Exam 2 Med Surg
st st st
Thestnursestassessesstastsurgicalstpatientstthestmorningstofstthestfirststpostoperat
ivestdaystandstnotesstrednessstandstwarmthstaroundstthestincision.stWhichstactio
nstbystthestnursestisstmoststappropriate?
a.stObtainstwoundstcultures.
b.stDocumentstthestassessment.
c.stNotifystthesthealthstcarestprovider.
d.stAssessstthestwoundsteveryst2sthoursst-stcorrectstanswer✔ ✔ Answer:stBst
Rationale:stThestincisionalstrednessstandstwarmthstarestindicatorsstofstthestnor
malstinitialst(inflammatory)ststagestofstwoundsthealingstbystprimarystintention.
Ast24-year-
oldstpatientstwhostisstreceivingstantibioticsstforstanstinfectedstlegstwoundsthasstast
temperaturestofst101.8°stFst(38.7°stC).stWhichstactionstbystthestnursestisstmoststa
ppropriate?
a.stApplystastcoolingstblanket.
b.stNotifystthesthealthstcarestprovider.
c.stGivestthestprescribedstPRNstaspirinst(Ascriptin)st650stmg.
d.stCheckstthestpatient'sstoralsttemperaturestagainstinst4sthours.st-
stcorrectstanswer✔ ✔ Answer:stDst
,Rationale:stMildsttostmoderatesttemperaturestelevationsst(lessstthanst103°stF)std
ostnotstharmstthestyoungstadultstpatientstandstmaystbenefitsthoststdefensestmecha
nisms.stThestnursestshouldstcontinuesttostmonitorstthesttemperature.stAntipyret
icsstarestnotstindicatedstunlessstthestpatientstisstcomplainingstofstfever-
relatedstsymptoms.stTherestisstnostneedsttostnotifystthestpatient'ssthealthstcarestpr
oviderstorsttostusestastcoolingstblanketstforstastmoderatesttemperaturestelevation.
Whichstnursingstactionstisstmoststlikelysttostdetectstearlystsignsstofstinfectionstinst
astpatientstwhostissttakingstimmunosuppressivestmedications?
a.stMonitorstwhitestbloodstcellstcount.
b.stCheckstthestskinstforstareasstofstredness.
c.stCheckstthesttemperaturesteveryst2sthours.
d.stAskstaboutstfatiguestorstfeelingsstofstmalaise.st-stcorrectstanswer✔ ✔
Answer:stD
Rationale:stCommonstclinicalstmanifestationsstofstinflammationstandstinfecti
onstarestfrequentlystnotstpresentstwhenstpatientsstreceivestimmunosuppressives
tmedications.stThestearliestst manifestationstofstanstinfectionstmaystbest"juststnot
stfeelingstwell."
Whenstevaluatingstthestresponsesttosttreatmentstforstastpatientstwithstastfluidstim
balance,stthestmoststimportantstassessmentsttostincludestis
a.stskinstturgor.
b.stpresencestofstedema.
,c.sthourlysturinestoutput.
d.stdailystweight.st-stcorrectstanswer✔ ✔ Answer:stD
Rationale:stDailystweightstisstthestmoststeasilystobtainedstandstaccuratestmeansst
ofstassessingstvolumeststatus.stSkinstturgorstvariesstconsiderablystwithstage.stC
onsiderablestexcessstfluidstvolumestmaystbestpresentstbeforestfluidstmovesstinto
stthestinterstitialstspacestandstcausesstedema.stHourlysturinestoutputsstdostnotsttak
estaccountstofstfluidstintakestorstofstfluidstlossstthroughstinsensiblestloss,stsweati
ng,storstlossstfromstthestgastrointestinalsttractstorstwounds.
