PNVN 1631 (Medical Surgical Nursing I) Questions with 100% Correct Answers | Latest Update 2023/2024 | VERIFIED

The nurse clarifies that the master pacemaker of the heart is the: bundle of His. atrioventricular (AV) node. left ventricle. sinoatrial (SA) node. The SA node is the master pacemaker of the heart. Question 2 1 / 1 pts The patient has been hospitalized for hypertensive episodes three times in the last months. While preparing the discharge teaching plan, the nurse assesses that he does not comply with his medication regimen. The nurse’s immediate course of action would be to: have a serious talk with him and his family about compliance. reteach him about his medications. collect more information to identify his reasons for noncompliance. arrange for home visits after discharge. Nursing interventions include measures to prevent disease progression and complications. Reteaching about medication will not identify the cause of noncompliance. Question 3 1 / 1 pts The nurse finds a client tensing while lying in bed staring at the cardiac monitor. The client states, "There sure are a lot of wires around there. I sure hope we don't get hit by lightning!" Which is the nurse's best response? “Yes the equipment is a little scary. Can we talk about how the cardiac monitor works?” “Would you like a mild sedative to help you relax?” “I know about your concerns. Your family can stay with you every night if you want to.” “Oh don’t worry, the weather is supposed to be sunny and clear today.” Question 4 1 / 1 pts A nurse is collecting data on a child with a diagnosis of rheumatic fever. Which of the following questions would the nurse initially ask the mother of the child? “Has the child had any diarrhea?” “Has the child been vomiting?” “Does the child complain of chest pain?” “Has the child complained of a sore throat within the past few weeks or months?” Rationale: Rheumatic fever characteristically presents 2 to 6 weeks following an untreated or partially treated group A ß-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether any family members have had a sore throat or unexplained fever within the past 2 months. Although options 1, 2, and 3 may be asked during data collection, they would not be the initial concerns for a child with rheumatic fever. Test-Taking Strategy: Eliminate options 1 and 2 first because they are comparable or alike and both relate to the gastrointestinal system. From the remaining options, recalling that rheumatic fever characteristically presents 2 to 6 weeks following an untreated or partially treated group A ß-hemolytic streptococcal infection of the upper respiratory tract will direct you to option 4. If you had difficulty with this question, review the etiology related to rheumatic fever. Question 5 1 / 1 pts The client is to receive Lopressor (metoprolol tartrate) 0.05 grams po every day. Each scored tablet contains 50 mg. How many tablets would the client receive? 2 1/2 1 1 1/2 Question 6 1 / 1 pts Which action will the nurse implement to decrease the risk of clot formation in an older patient on bed rest? Encourage passive leg exercises and turning. Position pillows behind the knees. Assess peripheral pulses. Limit fluid intake. Using active or passive leg exercises for a patient on bed rest will prevent clot formation. Assessing pulses is not a preventive measure. Adequate hydration promotes fluidity of the blood and decreases the risk of clot formation. Placing pressure against the popliteal space will increase the risk of clot formation. Question 7 1 / 1 pts The patient is on the cardiac monitor undergoing a diagnostic procedure. Suddenly, the health care provider says, “The patient is having ventricular fibrillation!” Which piece of equipment is the most vital? Bag-valve mask Temporary pacemaker Crash cart Defibrillator AHN Study guide resource p.51 Incorrect Question 8 0 / 1 pts A client had abdominal aortic aneurysm graft procedure 2 days ago. This morning, the client says, "I don't feel any better than I did before surgery." The appropriate response by the nurse is: "It's only the second day post-op. Cheer up." "This is a normal frustration; it'll get better." "You will feel better in a week or two." "You are concerned that you don't feel any better after surgery." Rationale: Paraphrasing is restating the client's message in the nurse's own words. Option 3 uses the therapeutic communication technique of paraphrasing. The client is frustrated and is searching for understanding. Question 9 1 / 1 pts The physician ordered Timentin (ticarcillin) 500 mg in 50 mL to infuse over 30 minutes. The drop factor is 15 gtt/mL. Calculate the flow rate in drops per minute. 18 42 38 25 Question 10 1 / 1 pts What will the nurse advise the patient to do to avoid the development of tolerance to nitroglycerin? Use the sublingual form only. Store the drug in a dark container, free from light and moisture. Allow for a daily 8- to 12-hour nitrate free period. Administer subsequent doses parenterally. An 8- to 12-hour nitrate free period will eliminate the development of tolerance to nitroglycerin. Route of administration and medication storage methods do not affect tolerance. Question 11 1 / 1 pts The nurse making the schedule for the daily dose of furosemide (Lasix) would schedule the administration for which of the following times? With any meal At bedtime In the morning Late in the afternoon Diuretics should be scheduled for morning administration to avoid causing the patient nocturia. Question 12 1 / 1 pts The nurse is aware that the symptoms of an impending myocardial infarction (MI) differ in women