Ati Med Surg Final Exam

b. decrease - A patient has a new onset of shallow and slow respirations. While the patient's body attempts to compensate, what happens to the patient's pH level? A. Stabilizes B. Decreases C. Fluctuates D. Increases D. Maintain adequate hydration - The nurse is planning care for an older adult patient with respiratory acidosis. Which intervention should the nurse include in this patient's plan of care? A. Administer prescribed intravenous fluids carefully. B. Reduce environmental stimuli. C. Administer intravenous sodium bicarbonate. D. Maintain adequate hydration B. Patient in need of permanent parental nutrition - Which patient is the most likely candidate for a tunneled central venous catheter? A. Patient in need of IV antibiotics for 2 days. B. Patient in need of permanent parental nutrition C. Patient in need of fluid replacement D. Patient with trauma from a motor vehicle accident A. Contraction of skeletal muscle E. Carbohydrate metabolism - The electrolyte magnesium is responsible for which functions? (Select all that apply.) A. Contraction of skeletal muscle B. Formation of hydrochloric acid C. Regulation of intracellular osmolarity D. Formation of ATP E. Carbohydrate metabolism C. "Fluid volume excess is common due to increased levels of antidiuretic hormone in response to the stress of surgery." - The nurse is caring for a patient who is receiving intravenous fluids postoperatively following cardiac surgery. The nurse is aware that this patient is at risk for fluid volume excess. The family asks why the patient is at risk for this condition. Which response by the nurse is the most appropriate? A. "Fluid volume excess is caused by new onset liver failure caused by the surgery." B. "Fluid volume excess is caused by inactivity." C. "Fluid volume excess is common due to increased levels of antidiuretic hormone in response to the stress of surgery." D. "Fluid volume excess is caused by the intravenous fluids." A. spinach B. low-fat milk D. sweet potato - The nurse educates a patient who is prescribed furosemide (Lasix) for congestive heart failure on foods rich in potassium. Which patient menu choices indicate to the nurse a correct understanding of the information presented? Select all that apply. A. Spinach B. Low-fat milk C. Pasta D. A sweet potato E. Apple sauce D. Catheter should be removed slowly and a sterile occlusive dressing placed over the insertion site immediately. - When removing a patient's central line dressing, which action by the nurse is the priority? A. Pulling the tape off in the direction of the catheter B. Applying sterile gloves C. Inspecting the insertion site for signs of infection D. Catheter should be removed slowly and a sterile occlusive dressing placed over the insertion site immediately C. Stopping the blood infusion, removing the tubing from the IV catheter, and replacing it with normal saline. - The nurse is administering a blood transfusion to an adult patient. The patient reports feeling cold and is shivering 15 minutes after the initiation of the transfusion. The patient's blood pressure has decreased since the last assessment. Which is the nurse's priority action? A. Slowing the infusion rate and notifying the healthcare provider B. Stopping the blood infusion, and infusing normal saline through the existing intravenous (IV) tubing C. Stopping the blood infusion, removing the tubing from the IV catheter, and replacing it with normal saline D. Slowing the infusion rate and continuing to monitor the blood pressure every 5 minutes B. Tap the facial nerve anterior to the earlobe and just below the zygomatic arch, and observe for facial twitching on the same side as the stimulus - A nurse is assessing a client for signs of hypocalcemia. which action should the nurse perform to assess for the presence of Chvostek's sign? A. Apply a blood pressure cuff to the upper arm, inflate the cuff to a reading high than the clients systolic blood pressure for 1-4 minutes and observe for carpopedal spasm B. Tap the facial nerve anterior to the earlobe and just below the zygomatic arch, and observe for facial twitching on the same side as the stimulus C. Assess the biceps, triceps, and brachioradialis reflexes of the arm and wrist , and observe for hyperstimualtion D.Instruct the client to hyperventilate, and observe for muscle spasms of the hands or feet. B. Hypotonic fluid loss C. Hypertonic fluid loss E. Hyponatremia - A patient is taking diuretic drugs. Which fluid or electrolyte imbalance can occur in this patient (select all that apply) A. Hypocalcemia B. Hypotonic fluid loss C. Hypertonic fluid loss D. Hyperkalemia E. Hyponatremia C. 5% dextrose in Lactated ringers - Which intravenous (IV) fluid should the nurse prepare when a patient requires a hypertonic solution? A. 0.33% sodium chloride B. 2.5% dextrose in water C. 5% dextrose in Lactated ringers D. 0.9% normal saline C. Metabolic acidosis - A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? A. Respiratory acidosis B. Metabolic alkalosis C. Metabolic acidosis D. Respiratory alkalosis B. Respiratory acidosis - A patient with lung cancer is admitted to the hospital for respiratory distress. Which imbalances does the nurse expect this patient to have? . A. Hypermagnesemia B. Respiratory acidosis C. Hypokalemia D. Metabolic alkalosis A,B,C,D - Which patients may benefit from central intravenous (IV) access? Select all that apply. A. The patient requiring long-term IV therapy. B. The patient requiring numerous IV infusions that are not compatible and cannot be infused together. C. The patient receiving caustic (harmful to tissue) IV therapy. D. The unstable patient requiring reliable IV access for administration of medications required. immediately. E. The patient who is afraid of needles and does not want a catheter in the peripheral extremity. A. Reporting patient's complaints of pain or leakage from the IV site when bathing the patient - Which aspect of intravenous (IV) therapy could the nurse safely delegate to the unlicensed assistive