Whenstcaringstforstanstalertstandstorientedstelderlystpatientstwithstasthistorystofstd
ehydration,stthesthomesthealthstnursestwillstteachstthestpatientsttostincreasestflui
dstintake
a.stwhenstthestpatientstfeelsstthirsty.
b.stinstthestlatesteveningsthours.
c.stasstsoonstasstchangesstinstLOCstoccur.
d.stifstthestoralstmucosastfeelsstdry.st-stcorrectstanswer✔ ✔ Answer:stDst
Rationale:stAnstalert,stelderlystpatientstwillstbestablesttostself-
assessstforstsignsstofstoralstdrynessstsuchstasstthickstoralstsecretionsstorstdry-
appearingstmucosa.stThestthirststmechanismstdecreasesstwithstagestandstisstnotst
anstaccuratestindicatorstofstvolumestdepletion.stManystolderstpatientsstpreferstto
strestrictstfluidsstslightlystinstthesteveningsttostimprovestsleepstquality.stThestpati
entstwillstnotstbestlikelysttostnoticestandstactstappropriatelystwhenstchangesstinstL
OCstoccur.
, Astpatientstissttakingsthydrochlorothiazide,stastpotassium-
wastingstdiuretic,stforsttreatmentstofsthypertension.stThestnursestwillstteachstthe
stpatientsttostreportstsymptomsstofstadversesteffectsstsuchstas
a.stgeneralizedstweakness.
b.stfacialstmusclestspasms.
c.stfrequentstlooseststools.
d.stpersonalitystchanges.st-stcorrectstanswer✔ ✔ Answer:stAst
Rationale:stGeneralizedstweaknessstprogressingsttostflacciditystisstastmanifest
ationstofsthypokalemia.stFacialstmusclestspasmsstmightstoccurstwithsthypocalc
emia.stLooseststoolsstarestassociatedstwithsthyperkalemia.stPersonalitystchang
esstarestnotstassociatedstwithstelectrolytestdisturbances,stalthoughstchangesstinst
mentalststatusstarestcommonstmanifestationsstwithstsodiumstexcessstorstdeficit.
Thestlong-term-
carestnursestisstevaluatingstthesteffectivenessstofstproteinstsupplementsstonstastp
atientstwhosthasstlowstserumsttotalstproteinstlevel.stWhichstofstthesestdatastindica
testthatstthestpatient'sstconditionsthasstimproved?
a.stAbsencestofstperipheralstedema
b.stGoodstskinstturgor
c.stHematocritst28%
d.stBloodstpressurest110/72stmmstHgst-stcorrectstanswer✔ ✔ Answer:stAst
st st st
Thestnursestassessesstastsurgicalstpatientstthestmorningstofstthestfirststpostoperat
ivestdaystandstnotesstrednessstandstwarmthstaroundstthestincision.stWhichstactio
nstbystthestnursestisstmoststappropriate?
a.stObtainstwoundstcultures.
b.stDocumentstthestassessment.
c.stNotifystthesthealthstcarestprovider.
d.stAssessstthestwoundsteveryst2sthoursst-stcorrectstanswer✔ ✔ Answer:stBst
Rationale:stThestincisionalstrednessstandstwarmthstarestindicatorsstofstthestnor
malstinitialst(inflammatory)ststagestofstwoundsthealingstbystprimarystintention.
Ast24-year-
oldstpatientstwhostisstreceivingstantibioticsstforstanstinfectedstlegstwoundsthasstast
temperaturestofst101.8°stFst(38.7°stC).stWhichstactionstbystthestnursestisstmoststa
ppropriate?
a.stApplystastcoolingstblanket.
b.stNotifystthesthealthstcarestprovider.
c.stGivestthestprescribedstPRNstaspirinst(Ascriptin)st650stmg.
d.stCheckstthestpatient'sstoralsttemperaturestagainstinst4sthours.st-
stcorrectstanswer✔ ✔ Answer:stDst
,Rationale:stMildsttostmoderatesttemperaturestelevationsst(lessstthanst103°stF)std
ostnotstharmstthestyoungstadultstpatientstandstmaystbenefitsthoststdefensestmecha
nisms.stThestnursestshouldstcontinuesttostmonitorstthesttemperature.stAntipyret
icsstarestnotstindicatedstunlessstthestpatientstisstcomplainingstofstfever-
relatedstsymptoms.stTherestisstnostneedsttostnotifystthestpatient'ssthealthstcarestpr
oviderstorsttostusestastcoolingstblanketstforstastmoderatesttemperaturestelevation.
