Nursing: Medical-Surgical Review. Questions with accurate answers. 100% Approved pass rate.

Nursing: Medical-Surgical Review. Questions with accurate answers. 100% Approved pass rate. Document Content and Description Below Nursing: Medical-Surgical Review. Questions with accurate answers. 100% Approved pass rate. Which method elicits the most accurate information during a physical assessment of an older adult? A. use reliable assessment tools for older adults B. Review the past medical record for medications C. Ask the client to recount one's health history D. Obtain the client's information from a caregiver - A. use reliable assessment tools for older adults Specific assessment tools (D) for an older adult, such as Older Adult Resource Services Center Instrument, mini-mental assessment, fall risk, depression, or skin breakdown risk, consider age-related physiologic and psychosocial changes related to aging and provide the most accurate and complete information. A and B are subjective and may vary in reliability based on the client's memory and caregiver's current involvement. Although C is a good resource to identify polypharmacy, a written record may not be available or currently accurate. A client who has just tested positive for HIV does not appear to hear what the nurse is saying during post-test counseling. Which information should the nurse offer to facilitate the client's adjustment to HIV infection? A. teach the client about the medications that are available for treatment B. discuss retesting to verify the results, which will ensure continuing contact C. identify the need to test others who have had risky contact with the client D. inform the client how to protect sexual and needle-sharing partners - B. discuss retesting to verify results, which will ensure continuing contact encouraging retesting supports hope and gives the client time to cope with the diagnosis. Although post-test counseling should include education about A, B, and C, retesting encourages the client to maintain medical follow-up and management. The nurse is caring for a client with HIV infection who develops Mycobacterium avium complex (MAC). what is the most significant desired outcome for this client? A. free from injury of drug side effects B. maintenance of intact perineal skin c. adequate oxygenation D. return to pre-illness weight - D. return to pre-illness weight MAC is an opportunistic infection that presents as a TB like pulmonary process. MAC is a major contributing factor to the development of wasting syndrome, so the most significant desired outcome is the client's return to a pre-illness weight. drug schedules and side effects remain a life-long management problem. Client outcomes for adequate oxygenation are often dependent on management of anemia, maintenance of activities without fatigue, and supplemental oxygen to prevent hypoxia. Skin integrity is dependent upon resolution of diarrhea, which is not as significant as optimal nutrition. A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate 4 mg every 2 hours and a clear liquid diet. the client complains of feeling distended and has sharp, cramping gas pains. What nursing intervention should be implemented? A. assist the client to ambulate in the hall B. obtain a prescription for a laxative C. administer the prescribed morphine sulfate D. withhold all oral fluid and food - a. assist the client to ambulate in the hall Post-operative abdominal distention is caused by decreased peristalsis as a result of handling the intestine during surgery, limited dietary intake before and after surgery, and anesthetic and analgesic agents. Peristalsis is stimulated and distention minimized by implementing early and frequent ambulation. Based on the client's status, laxatives or withholding dietary progression are not indicated at this time. although pain management should be implemented, another analgesic prescription may be needed because morphine reduces intestinal motility and contributes to the client's gas pains. A client with Meniere's disease is incapacitated by vertigo and is lying in bed grasping the side rails and staring at the television. Which nursing intervention should the nurse implement? A. keep the head of the bed elevated 30 degrees B. turn off the television and darken the room c. encourage fluids to 3000 mL per day D. change the client's position every two hours - B. turn off the television and darken the room to decrease the client's vertigo during an acute attack of Meniere's disease, any visual stimuli or rotational movement, such as sudden head movements or position changes, should be minimized. Turning off the television and darkening the room minimize fluorescent lights, flickering television lights, and distracting sound. The other are ineffective in managing the client's symptoms. a client who has a chronic cough with blood-tinged sputum returns to the unit after a bronchoscopy. What nursing interventions should be implemented in the immediate post-procedural period? A. check vital signs every 15 minutes for 2 hours B. allow the client nothing by mouth until the gag reflex returns C. encourage fluid intake to promote elimination of the contrast media D. keep the client on bed rest for 8 hours - B. allow the client nothing by mouth until the gag reflex returns the nasal pharynx and oral pharynx