NUR 410 Med-Surg: Final Exam Comprehensive Questions and Answers 100% Accuracy|Updated 2024

Which IV solution should the nurse anticipate administering to a client who sustained severe burns? A. D5W (5% dextrose in water) B. Lactated Ringers solution C. D5 1/2 normal saline with 20 mEq of potassium chloride. D. Hespan - ANS B. Lactated Ringers solution The nurse on the burn unit provides care for a client with a new autograft on the left elbow. Which actions does the nurse take to improve skin graft outcomes? (select all that apply) A. Conduct range of motion exercises daily. B. Maintain gauze dressing over autograft for 3-5 days. C. Assist with incentive spirometry hourly while awake. D. Increase ambulation to tolerance. E. Immobilize the left arm. - ANS B & E The nurse assesses a newly admitted client following a burn injury. Which assessment findings cause the nurse to suspect inhalation injury? (Select all that apply) Facial burns Singed nasal hair Hemoptysis Heart rate 112 beats/min Audible Stridor - ANS Audible stridor Facial burns Singed nasal hair A client admitted to the emergency room with burns covering 45% of the total body surface area (TBSA) requires aggressive fluid resuscitation. What is the anticipated duration for fluid resuscitation intervention? . 12 hours B. 24 hours C. 48 hours D. 72 hours - ANS B. 24 hours The clinic nurse instructs a client with partial-thickness burns of the thighs on how to clean and dress the wounds. At the next visit, the nurse notes the wounds are dirty and not covered by dressings. What actions does the nurse take? A. Inform the client the health care provider will not treat someone who is noncompliant. B. Review the dressing change, using the teach-back method. C. Ask the client why she is not following the instructions. D. Describe the physiology of burn healing and infection processes. - ANS B. Review the dressing change, using the teach-back method. The triage nurse assesses a client with burns on the right arm and leg. The client is crying with pain, the burnt skin is red, and large wet blisters are present. Which depth of injury does the nurse suspect? A. Full thickness burn B. Superficial partial thickness burn C. Superficial burn D. Deep partial thickness burn - ANS B. Superficial partial thickness burn What pain medication should the nurse administer to a client with a 35% TBSA burn? A. Morphine IVP B. Fentanyl patch C. Ketorolac IVP D. Morphine IM - ANS A. Morphine IVP While collecting a medical history on a client who experienced a severe burn, which statement by the client's husband requires intervention? A. "She takes medication for menopause." B. "I think it has been at least 15 years since her last tetanus shot". C. "She smokes 1.5 packs of cigarettes a day." D. "She found out she has COPD about 2 years ago." - ANS B. "I think it has been at least 15 years since her last tetanus shot". A client has burns covering the anterior torso, anterior arms (bilateral), and anterior legs (bilateral). What percentage of the total body surface area (BSA) does the nurse estimate is affected? (Record your answer rounding to the nearest whole number.) 27 % 45 % 54 % 72 % - ANS 45 % A client sustains major burns on the anterior thorax, head, and bilateral upper extremities following a house fire. What is the initial A. Restore hemodynamic stability. B. Maintain patent airway. C. Prevent infection. D. Initiate intravascular resuscitation. - ANS B. Maintain patent airway. During Fluid Resuscitation, how much fluid should be administered in the first 8 hrs? And then the next 16 hrs? - ANS Half of the fluid is given in the first 8hrs. The remaining is given in the next 16 hrs. Care for graft site - ANS elevate and immobilize the graft site keep free from pressure avoid weight bearing activities use cotton tip to removed exudate monitor for signs of infection avoid softeners/hard detergents protect from sun light use splints as prescribed How long must compression dressing be worn each day? and for what purpose? - ANS 23 out of 24 hours. Saves mobility and prevents scarring Important concepts for burns - ANS -Cardiac monitoring -Infection Control -Shock (sepsis) A client is brought to the emergency department with 35% TBSA burns. Which actions should the nurse implement for this client? A. Administer oxygen as required. B. Apply a cooling blanket on the client. C. Assess airway for patency. D. Elevate extremities if no fractures are present. E. Administer IVF resuscitation. F. Administer IM pain medication as needed - ANS A, C, D, E Which client should the nurse see first? A. The client with burns to the chest and neck while grilling. B. The client with a burn to her left hand and arm from spilling boiling