Whichstnursingstactionstisstmoststlikelysttostdetectstearlystsignsstofstinfectionstinst
astpatientstwhostissttakingstimmunosuppressivestmedications?
a.stMonitorstwhitestbloodstcellstcount.
b.stCheckstthestskinstforstareasstofstredness.
c.stCheckstthesttemperaturesteveryst2sthours.
d.stAskstaboutstfatiguestorstfeelingsstofstmalaise.st-stcorrectstanswer✔ ✔
Answer:stD
Rationale:stCommonstclinicalstmanifestationsstofstinflammationstandstinfecti
onstarestfrequentlystnotstpresentstwhenstpatientsstreceivestimmunosuppressives
tmedications.stThestearliestst manifestationstofstanstinfectionstmaystbest"juststnot
stfeelingstwell."
Whenstevaluatingstthestresponsesttosttreatmentstforstastpatientstwithstastfluidstim
balance,stthestmoststimportantstassessmentsttostincludestis
a.stskinstturgor.
b.stpresencestofstedema.
,c.sthourlysturinestoutput.
d.stdailystweight.st-stcorrectstanswer✔ ✔ Answer:stD
Rationale:stDailystweightstisstthestmoststeasilystobtainedstandstaccuratestmeansst
ofstassessingstvolumeststatus.stSkinstturgorstvariesstconsiderablystwithstage.stC
onsiderablestexcessstfluidstvolumestmaystbestpresentstbeforestfluidstmovesstinto
stthestinterstitialstspacestandstcausesstedema.stHourlysturinestoutputsstdostnotsttak
estaccountstofstfluidstintakestorstofstfluidstlossstthroughstinsensiblestloss,stsweati
ng,storstlossstfromstthestgastrointestinalsttractstorstwounds.
Whenstcaringstforstanstalertstandstorientedstelderlystpatientstwithstasthistorystofstd
ehydration,stthesthomesthealthstnursestwillstteachstthestpatientsttostincreasestflui
dstintake
a.stwhenstthestpatientstfeelsstthirsty.
b.stinstthestlatesteveningsthours.
c.stasstsoonstasstchangesstinstLOCstoccur.
d.stifstthestoralstmucosastfeelsstdry.st-stcorrectstanswer✔ ✔ Answer:stDst
Rationale:stAnstalert,stelderlystpatientstwillstbestablesttostself-
assessstforstsignsstofstoralstdrynessstsuchstasstthickstoralstsecretionsstorstdry-
appearingstmucosa.stThestthirststmechanismstdecreasesstwithstagestandstisstnotst
anstaccuratestindicatorstofstvolumestdepletion.stManystolderstpatientsstpreferstto
strestrictstfluidsstslightlystinstthesteveningsttostimprovestsleepstquality.stThestpati
entstwillstnotstbestlikelysttostnoticestandstactstappropriatelystwhenstchangesstinstL
OCstoccur.
, Astpatientstissttakingsthydrochlorothiazide,stastpotassium-
wastingstdiuretic,stforsttreatmentstofsthypertension.stThestnursestwillstteachstthe
stpatientsttostreportstsymptomsstofstadversesteffectsstsuchstas
a.stgeneralizedstweakness.
b.stfacialstmusclestspasms.
c.stfrequentstlooseststools.
d.stpersonalitystchanges.st-stcorrectstanswer✔ ✔ Answer:stAst
Rationale:stGeneralizedstweaknessstprogressingsttostflacciditystisstastmanifest
ationstofsthypokalemia.stFacialstmusclestspasmsstmightstoccurstwithsthypocalc
emia.stLooseststoolsstarestassociatedstwithsthyperkalemia.stPersonalitystchang
esstarestnotstassociatedstwithstelectrolytestdisturbances,stalthoughstchangesstinst
mentalststatusstarestcommonstmanifestationsstwithstsodiumstexcessstorstdeficit.
Thestlong-term-
carestnursestisstevaluatingstthesteffectivenessstofstproteinstsupplementsstonstastp
atientstwhosthasstlowstserumsttotalstproteinstlevel.stWhichstofstthesestdatastindica
testthatstthestpatient'sstconditionsthasstimproved?
a.stAbsencestofstperipheralstedema
b.stGoodstskinstturgor
c.stHematocritst28%
d.stBloodstpressurest110/72stmmstHgst-stcorrectstanswer✔ ✔ Answer:stAst
