med surg nclex 2/4 Actual Questions and Answers {2022/23} {100% verified }

med surg nclex 2/4 Actual Questions and Answers {2022/23} An elderly client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client is most likely to reveal which sign/symptom? Leukocytosis and febrile. Polycythemia and crackles. Pharyngitis and sputum production. Confusion and tachycardia. Confusion and tachycardia. The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate (D). (A, B, and C) are often absent in the elderly with bacterial pneumonia. A male client receives a local anesthetic during surgery. During the post-operative assessment, the nurse notices the client is slurring his speech. Which action should the nurse take? Determine the client is anxious and allow him to sleep. Evaluate his blood pressure, pulse, and respiratory status. Review the client's pre-operative history for alcohol abuse. Continue to monitor the client for reactivity to anesthesia. Evaluate his blood pressure, pulse, and respiratory status. Slurred speech in the post-operative client who received a local anesthetic is an atypical finding and may indicate neurological deficits that require further assessment, so obtaining the client's vital signs (B) will provide information about possible cardiovascular complications, such as stroke. The client's anxiety (A), a history of alcohol abuse (D), or local anesthesia (D) are unrelated to the client's sudden onset of slurred speech. A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client? Losing weight. Decreasing caffeine intake. Avoiding large meals. Raising the head of the bed on blocks Raising the head of the bed on blocks Raising the head of the bed on blocks (D) (reverse Trendelenburg position) to reduce reflux and subsequent aspiration is the most effective recommendation for a client experiencing severe gastroesophageal reflux during sleep. (A, B and C) may be effective recommendations but raising the head of the bed is more effective for relief during sleep. What is the correct procedure for performing an ophthalmoscopic examination on a client's right retina? Instruct the client to look at examiner's nose and not move his/her eyes during the exam. Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye. From a distance of 8 to 12 inches and slightly to the side, shine the light into the client's pupil. For optimum visualization, keep the ophthalmoscope at least 3 inches from the client's eye. For optimum visualization, keep the ophthalmoscope at least 3 inches from the client's eye. The client should focus on a distant object in order to promote pupil dilation. The ophthalmoscope should be set on the 0 lens to begin (creates no correction at the beginning of the exam), and should be held in front of the examiner's left eye when examining the client's right eye. For optimum visualization, the ophthalmoscope should be kept within one to three inches of the client's eye (D). (A and B) describe incorrect methods for conducting an ophthalmoscopic examination. (C) should illicit a red reflex as the light travels through the crystalline lens to the retina. Dysrhythmias are a concern for any client. However, the presence of a dysrhythmia is more serious in an elderly person because elderly persons usually live alone and cannot summon help when symptoms appear. elderly persons are more likely to eat high-fat diets which make them susceptible to heart disease. cardiac symptoms, such as confusion, are more difficult to recognize in the elderly. elderly persons are intolerant of decreased cardiac output which may result in dizziness and falls. elderly persons are intolerant of decreased cardiac output which may result in dizziness and falls. Cardiac output is decreased with aging (D). Because of loss of contractility and elasticity, blood flow is decreased and tachycardia is poorly tolerated. Therefore, if an elderly person experiences dysrhythmia (tachycardia or bradycardia), further compromising their cardiac output, they are more likely to experience syncope, falls, transient ischemic attacks, and possibly dementia. Most elderly persons do not eat high-fat diets (B) and most are not confused (C). Although many elderly persons do live alone, inability to summon help (A) cannot be assumed. A 58-year-old client, who has no health problems, asks the nurse about the Pneumovax vaccine. The nurse's response to the client should be based on which information? The vaccine is given annually before the flu season to those over 50 years of age. The immunization is administered once to older adults or persons with a history of chronic illness. The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to five years. The immunization is administered once to older adults or persons with a history of chronic illness. It is usually recommended that persons over 65 years of age and those with a history of chronic illness receive the vaccine once in a lifetime (B). (Some resources recommend obtaining the vaccine at 50 years of age.) The influenza vaccine is given once a year, not the Pneumovax (A). Although the vaccine might be given to a person traveling overseas, that is not the main rationale for administering the vaccine (C). It is usually given once in a lifetime (D), but with immunosuppressed clients or clients with a history of pneumonia re-vaccination is sometimes required. A female client receiving IV vasopressin (Pitressin) for esophageal varice rupture reports to the nurse that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse initiate? Start an IV nitroglycerin infusion. Nasogastric lavage with cool saline. Increase the vasopressin infusion. Prepare for endotracheal intubation. Start an IV nitroglycerin infusion Vasopressin is used to promote vasoconstriction, thereby reducing bleeding. Vasoconstriction of the coronary arteries can lead to angina and myocardial infarction, and should be counteracted by IV nitroglycerin per prescribed protocol (A). (B) will not resolve the cardiac problem. (C) will worsen the problem. Endotracheal intubation may be needed if respiratory distress occurs (D). A client is admitted to the hospital with a medical diagnosis of pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor because they occur in the lower lobe alveoli which are more sensitive to infection. gram-negative organisms are more resistant to antibiotic therapy. they occur in healthy young adults who have recently been debilitated by an upper respiratory infection. gram-negative pneumonias usually affect infants and small children. . gram-negative organisms are more resistant to antibiotic therapy. The gram-negative organisms are resistant to drug therapy (B) which makes recovery very difficult. Gram-negative pneumonias affect all lobes of the lung (A). The mean age for contracting this type of pneumonia is 50 years (C and D), and it usually strikes debilitated persons such as alcoholics, diabetics, and those with chronic lung dise