Understanding Med-Surg Chapter 1 Questions and Answers with verified solutions

Understanding Med-Surg Chapter 1 Questions and Answers with verified solutions 31. A patient with a history of respiratory disease is recovering from total hip replacement surgery. In which order should the nurse address the patients diagnoses? (Place in order from 1 to 4.) A. _____ Acute pain related to surgery B. _____ Risk for injury related to unsteady gait C. _____ Deficient knowledge related to use of a walker D. _____ Impaired gas exchange related to compromised respiratory system - ANS -D,A,B,C A patient with a family history of diabetes is experiencing high blood glucose levels, confusion, an unsteady gait, and dehydration. Which nursing diagnoses should the nurse identify as appropriate for this patients care? (Select all that apply.) a. Diabetes b. Dehydration c. Risk for falls d. Hyperglycemia e. Deficient fluid volume - ANS -c. Risk for falls e. Deficient fluid volume A patient with a newly fractured femur reports a pain level of 8/10, and analgesic medication is not due for another 50 minutes. Which actions should the nurse take? a. Reposition the patient. b. Give the medication in 30 minutes. c. Notify the registered nurse (RN) or physician. d. Tell the patient it is too early for pain medication - ANS -c. Notify the registered nurse (RN) or physician. A RN delegates a patient care assignment to the LPN/LVN. Which phase of the nursing process should the LPN/LVN perform independently? a. Assessment b. Planning care c. Implementation d. Nursing diagnosis - ANS -c. Implementation After collecting data the nurse identifies diagnoses to guide the patients care. Which diagnoses did the nurse document correctly? (Select all that apply.) a. Diabetes b. Acute pain c. Pancreatitis d. Activity intolerance e. Impaired physical mobility - ANS -b. Acute pain d. Activity intolerance e. Impaired physical mobility After identifying nursing diagnoses, the nurse plans outcomes for a patient with gastroesophageal reflux disease. Which outcome should the nurse use to evaluate this patients care? a. The patient will have less heartburn. b. The patient will sleep through the night. c. The patients esophageal burning will resolve 30 minutes after taking oral antacids. d. The patient will state that burning only occurs when eating foods high in acid content - ANS -c. The patients esophageal burning will resolve 30 minutes after taking oral antacids. After receiving morning report, which patient should the licensed practical nurse/licensed vocational nurse (LPN/LVN) assess first? a. A patient who needs discharge teaching b. A patient who needs assistance to ambulate c. A patient who states, No one cares about me. d. A patient who has a temperature of 106F (41.1C) - ANS -d. A patient who has a temperature of 106F (41.1C) During a class discussion, two nursing students demonstrated intellectual courage. What action did the nursing students perform? a. Considered being in the other persons situation b. Expected proof that the use of restraints is safe c. Conducted additional research on the use of restraints in patient care d. Listened to each others point of view regarding the use of patient restraints - ANS -d. Listened to each others point of view regarding the use of patient restraints During morning report, the LPN/LVN is assigned a group of patients. Which patient should the LPN/LVN see first? a. A patient scheduled for magnetic resonance imaging (MRI) due to back pain b. A patient reporting constipation and stomach cramps c. A 2-day postsurgical patient reporting pain at a level of 6 d. A patient with pneumonia who is short of breath and anxious - ANS -d. A patient with pneumonia who is short of breath and anxious The LPN/LVN is reviewing a patients list of nursing diagnoses. Which diagnoses should the LPN/LVN identify as a priority for this patient? a. Anxiety b. Constipation c. Deficient fluid volume d. Ineffective airway clearance - ANS -d. Ineffective airway clearance The nurse approaches a person in a restaurant who appears to be experiencing respiratory distress. Which action should the nurse perform first? a. Diagnose the problem. b. Help the person lie down. c. Gather data from other people. d. Collect data about the persons condition - ANS -d. Collect data about the persons condition The nurse finishes collecting data on a patient with injuries from a motor vehicle crash. Which data should the nurse document as objective? (Select all that apply.) a. Patient in no acute distress b. I cant believe I wrecked my car. c. Complains of pain when moving arms d. Oxygen saturation level 92% on room air e. Mid-forehead wound 3 cm long, oozing blood - ANS -d. Oxygen saturation level 92% on room air e. Mid-forehead wound 3 cm long, oozing blood The nurse identifies the diagnosis Fluid Volume Overload as appropriate for a patient with heart failure. Which collected data should the nurse use to provide evidence for this diagnosis? a. Skin warm to the touch b. Oriented to person only c. Respiratory rate 20 and shallow d. +3 pitting edema of both feet and ankles - ANS -d. +3 pitting edema of both feet and ankles The nurse identifies the diagnosis Potential for Ineffective Gas Exchange as appropriate for a patient with pneumonia. Which independent nursing actions should the nurse plan for this problem? (Select all that apply.) a. Apply oxygen, 2 liters, per nasal cannula. b. Turn and reposition in bed every 2 hours. c. Coach to deep breathe and cough every hour. d. Administer intramuscular antibiotic medication. e. Encourage to drink 240 mL of fluid every 2 hours. - ANS -b. Turn and reposition in bed every 2 hours. c. Coach to deep breathe and cough every hour. e. Encourage to drink 240 mL of fluid every 2 hours. The nurse is caring for a patient recovering from a stroke. Use the nursing process to order the observations made or actions performed while caring for this patient (AE). A. Hand grasp absent left hand B. Alteration in Cerebral Perfusion C. The patient flexed left thumb and index finger. D. Coached to squeeze rubber ball placed in left hand.