VATI Med-Surg pre-assessment Questions and Answers with verified solutions

VATI Med-Surg pre-assessment Questions and Answers with verified solutions A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply) A. Troponin I B. Troponin T C. Plasma low-density lipoproteins (LDL) D. CPK E. Myoglobin - ANS -A. Troponin I B. Troponin T D. CPK E. Myoglobin Troponin I is a myocardial muscle protein that is released when there is injury to cardiac muscle. Levels are elevated as early as 2 to 3 hr following a myocardial infarction. Troponin T is a myocardial muscle protein that is released when there is injury to cardiac muscle. Levels are elevated as early as 2 to 3 hr following a myocardial infarction. CPK, or creatine phosphokinase, is an enzyme that is elevated in the presence of muscle injury. Although CPK is not specific for myocardial damage, it is used in conjunction with other diagnostic tests to support a diagnosis of myocardial infarction. A CPK isoenzyme, CK-MB, is specific to cardiac muscle and a significant elevation in this isoenzyme indicates a myocardial infarction has occurred. Elevation of myoglobin indicates myocardial injury. Myoglobin levels will significantly increase within approximately 3 hours following myocardial infarction. This test is used in conjunction with other diagnostic tests to support a diagnosis of myocardial infarction. A nurse is assessing a client who has diabetes insipidus. Which of the following findings is a manifestation of this diagnosis? A. Hypertension B. Bounding peripheral pulses C. Tachycardia D. Hyperglycemia - ANS -C. Tachycardia Tachycardia is a manifestation of diabetes insipidus due to dehydration from fluid loss. Hypotension is a manifestation of diabetes insipidus. Weak peripheral pulses are a manifestation of diabetes insipidus. A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect? A. Bradycardia B. Bradypnea C. Lethargy D. Intercostal retrations - ANS -D. Intercostal retrations Hypoxia is a condition in which the tissues of the body are oxygen-starved. It follows hypoxemia (low oxygen in the blood) and is manifested as substernal or intercostal retractions as the body works harder to draw more oxygen into the lungs. A client who is hypoxic is more likely to have tachycardia than bradycardia. A nurse is assessing a client who has type 1 diabetes mellitus and finds the client lying in bed, sweating, and reporting feeling anxious. Which of the following complications should the nurse expect? A. Hypoglycemia B. Nephropathy C. Hyperglycemia D. Ketoacidosis - ANS -A. Hypoglycemia Manifestations of hypoglycemia include sweating, tachycardia, tremors, palpitations, hunger, and anxiety. Manifestations of nephropathy include hypertension, microalbuminuria, and elevated uric acid levels. Manifestations of hyperglycemia include warm skin, rapid respirations, and changes in mental status. Manifestations of ketoacidosis include tachycardia, Kussmaul respirations, nausea, and lethargy. A nurse is caring for a client following a below-the-knee amputation Day 1 0930 Client had all pre-operative steps completed in preparation for a right below the knee amputation. Consent signed. Client has a history of peripheral vascular disease. Client lives with their spouse and has a past medical history of diabetes mellitus, peripheral neuropathy, and osteomyelitis in the right lower leg. Alert and oriented. 1330 Client is drowsy, awake with stimulation. General anesthesia is wearing off. Oriented x 3 in post-anesthesia unit. Procedure went as expected. Right popliteal pulse was weak, 1+. Left popliteal pulse 2+. Right lower limb is warm. Skin turgor +2, cap refill < 2 sec bilaterally. Current pain level described by client as 8 on a scale of 0 to 10. Transfer to surgical unit. Day 1 1400 Client is awake and oriented. Client reports pain in right leg at the incision site, which they rate as an 8 on a scale o - ANS -The nurse should address the client's pain, followed by the client's dressing. Pain is correct. The nurse should first address the client's pain of 8 on a scale of to 10. The description of the pain could be an indication of phantom limb pain. Interventions for phantom limb pain includes administering an antiepileptic, an antispasmodic, or a beta blocker. Other interventions include massage, exercises, TENS and distraction therapy. The nurse will first address the pain and then reapply the dressing that has become loose and unsupportive to the affected extremity. A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first? A. Check the client for a fecal impaction. B. Examine the client for areas of skin breakdown. C. Check the client's bladder for distention. D. Place the client in a sitting position. - ANS -D. Place the client in a sitting position. The nurse should use the least invasive intervention first. Therefore, the nurse should place the client in a sitting position to decrease the manifestation of hypertension. The nurse might have to check the client for fecal impaction, which can precipitate autonomic dysreflexia. However, the nurse should use a less invasive intervention first. The nurse might have to examine the client's skin for areas of skin breakdown or pressure, which can trigger autonomic dysreflexia. However, the nurse should use a less invasive intervention first. The nurse might have to check the client for bladder distention, which can precipitate autonomic dysreflexia. However, the nurse should use a less invasive intervention first. A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? A. Continue to monitor the client. B. Immediately notify the provider. C. Reposition the client toward the left side. D. Clamp the chest tube near the water seal. - ANS -A. Continue to monitor the client. The fluid in the water seal chamber rises 2 to 4 inches during inhalation and falls during exhalation. This is a process called tidaling. An absence of tidaling might indicate a fully expanded lung or an obstruction in the chest tube. The nurse does not need to contact the provider at this time. The fluid in the water seal chamber is expected to rise during inhalation and fall during exhalation. A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse take to reduce the risk for ventilator-associated pneumonia? A. Position the head of the client's bed in the flat position. B. Turn the client every 4 hr. C. Rinse the client's mouth with an antimicrobial solution every 4 hr. D. Perform hand hygiene prior to suctioning the client's endotracheal tube. - ANS -C. Rinse the client's mouth with an antimicrobial solution every 4 hr. The nurse should brush the client's teeth every 8 hr and rinse the client's mouth with an antimicrobial rinse every 2 hr to reduce the growth of bacteria. The nurse should elevate the head of the client's bed 30° to reduce the risk for aspiration and pneumonia. The nurse should turn the client every 2 hr to promote lung expansion and reduce the risk for pneumonia. The nurse should perform hand hygiene prior to suctioning the client's endotracheal tube to reduce the risk of introducing bacteria. A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take? A. Instruct the client to cough and deep breathe. B. Place the client in a supine position. C. Place a warming blanket on the client. D. Use log rolling to reposition the client. - ANS -D. Use log rolling to reposition the client. Treatment of increased ICP focuses on decreasing the pressure. An important intervention includes positioning the client in a neutral position and avoiding flexion of the neck and hips. In order to avoid hip flexion, the client should be log rolled when repositioned. A client who has increased ICP is at risk for brain herniation, a potentially life-threatening condition. Actions, such as deep breathing, coughing, and blowing the nose, can increase ICP. The nurse should take measures to maintain or reduce the client's ICP. An important intervention for ICP is positioning the client in a neutral position with the head of the bed elevated to 30° to 45°. This placement allows the cerebral spinal fluid to flow freely through the brain and spinal cord, minimizes pressure within the central nervous system, and prevents aspiration. A client who has increased ICP can develop a fever in response to systemic trauma, the presence of blood in the cranium, infection, or as a generalized inflammatory response to the brain injury. Therapeutic