water. C. The client with a full-thickness burn to the leg from riding his motorcycle. D. The client with a chemical burn to his left leg. - ANS A. The client with burns to the chest and neck while grilling. Review the client's information below and identify the intervention to implement first. Vital Signs Temperature 97.6 orally Heart Rate: 114 Respiratory Rate: 24 Blood Pressure 98/54 Oxygen Saturation 94 on venturi mask Assessment Serous exudate from the wound Lungs clear to auscultation but diminished Urine output 20 ml for the past hours Pain rating a 5 out of 10 A. Administer prescribed antibiotics. B. Increase the IVF per order. C. Encourage the use of the incentive spirometer. D. Administer the PRN pain medication. - ANS B. Increase the IVF per oder. An adult client was burned in a car fire. The client sustained a circumferential burn to the right arm, the anterior torso, and half of the anterior face. What percent of the body was burned using the rule of nines? A. 15.75% B. 27% C. 29.25% D. 31.5% - ANS C. 29.25% Which is the most serious complication for which the nurse must monitor a client with kidney failure? A. Platelet dysfunction B. Hyperkalemia C. Weight loss D. Anemia - ANS B. Hyperkalemia A client who has been receiving hemodialysis for several years is to receive a kidney transplant. What should the nurse say in the client's preoperative teaching plan? Select all that apply. A. The kidney may not function immediately B. Precautions are needed to prevent infection C. A urinary catheter will be in place postoperatively D. The atrioventricular fistula will be used for drawing blood specimens preoperatively E. Immunosuppressive medications will be given a week before surgery - ANS A. The kidney may not function immediately B. Precautions are needed to prevent infection C. A urinary catheter will be in place postoperatively A nurse is caring for a client with chronic kidney failure. What should the nurse teach the client to limit the intake of to help control uremia associated with end stage renal disease (ESRD)? A. Sodium B. Fluid C. Protein D. Potassium - ANS C. Protein A nurse is caring for a client who had a kidney transplant. Which test is most important for determining whether a client's newly transplanted kidney is working effectively? A. Renal scan B. White blood cell (WBC) count C. 24-hour urine output D. Serum creatinine - ANS D. Serum creatinine A client who is to begin continuous ambulatory peritoneal dialysis asks the nurse what this entails. What information should the nurse include when answering the client's question? A. Constant contact is maintained between the dialysate and the peritoneal membrane B. Peritoneal dialysis is performed in an ambulatory clinic C. About a quarter of a liter of dialysate is maintained in the peritoneal cavity D. Hemodialysis and peritoneal dialysis will be done together. - ANS A. Constant contact is maintained between the dialysate and the peritoneal membrane A client develops kidney damage as a result of a transfusion reaction. What is the most significant clinical response that the nurse should assess when determining kidney damage? A. Glycosuria B. Acute flank pain C. Hematuria D. Decreased urinary output - ANS D. Decreased urinary output The nurse would clarify which provider prescription for the client with acute kidney injury in the oliguric phase? A. Normal saline 125 ml/hr continuous intravenous infusion B. Furosemide 40 mg by mouth daily C. Place on a 1500 mg per day sodium restriction D. Decrease protein dietary intake - ANS A. Normal saline 125 ml/hr continuous intravenous infusion A male client receiving hemodialysis undergoes surgery to create an arteriovenous fistula. Before discharge, the nurse discusses care at home with the client and his wife. Which statement by the client's wife indicates that further teaching is required? A. "We really should check the fistula every day for signs of redness and swelling." B. "I must touch the shunt several times a day to feel for the bruit." C. "I have to take his blood pressure every day in the arm with the fistula." D. "He will have to be very careful at night not to lie on the arm with the fistula." - ANS C. "I have to take his blood pressure every day in the arm with the fistula." A nurse is caring for a client receiving hemodialysis for chronic kidney disease. The nurse should monitor the client for what complication? A. Bladder infection B. Peritonititis C. Hepatitis B D. Renal calculi - ANS C. Hepatitis B A client is receiving epoetin (Epogen) for the treatment of anemia associated with chronic renal failure. Which client statement indicates to the nurse that further teaching about this medication is necessary? A. "I understand that I may