are anesthetized with local anesthetic spray prior to bronchoscopy, and the bronchoscope is coated with lidocaine gel to inhibit the gag reflex and prevent laryngeal spasm during insertion. The client should be NPO until the client's gag reflex returns to prevent aspiration from any oral intake or secretions. The others are not indicated after bronchoscopy The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing spontaneously. to evaluate if the client can tolerate cuff deflation to promote speaking and swallowing, what action should the nurse implement? A. observe the client for coughing colored sputum after drinking a small amount of colored water B. ask the client to try to speak C. auscultate for pulmonary crackles after the client drinks a small amount of clear water D. assess for respiratory distress - A. observe the client four coughing colored sputum after drinking a small amount of colored water to evaluate the risk for aspiration after the cuff is deflated, the client should be instructed to swallow a small amount of colored water, then be observed for coughing up colored sputum, or the tracheostomy should be suctioned for the presence of colored water. What assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is beginning to improve after treatment? A. vesicular breath sounds decrease B. wheezing becomes louder C. bronchodilators stimulate coughing D. cough remains unproductive - B. wheezing becomes louder In an acute asthma attack, air flow may be so significantly restricted that wheezing is diminished. If the client is successfully responding to bronchodilators and respiratory treatments, wheezing becomes louder as air flow increases in the airways. As the airways open and mucous is mobilized in response to treatment, the cough becomes more productive. vesicular sounds are soft, low-pitched, gentle, rustling sounds heard over lung fields. A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell crisis. What is the most important nursing action to implement? A. limit the client's intake of oral fluids B. teach the client about prevention of crises C. evaluate the effectiveness of narcotic analgesics D. encourage the client to ambulate as tolerated - C. evaluate the effectiveness of narcotic analgesics Pain management is the priority for a client during sickle cell crisis. Continuous narcotic analgesics are the mainstay of pain control, which should be evaluated frequently to determine if the client's pain is adequately controlled. The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving chemotherapy. Laboratory results reveal a platelet count of 10,000/mL. What action should the nurse implement? A. provide oral hygiene every 2 hours B. check for fever every 4 hours C. encourage fluids to 3000 mL/day D. check stools for occult blood - D. check stools for occult blod Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common side effect of chemotherapy. A client with thrombocytopenia should be assessed frequently for occult bleeding in the emesis, sputum, feces, urine, nasogastric secretions, or wounds. A client is admitted for complaints of chest pain and aching for the past 4 days. the results for serum creatine kinase-MB (CK-MB) and troponin are obtained. What rationale should the nurse use to evaluate the laboratory findings? A. serum myoglobin levels are needed to confirm myocardial damage B. myocardial damage that occurred several days earlier is best validated by serum troponin levels C. the most reliable indicator of myocardial necrosis is serum CK-MB D. serum cardiac markers are inconclusive in determining myocardial injury after waiting several days - B. myocardial damage that occurred several days earlier is best validated by serum troponin levels Serum CK-MB and troponin are the two most important serum cardiac markers for confirming myocardial infarction. CK-MB begins to rise in the first 3 to 12 hours after the myocardial infarction, peaks in 24 hours, and returns to normal in 2 to 3 days. the troponin level rises as quickly but remains elevated for 2 weeks. Three weeks after discharge fro an acute myocardial infarction (MI), a client returns to the cardiac center for follow-up. When the nurse asks about sleep patterns, the client tells the nurse that he sleeps fine but that his wife moved into the spare bedroom to sleep when he returned home. He states "I guess we will never have sex again after this." Which response is best for the nurse to provide? A. sexual activity can be resumed whenever you and you wife feel like it because the sexual response is more emotional rather than physical B. you should discuss your questions about your sexual activity with your healthcare provider because sexual activity may be limited by your heart damage C. sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of stairs and may be resumed like other activities D. sexual intercourse can be strenuous on your heart, but closeness and intimacy, such as holding and cuddling, can be maintained with your wife - C. sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of stairs and may be resumed like other activities sexual intercourse after an MI, or acute coronary syndrome, has been found to require no more energy expenditure or cardiac stress than walking briskly up two flights of stairs, as long as other guidelines, such as limiting