VATI Med Surg New Questions With Solved Answers

A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? (Select all that apply.) - Answer Poripheral edema Hepatomegaly Abdominal distention A nurse is caring for a client who has heart failure and a new prescription for furosemide. The nurse should monitor the client for which of the following adverse effects of the medication? - Answer Tinnitus The nurse should monitor clients who take furosemide for tinnitus and hearing loss. Audiometry is recommended for clients recelving prolonged IV furosemide. A nurse is reinforcing teaching with a client who is recovering from severe diarrhea and is ready to resume eating solid foods. Which of the following food items should the nurse recommend? - Answer Yogurt The nurse should recommend adding yogurt to the diet to provide probiotics and add substance to the stool, making it more formed. A client who is recovering from diarrhea should consume a diet that is low in fiber. Taking probiotics can also help restore the natural gastrointestinal flora. A nurse is monitoring a client who has a new prescription for furosemide for peripheral edema. For which of the following adverse effects should the nurse monitor? - Answer Muscle weakness Furosemide is a loop diuretic, which is used to treat hypertension and edema. Furosemide can cause excess excretion of potassium. The nurse should monitor the client for manifestations of hypokalemia such as nausea, muscle weakness, and spasms. A nurse is contacting the provider of a client who has heart failure and a potassium level of 3.4 mEq/L. Which of the following client medications should the nurse expect the provider to withhold? - Answer Digoxin The nurse should expect the provider to withhold digoxin when the client's potassium level is low to decrease the client's risk of dysrhythrmias due to digoxin toxicity. Potassium assists in displacing digoxin, because digoxin binds to potassiurm, and reduces the risk for digoxin toxicity. A nurse is assisting with the care of a client who has cellulitis and is receiving IV ceftriaxone. During data collection, the nurse notes the client is flushed and the client reports urticaria. After stopping the IV infusion, which of the following actions should the nurse take first? - Answer Check the client's respirations. After stopping the IV infusion, the first action the nurse should take when using the airway, breathing, circulation approach to client care is to count the client's respirations and monitor for dyspnea because a client experiencing an allergic reaction can progress to anaphylactic shock and death. A registered nurse (RN) in an acute care facility is caring for a group of clients with the assistance of a licensed practical nurse (LPN). Which of the following tasks should the RN delegate to the LPN? (Select all that apply.) - Answer Inserting an NG tube Monitoring an IV infusion Administering IM medications A nurse is reinforcing teaching with a young adult client about testicular self-examination. Which of the following instructions should the nurse include? - Answer "Examine your testicles after a warm shower." After exposure to warm water in a shower or bath, the scrotum relaxes and becomes easy to palpate. The testicle should feel smooth and round, and the client should report any lumps to his provider. A nurse is assisting in the planning of a health education class for a group of older adult clients. Which of the following recommendations should the nurse include? - Answer Obtain a pneumococcal immunization The pneumococcal immunization should be obtained to prevent pneumonia and is generally given at or near the age of 65, One dose provides lifelong immunity A nurse is preparing to administer eardrops to an adult client who has otitis media. Which of the following actions should the nurse plan to take? - Answer Warm the bottle by holding it in the palm for 5 min before administration. The nurse should plan to warm the bottle of drops slightly by holding it in the palm of the hand or putting the bottle in a pocket for about 5 min. Administering cold ear drops can cause the client to experience discomfort or dizziness. A nurse is reinforcing teaching about the use of an oxygen concentrator in the home for a client who has end-stage emphysema. Which of the following instructions should the nurse include to promote client safety? - Answer Maintain an electrical backup system. medical services and the electric company of the The nurse should remind the client to maintain an electrical backup system to ensure continuity of oxygen therapy. This includes notifying local emergency use of home oxygen equipment. In the event of power loss, the client should notify 911, the provider, and the home health care agency. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client has reduced urinary output, red urine, and reports bladder pain. Which of the following actions should the nurse take first? - Answer Increase the flow rate of the irrigation When providing client care, the nurse should use the least restrictive intervention first; therefore, the nurse should first increase the flow rate of continuous bladder irrigation to keep the urinary output light pink or yellow. A nurse is reinforcing teaching with a newly licensed nurse about enoxaparin. The nurse should include in the teaching that which of the following medications can interact with enoxaparin? (Select all that apply.) - Answer Clopidogrel Aspirin Ginkgo biloba A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse expect? - Answer Cardiac dysrhythmias The nurse should monitor the client who has hypokalemia, an electrolyte imbalance, for life-threatening cardlac dysrhythmilas, abdominal pain, and distention. A nurse is collecting data from a client who reports dizziness and vertigo and is performing the Romberg test. Which of the following instructions should the nurse give the client about this test? - Answer "Open your eyes." The nurse