because acute chest pain is not present. Women are frequently misdiagnosed as having: menopausal complications. hepatitis A. indigestion. urinary infection. Indigestion, gallbladder attack, anxiety attack, and depression are frequent misdiagnoses for women having an MI. Question 13 1 / 1 pts Which of the following makes a correct pathway of blood through the heart? right atrium, tricuspid valve, left atrium, aortic valve, left ventricle right atrium, left atrium, pulmonary artery, pulmonary veins, aorta right atrium, pulmonary artery, mitral valve, left ventricle, aorta right atrium, mitral valve, pulmonary veins, left ventricle, aorta Question 14 1 / 1 pts A patient, age 34, is diagnosed with infective endocarditis. The nurse identifies the nursing diagnosis of Activity intolerance related to generalized weakness for him. Which intervention does the nurse plan while he is febrile? Decreased activity and rest Allowing moderate activity if heart rate is not above 100 Activity as tolerated Monitoring vital signs during ambulation During the acute phase, it is essential to maintain the patient on decreased activity and provide a calm, quiet environment. Incorrect Question 15 0 / 1 pts The client with hypertension has been prescribed a low-sodium diet. The nurse teaching this client about foods that are allowed should plan to include which of the following in a list provided to the client? Boiled shrimp Tomato soup Summer squash Instant oatmeal Rationale: Foods that are lower in sodium are fruits and vegetables (“summer squash”) because they do not contain physiological saline. Highly processed or refined foods (“tomato soup” and “instant oatmeal”) are higher in sodium unless they are specifically noted as “low sodium.” Saltwater fish and shellfish are higher in sodium. Test-Taking Strategy: Begin to answer this question by eliminating “boiled shrimp” as being highest in sodium. Eliminate the other incorrect options because they are processed foods. Review the foods that are high and low in sodium if you had difficulty with this question. Question 16 1 / 1 pts The home health nurse caring for a patient with infective endocarditis overhears the patient making a dental appointment for an extraction next month. Which question is most important for the nurse to ask? “Do you have a toothache?” “Have you contacted your physician about your dental appointment?” “Do you think you should wait that long for your tooth extraction?’ “Is your dentist board certified?” Patients with endocarditis are put on a protocol of prophylactic antibiotics for any invasive procedure. The dentist and physician should be contacted before the extraction. Question 17 1 / 1 pts The clinic nurse is obtaining cardiovascular data on a client. The nurse prepares to check the client's apical pulse and places the stethoscope in which position? Midsternum equal with the nipple line At the midline of the chest just below the xiphoid process At the midclavicular line at the fifth left intercostal space At the midaxillary line on the left side of the chest Rationale: The heart is located in the mediastinum. Its apex or distal end points to the left and lies at the level of the fifth intercostal space. A stethoscope should be placed in this area to pick up heart sounds most clearly. The other options are incorrect because they do not represent the anatomical positioning of the heart's apex. Incorrect Question 18 0 / 1 pts A trauma patient arrives in the emergency department via EMS. He is bleeding profusely. A medical alert bracelet indicates that he is on heparin therapy. The nurse will most likely administer which medication that counteracts the action of heparin? Vitamin K Protamine sulfate Enoxaparin (Lovenox) Warfarin sodium (Coumadin) Protamine sulfate is the antidote to heparin. With the patient’s risk of fluid volume deficit as a result of trauma, the primary intervention would be to counteract the effects of heparin to prevent hemorrhage. Warfarin is an anticoagulant and would not counteract hemorrhage. Lovenox is chemically related to heparin and would not counteract hemorrhage. Vitamin K is used to control the bleeding that results from use of warfarin (Coumadin), not heparin. Incorrect Question 19 0 / 1 pts Which nursing assessment confirms that the angiotensin II receptor blocker (ARB) that a patient is taking is effective? Weight loss of more than 2 lb/wk. LDL cholesterol levels have decreased. Urinary output is decreased Blood pressure has decreased. The primary therapeutic outcome expected from angiotensin II receptor antagonists is reduction of blood pressure to within a normal range. Angiotensin II receptor antagonists bind angiotensin II receptor sites in the vascular smooth muscle, brain, heart, kidneys, and adrenal gland. The blood pressure-elevating (vasoconstricting) and sodium-retaining effects of angiotensin II are thus blocked. Weight loss, although advisable for treatment of hypertension, is not affected by ARBs. ARBs do not affect cholesterol levels. Urine output is not affected by ARBs. Question 20 1 / 1 pts A patient with angina pectoris is being discharged with nitroglycerin tablets. Which of the instructions does the nurse include in the teaching? “Continue with your activity. If the pain does not go away in 10 minutes, begin taking the nitro tablets one every 5 minutes for 20 minutes, then go lie down.” “When your chest pain begins, lie down and place one tablet under your tongue. If the pain continues, take another tablet in 5 minutes.” “Place one tablet under your tongue. If the pain is not relieved in 15 minutes, go to the hospital.