VATI- Med-Surg Physiological Adaptations Quiz practice exam questions and answers 2024

A nurse is caring for a client dx w/ DM. The RN notes that the client has a mild tremor, slight diaphoresis & is fully oriented. Which of the following RN actions should have the highest priority? a. give 4oz of orange juice b. give D5W c. STAT glucose level d. assess BG level d. assess BG level Client is admitted to the Surgical unit after sustaining a compound fracture of the L. femur. Client is A&Ox1 w/ the following VS: T 99.4F, P 88, RR 20, BP 94/58. a 4cm area of bright red blood on pressure dressing on the L lower extremity. Client is receiving IV of NS at 150mL/hr. 1 hr afterward, client is confused & combative. Which is the following is the most like cause of the change in the client's condition? a. fluid overload r/t aggressive NS volume replacement b. hypovolemic shock r/t hemorrhage from the open wound c. hypoxia r/t fat embolism from the fracture bone d. infectious process r/t to contamination of the open wound. c. hypoxia r/t fat embolism from the fracture bone Initial s/s w/i 24-48 hrs post-fracture include confusion & combativeness 2nd hypoxemia A RN is caring for a client on the telemetry unit who is 2 days post CABG. RN recognized cardiac rhythm change from normal sinus rhythm to A.fib. Which of the following should be completed first? a. prepare a diltizem drip b. notify HCP c. assess BP d. prepare for cardioversion c. assess BP Clients react differently to A. fib. Some become HoTN & develop shock-like symptoms; changes in LOC; cool, clammy skin; dyspnea; & CP. While other are normotensive despite the decrease in CO, they are asymptomatic or considered stable. care for client who is prescribed antiembolic stocking following abdominal sx. Which of the following interventions should the nurse include? a. remove stocking 1 to 3x/day for skin care & inspection b. encourage client to only wear stockings when out of bed c. remove stocking every 2hr then reapply after 1 hr off d ensure stocking are loose fitting over the calves a. remove stocking 1 to 3x/day for skin care & inspection Client's extremities should be monitored for calf pain, warmth, erythema, & edema While teaching lifestyle modifications to a client dx w/ HTN. Which of the following statements made by the client indicates a need for further teaching? a. "We have a glass of wine a couple of times a week with dinner." b. "I don't like to walk, but I do aerobics & work out at the gym during the week." c. "I will substitute mushroom for the bacon in my daily omelets." d. "Losing weight is so hard, but so far I am losing 2lbs/wk." c. "I will substitute mushroom for the bacon in my daily omelets." daily omelets are not recommended as eggs are high in cholesterol & can lead to an increased in BP due to promotion of atherosclerosis caring for a client with Addison's disease. Which of the following diets should the client follow? a. Low Na, high K & decreased fluids b. low Na, high calcium & decreased fluids c. high Na, low calcium & increase fluids d. high Na, low K & increased fluids d. high Na, low K & increased fluids Client w/ Addison's disease should have a diet high in Na, low in K, increased fluids, and encouraged to consume small freq meals to prevent low BG. caring for client experiencing a Na level of 119 mEq/L. Which action would be most appropriate at this time? a. provide oral hygiene & comfort measures b. encourage water & other fluids c. administer 0.9%NS d. monitor for diminished breath sounds c. administer 0.9%NS administer of isotonic IV therapy would be appropriate at this time for restoration of normal ECF volume client with DI who has been prescribed aqueous vasopressin. Which of the following outcomes indicates that the treatment has been effective? a. fluid intake 2.4L/24hrs b. HR of 125bpm c. BP of 90/50 mmHg d. UOP of 200 mL/hr a. fluid intake 2.4L/24hrs treatment with Lypressin should decrease UOP & oral fluid intake which of the following should the RN use to determine the neurological status of a client with a head injury? a. manifestation of seizure activity b. RR c. pain scale d. Glasgow Coma Scale d. Glasgow Coma Scale Client is admitted to the medical unit from convalescent center for treatment of urosepsis. The client's adult daughter reports to the RN, "I don't know what to do. I love my mom and would like to have her in my home, but I just can't be with her every min, and that's what she needs now." Which of the following would be the best approach to improve integration of the elderly mother into the family structure? a. suggest that the daughter move the client into the family home on a trial basis for several wks. b. offer to refer the daughter to a counselor in an effort to better deal with her feeling of guilty c. assist the daughter in finding a caregiver who can assist the client in the convalescent center. d. determine if the daughter would consider having the client visit in her home one a day a week d. determine if the daughter would consider having the client visit in her home one a day a week RN is reviewing a client's lab result. Which finding would lead the RN to suspect the client is experiencing dehydration? a. urine specific gravity of 1.025 b. serum sodium 130 mEq/L c. BUN 20 mg/100mL d. Hct 55% d. Hct 55% an increased Hct 50% is expected with dehydration A RN is caring for a toddler who is being treated for hypovolemia. Which of the following demonstrates to the RN the desired response to the fluid replacement? a. urine specific gravity of 1.025 b apical HR 130bpm c. UOP 48mL over the past 4 hrs d. central venous pressure 2 mmHg a. urine specific gravity of 1.025 normal urine specific gravity: 1.010 to 1.030. A RN is caring for a client recovering from an abdominal aortic aneurysm (AAA) repair. Which of the following findings would have the highest priority? a. BP 136/90 b. UOP 28mL/hr c. pedal pulse amplitude 2+ d. RR 12 bpm a. BP 136/90 A RN is caring for a client recently dx with DM. Which of the following is the physiologic basis for the polyuria manifested by individuals with untreated DM? a. hyperosmolarity of the extracellular fluids 2nd to hyperglycemia b. chronic stimulation of the detrusor muscle by the ketone bodies in the urine c. inadequate secretion of ADH d. early-stage renal failure causes a loss of urine concentrating capacity a. hyperosmolarity of the extracellular fluids 2nd to hyperglycemia The hyperosmolarity of the extracellular fluids causes fluid to leak out of the cells in order to return the body to an isotonic state; hence there is increased intravascular fluid kidneys must excrete. A client is dx with A. fib has a pacemaker set at a ventricular rate of 70 bpm. Which fo the following findings should the RN immediately report to the provider? a. HR 76 bpm and irregular b. HR 60 bpm and regular c. HR 96 bpm and irregular d. HR 96 bpm and regular b. HR 60 bpm and regular The pacer should have fired when native HR 70. Pacers have a variety of modes but in each mode used, the "demand" rate determines when they will begin to fire if the heart itself has not supplied an electrical impulse