Medical-Surgical Nursing Exam 1 Questions and Answers with verified solutions

Medical-Surgical Nursing Exam 1 Questions and Answers with verified solutions A 2-day postoperative patient is receiving 1000 mL normal saline over 10 hours. The patient has an intake of 4 ounces of orange juice, one 8-ounce cup of coffee, 3 cups of water, and 1 cup of tea. This patient has a total intake of _________ mL over the 12-hour period. - ANS -2520 A 63-year-old Arab American male states his left leg is "hot." What is the nurse's best first response? - ANS -Assess for pain A client experiencing shock has had a urinary output of 250 mL in the last 10 hours. What is the nurse's most appropriate response? - ANS -Notify the physician. A client has had abdominal surgery and has orders to be ambulated three times a day. Oral pain medication has been ordered for the client. What should the nurse do to facilitate ambulation? - ANS -Mediate 1 hour prior to ambulating the client. A client with chronic pain has been admitted with a fever. The nursing assessment reveals that the client has a decreased level of consciousness. What should the nurse ask the family about? - ANS -What medications the client has taken A college student is brought into the emergency department with possible frostbite of both feet after losing consciousness in a snow drift while walking home from a party. What actions should the nurse take at this time? Select all that apply. - ANS -Handle the feet gently. Elevate the feet to heart level. Cover the feet with dry sterile gauze. A community is experiencing an epidemic of chickenpox within school age children. The nurse should realize that which of the following factors results in a more than 80% infection rate among those exposed? - ANS -The causative virus has three modes of transmission. A family member of a patient in shock says that being in shock should not be that critical because it can be treated. What should the nurse explain about the major body damage caused by shock? - ANS -Inadequate oxygen delivered to cells A high school football player suffered an injury while playing and is brought to the emergency room. The primary survey shows an alert patient with patent airway, breathing, a carotid pulse, and skin color within normal limits. The patient reports, "I can't flex my foot or point my toes." On which area should the nurse expect diagnostic tests to focus for this patient? - ANS -The lower back A nurse is wearing a fit-tested, high-efficiency particulate air respirator when entering the room of a patient. For which patient is the nurse preparing to provide care? - ANS -A 36-year-old with tuberculosis A patient diagnosed with hypovolemic shock has an estimated blood loss of 500 mL, 250 mL of emesis, and 250 mL of insensible water losses. The health care provider prescribes the patient to receive 3 mL of 0.9% normal saline via IV infusion to replace each mL of fluid loss to be infused over 24 hours. How many mL of the fluid should the patient receive each hour? Calculate to the nearest whole number. - ANS -125 A patient experiencing painful back spasms plans to stop taking prescribed pain medication and resume weekly massage therapy sessions. How should the nurse respond to this patient's plan? - ANS -"Massage therapy should be used in addition to the pain medication." A patient has an epidural catheter placed for pain control. Which medications should the nurse question before providing them to the patient during routine medication administration? Select all that apply. - ANS -Aspirin 325 mg by mouth once a day Warfarin (Coumadin) 2.5 mg by mouth every evening A patient has been receiving 10 mg morphine IV every 4 to 6 hours for postoperative pain. At discharge, the patient rates the pain as a 4 on a 0-10 scale. On a prescription to be given to the patient at discharge, the physician has written morphine 10 mg by mouth four times a day as needed. What should the nurse do first? - ANS -Contact the physician regarding the prescription. A patient is being released from the hospital with a prescription for tetracycline. What should the nurse include in patient teaching? Select all that apply. - ANS -Advise limiting exposure to the sun. Inform patient of the possibility of gastrointestinal upset. Suggest eating crackers and some juice when taking this medicine. A patient is being treated for anaphylactic shock caused by a hornet sting. What should the nurse ensure occurs before the patient is discharged? - ANS -Receive a prescription for epinephrine auto-injector. A patient is demonstrating manifestations of an opioid overdose. Which drug should the nurse expect to be prescribed for this patient? - ANS -Naloxone (Narcan) A patient is diagnosed with a type of cancer that affects the skin and urinary system. What term should the nurse use to describe this type of cancer? - ANS -Carcinoma A patient is diagnosed with an illness caused by a prion. The nurse should plan patient care for which diseases process? - ANS -Creutzfeldt-Jakob syndrome A patient is diagnosed with an infection that has spread to the blood stream. Which term should the nurse use to document this patient's health problem? - ANS -Sepsis A patient is diagnosed with conjunctivitis. The nurse should explain that the patient was infected via which mechanism? - ANS -Vehicle-borne A patient is diagnosed with distributive shock. What should the nurse explain to the family as the cause of this type of shock? - ANS -Excessive dilation of venules and arterioles A patient is diagnosed with Rocky Mountain spotted fever. What should the nurse explain as the method by which this disease was transmitted to the patient? - ANS -Ticks A patient is diagnosed with shingles. What organism should the nurse explain as causing this health problem in the patient? - ANS -Varicella zoster A patient is diagnosed with the Epstein-Barr virus. Epstein-Barr put the patient at increased risk for which type of cancer? - ANS -Lymphoma A patient is diagnosed with the most common type of distributive shock. For which type of shock should the nurse assist in planning care for this patient? - ANS -Septic shock A patient is experiencing a drop in blood pressure. What should the nurse expect to assess in this patient? Select all that apply. - ANS -Epinephrine is released. The heart beats faster and stronger. The body retains sodium and water. Blood is shunted away from the skin, intestines, and kidneys. A patient is experiencing blurred vision, dysphagia, dysphonia, dysarthria, diplopia, and descending flaccid paralysis. For which type of poisoning should the nurse plan care for this patient? - ANS -Botulism A patient is experiencing moderate-to-severe pain. Which pain medication should the nurse expect to be prescribed for this patient? - ANS -Morphine A patient is experiencing respiratory depression, constipation, nausea and vomiting, and hypotension after receiving pain medication. Which class of analgesics is this patient most likely receiving? - ANS -Opioid analgesics A patient is experiencing severe diarrhea after each chemotherapy treatment. Which intervention(s) should the nurse incorporate in this patient's plan of care? Select all that apply. - ANS -Remove foods with high-fiber content. Eliminate foods containing lactose from the diet. Incorporate apples, strawberries, and citrus foods with each meal. A patient is having a regional block where a tourniquet is placed on an extremity to reduce the blood in the extremity and then have a local agent injected into the extremity. What type of block should the nurse document? - ANS -Bier block A patient is having procedural sedation and analgesia for a short surgical procedure. How often should the nurse monitor the patient's vital signs? - ANS -Every 5 minutes A patient is prescribed a dose of ondansetron (Zofran) before surgery. What should the nurse explain to the patient about the purpose of this medication? - ANS -Reduces emesis A patient is prescribed an antibiotic to treat a lung infection. What should the nurse emphasize to the patient about this medication? Select all that apply. - ANS -Take all of the medication as prescribed. Report evidence of side effects to the HCP. A patient is prescribed the alkylating agent ifosfamide (Ifex) as treatment for cancer. Which intervention(s) should the nurse include in this patient's plan of care? Select all that apply. - ANS -Monitor urine output for blood. Review daily complete blood counts.