still need blood transfusions if my blood values are very low." B. "I know that I will still have to take supplemental iron therapy with this medication." C. "I know many ways to protect myself from injury because I am at risk for seizures." D. "I realize it is important to take this medication because it will cure my anemia." - ANS D. "I realize it is important to take this medication because it will cure my anemia." Normal creatinine levels - ANS 0.8-1.4 mg/dL Normal BUN levels - ANS 10-20 GFR is concerning if it is < than ? - ANS 60 Diet for CKD - ANS low sodium, low protein, low phosphorus A client is admitted to the hospital with a diagnosis of chronic kidney disease. Which manifestations should the nurse monitor the client with CKD for? Select all that apply. A. Parasthesias B. Polyuria C. Hypotension D. Metabolic Acidosis E. Widening pulse pressure - ANS A. Parasthesias D. Metabolic Acidosis A 6-year-old child is in the acute phase of nephrotic syndrome. The mother asks the nurse about play activities for her child. What should the nurse suggest? A. 20 piece puzzles B. Hula hoop C. Stuffed animal D. Video games - ANS D. Video games A nurse is caring for a client with acute renal failure. Which findings should the nurse anticipate when reviewing the laboratory report of the client's blood level of calcium, potassium, and creatinine? Select all that apply. A. Calcium: 7.6 mg/dL B. Calcium: 10.5 mg/dL C. Potassium 5.9 mEq/L D. Potassium 3.2 mEq/L E. Creatinine: 3.2 mg/dL F. Creatinine: 1.1 mg/dL - ANS A. Calcium: 7.6 mg/dL C. Potassium 5.9 mEq/L E. Creatinine: 3.2 mg/dL A nurse in the pediatric clinic should be most observant for signs of cerebral palsy in a 6-month-old infant who was born: Selected Answer:C. A. In an elective cesarean birth B. Exhibiting the Moro reflex C. During the 32nd week of gestation D. To a 40-year-old mother - ANS C. During the 32nd week of gestation After a client is treated for a spinal cord injury, the health care provider informs the family that the client is a paraplegic. The family asks the nurse what this means. What explanation should the nurse provide? :A. One side of the body is paralyzed B. Lower extremities are paralyzed C. Upper extremities are paralyzed D. Both lower and upper extremities are paralyzed - ANS B. Lower extremities are paralyzed A client is in the intensive care unit after sustaining a T2 spinal cord injury. Which priority interventions should the nurse include in the client's plan of care? Select all that apply. A. Minimizing environmental stimuli B. Discussing long-term treatment plans with the family C. Initiating a bowel and bladder training program D. Monitoring and maintaining blood pressure E. Assessing for respiratory complications - ANS D. Monitoring and maintaining blood pressure E. Assessing for respiratory complications A young adult client is hospitalized with a spinal cord injury. The client, knowing that the paralysis may be permanent, says, "I wish God would end my suffering and take me." What is the most therapeutic initial response by the nurse? A. "Would you like to speak to a religious advisor?" B. "Being incapacitated is difficult for you." C. "Have you talked to your family about your feelings?" D. "You shouldn't give up hope." - ANS B. "Being incapacitated is difficult for you." Why does the nurse plan to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level? A. There is a damage above the sixth thoracic vertebra. B. There is partial transection of the cord. C. Reflexes have been lost. D. Flaccid paralysis of the lower extremities has occurred. - ANS A. There is a damage above the sixth thoracic vertebra. A nurse is concerned about helping the parents of an infant with cerebral palsy set long-term goals for the family. These goals should be set with the understanding that: A. Progressive deterioration requires future institutionalization. B. Diminished immune responses require protection from infection. C. Cognitive impairments require special education. D. Unknown extent of the disability requires continual adjustments - ANS D. Unknown extent of the disability requires continual adjustments. What is the primary reason the nurse encourages a client with a spinal cord injury to increase oral fluid intake? A. To prevent urinary tract infections B. To prevent electrolyte imbalances C. To prevent skin breakdown D. To prevent dehydration - ANS A. To prevent urinary tract infections A 9-year-old child who has cerebral palsy and scoliosis also is mentally challenged and blind. The child is incontinent, has contractures of the elbows and wrists, and sits in a customized wheelchair most of the day. One goal of nursing care is for the child's skin integrity to remain intact. Which