med surg nclex 2/4 – Flashcards
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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.
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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.
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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.
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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.
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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
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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).
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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. .
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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 diseases.
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Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation? Place HIV positive clients in strict isolation and limit visitors. Wear gloves when coming in contact with the blood or body fluids of any client. Conduct mandatory HIV testing of those who work with AIDS clients. Freeze HIV blood specimens at -70° F to kill the virus.
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Wear gloves when coming in contact with the blood or body fluids of any client The CDC guidelines recommend that healthcare workers use gloves when coming in contact with blood or body fluids from ANY client (B) since HIV is infectious before the client becomes aware of symptoms. (A) is not recommended, nor is it necessary. (C) is very controversial, difficult to enforce, and is not recommended by CDC. (D) does not guarantee to kill the virus. Additionally, the purpose of the blood specimen will determine how it is stored and handled
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In assessing cancer risk, the nurse identifies which woman as being at greatest risk of developing breast cancer? A 35-year-old multipara who never breastfed. A 50-year-old whose mother had unilateral breast cancer A 55-year-old whose mother-in-law had bilateral breast cancer. A 20-year-old whose menarche occurred at age 9. .
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A 50-year-old whose mother had unilateral breast cancer The most predictive risk factors for development of breast cancer are over 40 years of age and a positive family history (occurrence in the immediate family, i.e., mother or sister). Other risk factors include nulliparity, no history of breastfeeding, early menarche and late menopause. Although all of the women described have one of the risk factors for developing breast cancer, (B) has the greater risk over (A, C, and D).
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In preparing a discharge plan for a 22-year-old male client diagnosed with Buerger's disease (thromboangiitis obliterans), which referral is most important? Genetic counseling. Twelve-step recovery program. Clinical nutritionist. Smoking cessation program.
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Smoking cessation program Buerger's disease is strongly related to smoking. The most effective means of controlling symptoms and disease progression is through smoking cessation (D). The cause of Buerger's disease is unknown; a genetic predisposition is possible, but (A) will not be of value. The client with Buerger's disease does not need referral to a 12-step program any more than the general population (B). Diet is not a significant factor in the disease, and general healthy diet guidelines can be provided by the nurse (C
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Small bowel obstruction is a condition characterized by which finding? Severe fluid and electrolyte imbalances Metabolic acidosis. Ribbon-like stools. Intermittent lower abdominal cramping.
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Severe fluid and electrolyte imbalances Among the findings characteristic of a small bowel obstruction is the presence of severe fluid and electrolyte imbalances (A). (B, C, and D) are findings associated with large bowel obstruction.
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In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance? Sodium. Antidiuretic hormone. Potassium. Glucose.
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Potassium Clients with primary aldosteronism exhibit a profound decline in the serum levels of potassium (C) (hypokalemia)--hypertension is the most prominent and universal sign. (A) is normal or elevated, depending on the amount of water reabsorbed with the sodium. (B) is decreased with diabetes insipidus. (D) is not affected by primary aldosteronism.
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During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. What should be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope? This is a normal auscultatory finding. May indicate pneumothorax. May indicate pneumonia. May indicate severe emphysema.
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May indicate pneumonia. This test (whispered pectoriloquy) demonstrates hyperresonance and helps determine the clarity with which spoken words are heard upon auscultation. Normally, the spoken word is not well transmitted through lung tissue, and is heard as a muffled or unclear transmission of the spoken word. Increased clarity of a spoken word is indicative of some sort of consolidation process (e.g., tumor, pneumonia) (C), and is not a normal finding (A). When lung tissue is filled with more air than normal, the voice sounds are absent or very diminished (e.g., pneumothorax, severe emphysema) (B and D).
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A client receiving cholestyramine (Questran) for hyperlipidemia should be evaluated for what vitamin deficiency? K. B12. B6. C.
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K. Clients should be monitored for an increased prothrombin time and prolonged bleeding times which would alert the nurse to a vitamin K deficiency (A). These drugs reduce absorption of the fat soluble (lipid) vitamins A, D, E, and K. (B, C, and D) are not fat soluble vitamins.
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The nurse is taking a history of a newly diagnosed Type 2 diabetic who is beginning treatment. Which subjective information is most important for the nurse to note? A history of obesity. An allergy to sulfa drugs. Cessation of smoking three years ago. Numbness in the soles of the feet.
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An allergy to sulfa drugs. An allergy to sulfa drugs may make the client unable to use some of the most common antihyperglycemic agents (sulfonylureas). The nurse needs to highlight this allergy for the healthcare provider. (A) is common and warrants counseling, but does not have the importance of (B). (C) does increase the risk for vascular disease, but it is not as important to the treatment regimen as (B). Diabetic neuropathy, as indicated by (D), is common with diabetics, but when the serum glucose is decreased, new onset numbness can possibly improve.
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The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1 tablet PO PRN, for a client with chronic renal failure who is complaining of indigestion. What intervention should the nurse implement? Administer 30 minutes before eating. Evaluate the effectiveness 1 hour after administration. Instruct the client to swallow the tablet whole. Question the healthcare provider's prescription.
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Question the healthcare provider's prescription. Magnesium agents are not usually used for clients with renal failure due to the risk of hypermagnesemia, so this prescription should be questioned by the nurse (D). (A, B, and C) are not recommended nursing actions for the administration of aluminum and magnesium hydroxide (Maalox).
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A client is placed on a respirator following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kg q12h IV is prescribed. Which nursing diagnosis is the priority for this client? Impaired communication related to paralysis of skeletal muscles. High risk for infection related to increased intracranial pressure. Potential for injury related to impaired lung expansion. Social isolation related to inability to communicate.