should instruct the client to stand with their feet together and eyes open. Then the client should close their eyes to determine if they lose balance. The test is negative if the client can remain upright and keep balance with minimal swaying and without moving their feet to another position. A positive test can indicate a dysfunction of the cerebellum or inner ear. A nurse is collecting data from a client who reports amenorrhea and insomnia. Which of the following data should the nurse report to the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.) - Answer T4 The client's T4 is above the expected reference range of 4 to 12 mcg/dL, which indicates hyperthyroidism. The nurse should report this value to the provider so that treatment for hyperthyroidism can begin. A nurse is caring for a client who has a foot fracture and requires crutches. Which of the following actions should the nurse take to ensure client safety? - Answer Measure the crutches with two finger widths below the axilla. The axillary bar on crutches should be measured with two finger widths under the axilla, Measuring two finger widths below the axilla can reduce the risk for nerve damage. A nurse is collecting data from a client who is 4 hr postoperative following abdominal surgery. The nurse notes the wound is eviscerating. Which of the following actions should the nurse take? - Answer Place the client supine with her knees bent The nurse should place the client in a supine position with the knees bent to decrease strain on the abdominal muscles. This position also decreases tension on the surgical site. Wound evisceration is a medical emergency that requires immediate surgical repair. A nurse is preparing to remove personal protective equipment (PPE) after irrigating a client's wound infection and applying a fresh sterile dressing. Identify the sequence for removing PPE. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) - Answer The nurse should remove the most contaminated piece of PPE. the gloves, first, Next, the nurse should remove the face shield and then the gown. The nurse should remove the least contaminated piece of PPE, the mask or respirator, last. A nurse is reinforcing teaching with a client who is in the early stages of COPD and wants to use nicotine chewing gum to stop smoking. Which of the following recommendations should the nurse make? - Answer "Do not eat or drink anything for 15 minutes before or after chewing the gum. The client should not eat or drink anything 15 min before, during, or 15 min after chewing the gum. Food and beverages can interfere with the absorption of nicotine and diminish its therapeutic effects as nicotine replacement therapy. A nurse is reinforcing teaching with an older adult client about age-related changes. Which of the following physiological changes should the nurse include in the teaching? (Select all that apply.) - Answer Reduction in height Loss of skin elasticity Decreased near vision A nurse is collecting data from a client who has acute cholecystitis. Which of the following manifestations should the nurse expect? - Answer Pain radiating to the right shoulder Pain radiating to the right shoulder is a common manifestation of acute cholecystitis due to the contraction of the bile ducts of the gallbladder. A nurse is reinforcing teaching with a client who has a prescription for clopidogrel following a thrombotic stroke. Which of the following information should the nurse include in the teaching? - Answer The medication prevents clot formation. Clopidogrel is an antiplatelet medication that prevents platelets from sticking together and, as a result, prolongs bleeding time, It is used to prevent blockage of coronary arteries and prevent clot formation. A nurse is contributing to the plan of care for a client who is in skeletal traction. Which of the following interventions should the nurse include? - Answer Keep the client's body centered in the bed. The nurse should keep the client's body centered on the bed to maintain alignment of the body with the direction of the pull of traction. This will ensure continued alignment of the bone. A nurse is contributing to the plan of care for a client who has dysphagia following a stroke. Which of the following actions should the nurse include in the plan of care to prevent aspiration? - Answer Keep the client upright for 30 min after a meal. The nurse should keep the client upright for 30 to 60 min after a meal to reduce the risk for aspiration. A nurse is reinforcing postoperative teaching with a client who is scheduled for cataract surgery on his right eye. Which of the following instructions should the nurse include? - Answer "Wear a protective eye shield while sleeping The nurse should remind the client to wear an eye shield while sleeping. This protects the operative eye from injury due to rubbing or pressure from the pillow. A nurse is collecting data from a client who was admitted with a Glasgow coma scale (GCS) of 3. Which of the following findings should the nurse expect? - Answer Nonresponsive to commands A client who has a GCS of less than 8 has evidence of severe head injury and is in a comatose state. The GCS is a standardized tool that allows for the evaluation of a client's level of consciousness. The test is divided into three sections that evaluate eye opening, motor response, and verbal response. The GCS ranges from a high score of 15 (fully alert) to a low score of 3 (fully comatose). A nurse is caring for a client who has type 1 diabetes mellitus and has undergone a below-the-knee amputation. Which of the following is the nighest priority finding? - Answer Skin flap of the residual limb is cool to the touch When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is that the skin flap of the residual limb is cool to the touch. The nurse should immediately report this finding to the provider. The skin flap of the residual limb should be warm to the touch, indicating adequate tissue perfusion.