nursing action will best achieve this goal? A. Padding the child's lower extremities B. Repositioning the child every 4 hours C. Replacing the bed linens with sterile linens D. Changing disposable diapers every 2 to 3 hours - ANS D. Changing disposable diapers every 2 to 3 hours Answers:A. A nurse in the emergency department is caring for a 9-year-old child with a suspected spinal cord injury sustained while falling off a bicycle. What is the initial nursing action? A. Log-rolling the child to check for lacerations on the back B. Moving the child onto a firm stretcher for transport to the radiography department C. Placing the child's head on a pillow for support D. Immobilizing the child's spine to limit additional injury - ANS D. Immobilizing the child's spine to limit additional injury A mother whose infant was found to have cerebral palsy at 6 months of age asks why she was not told that her baby had cerebral palsy when the infant was born. How should the nurse respond? A. "Joint deformities don't appear until after 6 months of age." B. "The staff members didn't want to alarm you until it was necessary." C. "The neurological lesions changed as your baby matured." D. "Until there's control of voluntary movement a diagnosis can't be confirmed." - ANS D. "Until there's control of voluntary movement a diagnosis can't be confirmed." While completing a physical assessment, the nurse shines a light into the client's right eye and notes left pupil constriction. Which term does the nurse use for the assessment finding? A. Consensual response B. Accommodation C. Pupillary convergence D. Direct response - ANS A. Consensual response A client admitted for traumatic brain injury with a depressed skull fracture becomes restless. Which intervention is the priority related to this finding? A. Perform a focused assessment. B. Place the call light within reach. C. Prevent skin breakdown while immobile. D. Place the client on a bed alarm. - ANS A. Perform a focused assessment. The nurse manager creates the daily assignments. Which clients are appropriate to assign to the practical nurse (PN)? A. A postoperative client who has a prescription for packed red blood cell and platelet transfusions. B. A client who requires frequent administration of doses of IV push hydromorphone and promethazine. C. A client with quadriplegia who requires routine care and suctioning of a tracheostomy. D. A client who has heart failure and a peripheral IV catheter which needs to be removed. E. A client who pulled out a nasogastric tube and needs it replaced. - ANS C. A client with quadriplegia who requires routine care and suctioning of a tracheostomy. D. A client who has heart failure and a peripheral IV catheter which needs to be removed. E. A client who pulled out a nasogastric tube and needs it replaced. The nurse cares for a client with traumatic brain injury on continuous mechanical ventilation. The nurse assesses sluggish pupils and an increase in blood pressure. Which intervention does the nurse implement first? A. Call the healthcare provider to recommend and request hyperventilating the client. B. Auscultate four quadrants of the client's abdomen to complete assessment. C. Palpate carotid and radial pulses while noting rate, strength, and regularity. D. Dim room lights, turn off the TV, and quiet machine alarms if possible. - ANS A. Call the healthcare provider to recommend and request hyperventilating the client. The nurse cares for a client with Parkinson disease. Which intervention taken by the nurse promotes safe ambulation? A. Walk side by side with the client while supporting the client's back. B. Assist the client to stand and push a wheelchair along the hall. C. Encourage the client to place their hand along the wall as they walk. D. Provide the client with non-skid socks and a walker. - ANS D. Provide the client with non-skid socks and a walker. A nurse performs a home visit for a client with Parkinson disease. Which manifestation does the nurse recognize as consistent with the disease? A. Micrographia B. Tremors C. Loud voice D. Hypertension E. Bradykinesia - ANS A. Micrographia B. Tremors E. Bradykinesia A nurse is caring for a client who had a traumatic brain injury with increased intracranial pressure. What health care provider prescription should the nurse question? A. Keep head of bed at thirty degrees B. Teach isometric exercises C. Continue osmotic diuretics D. Continue anticonvulsants - ANS B. Teach isometric exercises A client is admitted with a closed head injury sustained in a motor vehicle accident (MVA). The nursing assessment indicates increased intracranial pressure (ICP). Which intervention should the nurse perform first? A. Increase the ventilator's respiratory