personnel (UAP)? A. Reporting patient's complaints of pain or leakage from the IV site when bathing the patient B. Changing the IV site dressing on the patient's left hand C. Watching the IV insertion site of the patient who complained of pain at the site D. Replacing patient's IV solution when bag runs dry if it is only D5W, without medications added C. Monitoring oxygen saturation - Which is the priority nursing action when providing care to a patient who is admitted with metabolic alkalosis? A. Administering prescribed medications B. Setting goals for the plan of care C. Monitoring oxygen saturation D. Teaching the family about risk factors C. Dehydration - An older adult patient, who lives in a long-term care facility, presents in the emergency department (ED) due to fever, nausea, and vomiting over the past two days. The patient denies thirst. The urine dipstick indicates a decreased urine specific gravity. Which medical diagnosis should the nurse anticipate when planning care for this patient? . A. Congestive heart failure B. Fluid overload C. Dehydration D. Hypertension D. Assessing respiratory rate and depth closely - The nurse provides care to a patient admitted for a traumatic brain injury. The patient's arterial blood gas (ABG) analysis indicates respiratory acidosis. Which action by the nurse is best when providing care to this patient? . A. Administering sodium bicarbonate, per prescription B. Monitoring peripheral vascular status C. Reassuring the patient to decrease anxiety D. Assessing respiratory rate and depth closely D. 20 - The nurse prepares to initiate intravenous (IV) access for an older adult patient who requires a blood transfusion. Which gauge needle is best for the nurse to use for this procedure? A. 22 B. 18 C. 24 D. 20 A. Dextrose 5% in 0.45% normal saline - The nurse is reviewing new healthcare provider orders on a patient admitted for treatment of severe dehydration. The patient's serum osmolality is 300 mOsm/kg. It is a priority for the nurse to follow up with the provider if which solution is ordered? A. Dextrose 5% in 0.45% normal saline B. 5% Dextrose in lactated Ringer's solution (D5LR) C. 0.45% Normal saline D. Dextrose 5% in 0.9% normal saline B. "Your request not to receive a transfusion would be honored." - During a presurgical admission assessment, the client states, "I've told my surgeon that I am Jehovah's Witness and I won't accept a blood transfusion," Which statement by the nurse would be MOST appropriate? . A. "Are you sure you wouldn't want a trasnfusion if one is needed?" B. "Your request not to receive a transfusion would be honored." C. "Don't worry; there is less blood loss with our newer equipment." D. "Tell me more about your fear of receiving a blood transfusion." D. Arterial blood gases - Which diagnostic test should the nurse anticipate when providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD) to monitor acid-base balance? . A. Pulse oximetry B. Bronchoscopy C. Sputum studies D. Arterial blood gases D. Daily weight - A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance? A. Hourly urine output B. Presence of edema C. Skin turgor D. Daily weight B. pH is 7.47 and PaCO2 is 25. - The nurse The nurse is providing care to a patient who is admitted to the hospital with sudden, severe abdominal pain. Which arterial blood gas supports the patient's current diagnosis of respiratory alkalosis? . A. pH is 7.35 and PaO2 is 88. B. pH is 7.47 and PaCO2 is 25. C. pH is 7.33 and PaCO2 is 36. D. pH is 7.30 and HCO3 is 30. D. Daily alcohol intake - A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value? . A. Over-the-counter (OTC) laxative use B. Dietary protein intake C. Multivitamin/mineral use D. Daily alcohol intake A. Implement measures to notify the local or state health department about the case. - The infection control nurse receives hospital laboratory confirmation that the client has positive sputum cultures for Mycobacterium tuberculosis.Which action should be taken by the nurse? A. Implement measures to notify the local or state health department about the case. B. Prepare a statement for the hospital spokesperson to release to the news agencies. C. Recommend that only staff with recent negative tuberculin skin tests provide care. D. Notify the nearest infection disease facility and prepare the client for transfer B. First to second intercoastal spaces - Where does the nurse auscultate bronchial vesicular sounds? A. Peripheral lung fields B. First to second intercoastal spaces C. Neck D. Trachea A. Offer high-calorie snacks between meals and at bedtime. - A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which intervention would be most appropriate for the nurse to include in the plan of care? A. Offer high-calorie snacks between meals and at bedtime. B. Assist the patient in choosing foods with high vegetable and mineral content. C. Encourage increased intake of whole grains. D. Increase the patient's intake of fruits and fruit juices. A, C, D, E. - Which interventions does the nurse implement when providing care for a patient who is admitted for the treatment of active tuberculosis? Select all that apply. . A. Places the patient in a private, negative airflow room B. Wears a surgical mask when providing patient care C. Places a surgical mask on the patient to transport to radiology D. Wear eye protection when collecting sputum samples E. Places the patient on droplet precautions A, B, D. - The nurse assesses for coarse crackles (coarse rales) in patients admitted with which respiratory disorders? Select all that apply. . A. Pneumonia B. Pulmonary edema C. Asthma D. Chronic obstructive pulmonary disease (COPD) E. Bronchitis A. Decreased force of cough D. Decreased functional cilia - Which age-related changes in the respiratory system cause decreased secretion clearance? (Select all that apply) . A. Decreased force of cough B. Small airway closure earlier in expiration C. Decreased functional immunoglobulin A (IgA) D. Decreased functional cilia E. Decreased chest wall compliance