 10 g/dl. TLS results in hyperkalemia, hypocalcemia, hyperuricemia, and hyperphosphatemia. A serum calcium level of 5 (B), which is low, is an indicator of possible tumor lysis syndrome. (A, C, and D) are not particularly related to TLS. Awarded 1.0 points out of 1.0 possible points. 12. 12.ID: During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first? o Use a laryngoscope to check for a foreign body lodged in the esophagus. o Reposition the head to validate that the head is in the proper position to open the airway. Correct o Turn the client to the side and administer three back blows. o Perform a finger sweep of the mouth to remove any vomitus. The most frequent cause of inadequate aeration of the client's lungs during CPR is improper positioning of the head resulting in occlusion of the airway (B). A foreign body can occlude the airway, but this is not common unless choking preceded the cardiac emergency, and (A, C and D) should not be the nurse's first action. Awarded 1.0 points out of 1.0 possible points. 13. 13.ID: A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure." Which symptoms are most important to teach the client? o Facial flushing. o Fever. o Pounding headache. o Feelings of dizziness. Correct Feelings of dizziness may occur as the result of a decreased heart rate, leading to decreased cardiac output (D). (A and C) will not occur as the result of pacemaker failure. (B) may be an indication of infection postoperatively, but is not an indication of pacemaker failure. Awarded 1.0 points out of 1.0 possible points. 14. 14.ID: 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? o Propanolol (Inderal). Correct o Captopril (Capoten). o Furosemide (Lasix). o Dobutamine (Dobutrex). Inderal (A) is a beta adrenergic blocking agent, which causes decreased heart rate and decreased contractility. Neither (B), an ACE inhibitor, nor (C), a loop diuretic, causes bradycardia. (D) is a sympathomimetic, direct acting cardiac stimulant, which would increase the heart rate. Awarded 1.0 points out of 1.0 possible points. 15. 15.ID: 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? o He visits his diabetic brother who just had surgery to amputate an infected foot. Correct o He is provided with the most current information about the dangers of untreated diabetes. o He comments on the community service announcements about preventing complications associated with diabetes. o His wife expresses a sincere willingness to prepare meals that are within his prescribed diet. 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). Awarded 1.0 points out of 1.0 possible points. 16. 16.ID: 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? o Start an IV nitroglycerin infusion. Correct o Nasogastric lavage with cool saline. o Increase the vasopressin infusion. Incorrect o Prepare for endotracheal intubation. 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). Awarded 0.0 points out of 1.0 possible points. 17. 17.ID: The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk for developing a cerebral vascular accident (CVA)? o Diabetes mellitus. Correc