PassPoint MedSurg Questions and Answers

PassPoint MedSurg Questions and Answers Question 1 See full question Report this Question A fourth heart sound (S4) indicates a You Selected:  failure of the ventricle to eject all blood during systole. Correct response:  failure of the ventricle to eject all blood during systole. Explanation: An S4 occurs as a result of increased resistance to ventricular filling following atrial contraction. This increased resistance is related to decreased ventricular compliance. A dilated aorta doesn't cause an extra heart sound, though it does cause a murmur. A nurse hears decreased myocardial contractility as a third heart sound. A nurse doesn't hear an S4 in a normally functioning heart. Remediation:  Gallop, Atrial (S4) Question 2 See full question Report this Question A home health nurse visits a client who's taking pilocarpine, a miotic agent, to treat glaucoma. The nurse notes that the client's pilocarpine solution is cloudy. What should the nurse do first? You Selected:  Advise the client to obtain a fresh container of pilocarpine solution to avoid omitting ordered doses. Correct response:  Advise the client to discard the drug because it may have undergone chemical changes or become contaminated. Explanation: A cloudy solution indicates that the drug has changed chemically or has become contaminated. Therefore, the nurse first should advise the client to discard the drug. Advising the client to obtain a fresh container of pilocarpine, watching the client or a family member administer the drug, and advising the client to keep the container closed tightly and protected from light are all appropriate actions to take after telling the client to discard the solution. Question 3 See full question Report this Question A client undergoes cystoscopy with bladder biopsy. After the procedure, which assessment is most appropriate for the nurse to make? You Selected:  Assess urine for excessive bleeding. Correct response:  Assess urine for excessive bleeding. Explanation: After cystoscopy with biopsy, the nurse would assess for excessive hematuria, which might indicate hemorrhage caused by the biopsy. Catheters are not routinely inserted after cystoscopy. The nurse would not assess for bladder distention unless the client was having difficulty voiding. Urine cultures are not routinely ordered after cystoscopy. Remediation:  Cystectomy Question 4 See full question Report this Question In the early postoperative period following abdominal surgery, the nurse notes a bright red, 3″ × 5″ (7.6 × 12.7 cm) area of drainage on the client’s dressing. What should be the nurse’s first action in response to this observation? You Selected:  Increase the IV flow rate. Correct response:  Take the client's vital signs. Explanation: The sudden onset of bright red drainage of this magnitude needs to be further assessed. Assessing vital signs is an important nursing action to determine whether there have been any changes in the client’s status. Additional steps would include reinforcing the dressing and notifying the health care provider (HCP). Increasing the IV flow rate does not address the bleeding. Changing the dressing would be done only if the HCP prescribed it. Remediation:  Postoperative Care Question 5 See full question Report this Question A nurse is teaching an older adult who has had a left modified radical mastectomy with axillary node dissection about lymphedema. What should the nurse tell the client about when lymphedema occurs? You Selected:  at any time after surgery Correct response:  at any time after surgery Explanation: Lymphedema after breast cancer surgery is the accumulation of lymph tissue in the tissues of the upper extremity extending down from the upper arm. It may occur at any time after surgery in women of any age. It is caused by the interruption or removal of lymph channels and nodes after axillary node dissection. Removal results in less efficient filtration of lymph fluid and a pooling of lymph fluid in the tissues on the affected side. Treatments or interventions should be instituted as soon as lymphedema is noted to prevent or reduce further progression. Range-of-motion exercises, elevation, and avoidance of injury in the affected arm are important when completing client teaching. The health care provider (HCP) may also prescribe a compression sleeve. Lymphoma is not caused by failure to remove all cancer cells. Lymphedema can occur after any surgery that disrupts lymph flow, not just radical mastectomy. Remediation:  Mastectomy  Lymphedema Question 6 See full question Report this Question A client is newly diagnosed with cancer and is beginning a treatment plan. Which action by the nurse will be most effective in helping the client cope? You Selected:  Assume decision making for the client. Correct response:  Identify available resources for the client and family. Explanation: Identifying available resources for the client and family represents a respectful effort to make options available and encourages the client to become involved in treatment decisions. Assuming decision making for the client may foster dependence. Encouraging strict compliance with all treatment regimens may increase anxiety and limit the client’s options and treatment choices. Informing the client of all possible adverse treatment effects may increase anxiety and fear by focusing on adverse outcomes too soon. Question 7 See full question Report this Question To promote comfort and optimal respiratory expansion for a client with chronic obstructive pulmonary disease during sexual intimacy, the nurse can suggest the couple do what? You Selected:  Have the affected partner assume a dependent position. Correct response:  Raise the affected partner’s head and upper torso on pillows. Explanation: Raising the upper torso for the affected partner facilitates respiratory function. The client should not use inhalers that are not a part of the treatment plan, and if the client’s health is well managed, it is not necessary to take additional medications to improve respiratory function. A dependent position may compromise respiratory expansion, even though energy may be conserved. Duration of sexual activity is not necessarily related to exertion. Remediation:  Chronic Obstructive Pulmonary Disease Question 8 See full question Report this Question A client with thyrotoxicosis says to the nurse, “I’m so irritable. I’m having problems at work because I lose my temper very easily.” Which response by the nurse would give the client the most accurate explanation of this behavior? “You are experiencing: You Selected:  worry about the seriousness of your illness.” Correct response:  excess thyroid hormone in your system.” Explanation: A typical sign of thyrotoxicosis is irritability caused by the high levels of circulating thyroid hormones in the body. This symptom decreases as the client responds to therapy. Thyrotoxicosis does not cause confusion. The client may be worried about her illness, and stress may influence her mood; however, irritability is a common symptom of thyrotoxicosis, and the client should be informed of that fact rather than blamed. Remediation:  Hyperthyroidism Question 9 See full question Report this Question The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) to assess for signs and symptoms of right-sided heart failure. Which sign or symptom should be included in the teaching plan? You Selected:  increased appetite Correct response:  peripheral edema Explanation: Right-sided heart failure is a complication of COPD that occurs because of pulmonary hypertension. Signs and symptoms of right-sided heart failure include peripheral edema, jugular venous distention, hepatomegaly, and weight gain due to increased fluid volume. Clubbing of nail beds is associated with conditions of chronic hypoxemia. Hypertension is associated with left-sided heart failure. Clients with heart failure have decreased appetites. Remediation:  Chronic Obstructive Pulmonary Disease  Heart Failure Question 10 See full question Report this Question Which food should the nurse teach a client with heart failure to limit when following a 2- gram sodium diet? You Selected:  hamburger Correct response:  canned tomato juice Explanation: Canned foods and juices such as tomato juice are typically high in sodium and should be avoided in a sodium-restricted diet. Canned foods and juices in which sodium has been removed or limited are available. The nurse should teach the client to read labels carefully. Apples and whole wheat breads are not high in sodium. Hamburger would have less sodium than canned foods or tomato juice. Remediation:  Hypernatremia  Heart Failure .....continued...