food and alcohol intake before intercourse, are followed. A male client with chronic atrial fibrillation and a slow ventricular response is scheduled for surgical placement of a permanent pacemaker. The client asks the nurse how this devise will help him. How should the nurse explain the action of a synchronous pacemaker? A. an impulse is fired every second to maintain a heart rate of 60 beats per minute B. ectopic stimulus in the atria is suppressed by the device of usurping depolarization C. ventricular irritability is prevented by the constant rate setting of a pacemaker D. an electrical stimulus is discharged when no ventricular response is sensed - D. an electrical stimulus is discharged when no ventricular response is sensed The artificial cardiac pacemaker is an electronic device used to pace the heart when the normal conduction pathway is damaged or diseased, such as a symptomatic dysrhythmia like atrial fibrillation with a slow ventricular response. Pacing modes that are synchronous (impulse generated on demand or as needed according to the patient's intrinsic rhythm) send an electrical signal from the pacemaker to the wall of the myocardium stimulating it to contract when no ventricular depolarization is sensed A man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the difficulty that he and his wife are having getting pregnant. what information is best for the nurse to provide? A. smoking can decrease the quantity and quality of sperm B. the first semen analysis should be repeated to confirm sperm counts C. only marijuana cigarettes affect sperm count D. cessation of smoking improves general health and fertility E. sperm specimens should be collected in 2 subsequent days - A, B, and D Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm counts vary from day to day and are dependent on emotional and physical status and sexual activity, so a single analysis may be inconclusive. A minimum o two analyses should be performed several weeks apart to assess male fertility. A couple trying to cope with an infertility problem wants to know what can be done to preserve emotional equilibrium. What is the best response for the nurse to provide? A. "talk only to other friends who are infertile since only they can help" B. "tell your friends and family so that they can help you" C. "get involved in a support group. I will give you some names" D. "start adoption proceedings immediately since obtaining an infant is very difficult" - C A support group provides a safe haven for the couple to share experiences and gain insight from others' experiences. Although talking about feelings may unburden the couple of negative feelings, infertility is a major stressor that affects the couple's relationships, so discussion with family and friends should be minimal. Limiting interaction to other infertile couples may address some psychosocial needs, but depending on where the other couples are in the recovery process, it may not be helpful. Giving an opinion about adoption is not therapeutic nor supportive of the psychosocial needs. The nurse is providing post-operative instructions for a female client after a mastectomy. Which information should the nurse include in the teaching plan? A. avoid lifting more than 4.5 kg (10 lb) or reaching above her head B. empty surgical drains once a week using procedural gloves C. report inflammation of the incision site or the affected arm D. wearing clothing with snug sleeves over the arm on the operative side - A and D Part of the client's teaching plan should include reporting evidence of inflammation at the incision or of the affected arm and to avoid lifting or reaching, which places the client at risk for injury to the extremity that may have compromised lymphatic drainage. the client should be instructed to empty surgical drains daily, no weekly. Activity that decreases circulation in the affected arm, such as carrying a handbag over the shoulder, wearing tight clothing, or tight jewelry, should be avoided. the nurse directs an unlicensed assisstive personnel (UAP) to obtain vital signs for a client who returns to the unit after having a mastectomy for cancer. What information should the nurse provide the UAP? A. elevate the arm with an IV infusing on the operative side with a pillow B. apply the blood pressure cuff to the arm on the non-operative side C. position the arm on the operative side close to the body D. collect a fingerstick blood specimen from the arm on the operative side - B. Blood pressure reading should be obtained from the arm on the unoperative side to reduce the risk of injury of the extremity that may have compromised lymphatic drainage postoperatively. The arm on the operative side of the mastectomy should be elevated on a pillow above the level of the right atrium to facilitate lymphatic drainage, not close to the body. An IV infusion or blood specimen collection should not involve the use of the arm on the operative side. Which client is at the highest risk for compromised psychological adjustment after a hysterectomy? A. a 62-year-old widow who has three friends who had uncomplicated hysterectomies B. A 29-year-old woman whose uterus ruptured after giving birth to her first child C. A 46-year-old woman with three children and a recent promotion at work D. A 55-year-old woman with abnormal bleeding and