rate to 20 breaths/minute. B. Administer 1 gram mannitol intravenously (IV) as prescribed. C. Place the head and neck in alignment. D. Administer 100 mg of pentobarbital IV as prescribed. - ANS C. Place the head and neck in alignment. The nurse cares for a client with Parkinson disease. Which intervention is included in the nursing care plan? A. Provide 3 scheduled meals per day. B. Allow extra time for meals and snacks. C. Encourage family members to feed the client. D. Provide frequent liquid-based meals. - ANS B. Allow extra time for meals and snacks. A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure? A. Regular, shallow breathing B. Thready, weak pulse C. Narrowing pulse pressure D. Lowered level of consciousness - ANS D. Lowered level of consciousness signs of thyroid storm - ANS fever tachycardia Increased systolic BP A nurse is assessing a client who is admitted to the hospital with a tentative diagnosis of a pituitary tumor. What signs of Cushing syndrome does the nurse identify? A. Hypotension and a rapid, thready pulse B. Retention of sodium and water C. Increased fatty deposition in the extremities D. Hypoglycemic episodes in the early morning - ANS B. Retention of sodium and water A health care provider prescribes propylthiouracil (PTU) for a client with hyperthyroidism. Two months after being started on the antithyroid medication, the client calls the nurse and complains of feeling tired and looking pale. What should the nurse do? A. Tell the client to increase the medication. B. Advise the client to get more rest. C. Instruct the client to skip one dose daily. D. Schedule the client for an appointment. - ANS D. Schedule the client for an appointment. Which is an important intervention that the nurse should include in the plan of care that is specific for a client with Addison disease? A. Restricting the client's fluid intake B. Protecting the client from exertion C. Encouraging the client to exercise D. Monitoring the client for hypokalemia - ANS B. Protecting the client from exertion A nurse is caring for a client with Addison disease. What should the nurse teach the client to do regarding an appropriate diet? A. Omit protein foods at each meal B. Restrict the daily intake of fluids to 1 L C. Add extra salt to food D. Limit intake to 1200 calories - ANS C. Add extra salt to food The nurse cares for a client with hyperthyroidism. The nurse implements which interventions to provide comfort for the client? A. Maintain a cool temperature in the room. B. Request stool softeners from the health care provider. C. Encourage family and friends to visit regularly. D. Provide the client warm beverages - ANS A. Maintain a cool temperature in the room. A client is admitted to the hospital with a diagnosis of cancer of the thyroid gland, and a thyroidectomy is performed. What should the nurse do during the first six to eight hours after the surgery? A. Encourage the client to perform deep-breathing and coughing exercises. B. Monitor for the complication of tetany resulting from hypocalcemia. C. Assess the sides and back of the client's neck for evidence of bleeding. D. Place two pillows behind the client's head. - ANS C. Assess the sides and back of the client's neck for evidence of bleeding. The nurse plans care for a client with Cushing disease. Which intervention does the nurse implement? A. Limit bathing to three times weekly. B. Measure intake and output carefully. C. Weigh the client every other day. D. Place the client on contact precautions. - ANS B. Measure intake and output carefully. The parents of a young man suspected of having Cushing syndrome expresses anxiety about their son's condition. What should the nurse tell the parents to help them better understand the illness? A. His physical changes are permanent but may improve with therapy. B. He will need to take exogenous steroids for several months. C. He may have mood swings or depression as a result of his illness. D. His condition will indicate improvement when he gains weight. - ANS C. He may have mood swings or depression as a result of his illness. A nurse assesses a client with hyperthyroidism. Which signs and symptoms of hyperthyroidism might be evident in the assessment? A. The client displays tremors of the hands. B. The client reports an increased appetite. C. The client displays edema of the feet. D. The client reports episodes of photophobia. E. The client reports progressive weight gain. - ANS A. The client displays tremors of the hands. B. The client reports an increased appetite. D. The client reports episodes of photophobia. A client has a history of hypothyroidism. Which skin condition should the nurse expect when performing a physical assessment? A. Smooth B.