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Impaired communication related to paralysis of skeletal muscles To increase the client's tolerance of endotracheal intubation and/or mechanical ventilation, a skeletal-muscle relaxant such as vecuronium is usually prescribed. Impaired communication (A) is a serious outcome because the client cannot communicate his/her needs. Although this client might also experience (D), it is not a priority when compared to (A). Infection is not related to increased intracranial pressure (B). The respirator will ensure that the lungs are expanded (C).
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The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information is most useful to the nurse when planning activities for the group? The length of time each group member has resided at the nursing home. A brief description of each resident's family life. The age of each group member. The usual activity patterns of each member of the group.
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The usual activity patterns of each member of the group. An older person's level of activity (D) is a determining factor in adjustment to aging as described by the Activity Theory of Aging. All information described in the options might be useful to the nurse, but the most useful information initially would be an assessment of each individual's adjustment to the aging process.
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Which symptoms should the nurse expect a client to exhibit who is known to have a pheochromocytoma? Numbness, tingling, and cramps in the extremities. Headache, diaphoresis, and palpitations. Cyanosis, fever, and classic signs of shock. Nausea, vomiting, and muscular weakness.
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Headache, diaphoresis, and palpitations. (B) is the typical triad of symptoms of tumors of the adrenal medulla (symptoms depend on the relative proportions of epinephrine and norepinephrine secretion). (A) lists the signs of latent tetany, exhibited by clients diagnosed with hypoparathyroidism. (C) lists the signs of an Addisonian (adrenal) crisis. (D) lists the signs of hyperparathyroidism.
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A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. What response is best for the nurse to provide? Estrogen deficiency causes the vaginal tissues to become dry and thinner. Infrequent intercourse results in the vaginal tissues losing their elasticity. Dehydration from inadequate fluid intake causes vulva tissue dryness. Lack of adequate stimulation is the most common reason for dyspareunia.
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Estrogen deficiency causes the vaginal tissues to become dry and thinner. Estrogen deprivation decreases the moisture-secreting capacity of vaginal cells, so vaginal tissues tend to become thinner, drier (A), and the rugae become smoother which reduces vaginal stretching that contributes to dyspareunia. Dyspareunia is not related to (B or C). While (D) can contribute to discomfort during intercourse, the primary cause is hormone-related.
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After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented? Report the findings to the surgeon. Irrigate the indwelling urinary catheter. Apply manual pressure to the bladder. Increase the IV flow rate for 15 minutes.
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Report the findings to the surgeon. An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine hourly (1 ml/kg/hour). Dark, concentrated, and low volume of urine output should be reported to the surgeon. Although other actions (B, C, and D) may be indicated, the assessment findings should be reported to the healthcare provider.
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What discharge instruction is most important for a client after a kidney transplant? Weigh weekly. Report symptoms of secondary Candidiasis. Use daily reminders to take immunosuppressants. Stop cigarette smoking.
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Use daily reminders to take immunosuppressants. After renal transplantation, acute rejection is a risk for several months, so immunosuppressive therapy, such as corticosteroids and azathioprine (Imuran), is essential in preventing rejection, so the priority instruction includes measures, such as daily reminders (C), to ensure the client takes these medications regularly. Daily weights, not weekly (A), provides a better indicator of weight gain related to rejection. Although fungal infections related to the immunosuppression should be reported (B), it is more important to ensure medication compliance to prevent rejection. Although smoking (D) increases the risk of atherosclerotic vascular disease which is common in clients with an organ transplant, (C) remains the priority.
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A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide? Lymph node involvement is not significant. Small tumors are aggressive and indicate poor prognosis. The tumor's estrogen receptor guides treatment options. Stage I indicates metastasis.
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The tumor's estrogen receptor guides treatment options. Treatment decisions (C) and prediction of prognosis are related to the tumor's receptor status, such as estrogen and progesterone receptor status which commonly are well-differentiated, have a lower chance of recurrence, and are receptive to hormonal therapy. Tumor staging designates tumor size and spread of breast cancer cells into axillary lymph nodes, which is one of the most important prognostic factors in early-stage breast cancer, not (A). Larger tumors are more likely to indicate poor prognosis, not (B). Stage I indicates the cancer is localized and has not spread systemically (D).
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A client taking furosemide (Lasix), reports difficulty sleeping. What question is important for the nurse to ask the client? What dose of medication are you taking? Are you eating foods rich in potassium? Have you lost weight recently? At what time do you take your medication?
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At what time do you take your medication? The nurse needs to first determine at what time of day the client takes the Lasix (D). Because of the diuretic effect of Lasix, clients should take the medication in the morning to prevent nocturia. The actual dose of medication (A) is of less importance than the time taken. (B) is not related to the insomnia. (C) is valuable information about the effect of the diuretic, but is not likely to be related to insomnia.
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A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints? Frequent urinary tract infections. Inability to get pregnant. Premenstrual syndrome. Chronic use of laxatives.
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inability to get pregnant. Dysmenorrhea, dyspareunia, and difficulty or painful defecation are common symptoms of endometriosis, which is the abnormal displacement of endometrial tissue in the dependent areas of the pelvic peritoneum. A history of infertility (B) is another common finding associated with endometriosis. Although (A, C, and D) are common, nonspecific gynecological complaints, the most common complaints of the client with endometriosis are pain and infertility.
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A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's medication record. Which medication is most likely the cause of the bradycardia? Propanolol (Inderal). Captopril (Capoten). Furosemide (Lasix). Dobutamine (Dobutrex).
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Propanolol (Inderal). Inderal (A) is a beta adrenergic blocking agent, which causes decreased heart rate and decreased contractility. Neither (B), an ACE inhibitor, nor (C), a loop diuretic, causes bradycardia. (D) is a sympathomimetic, direct acting cardiac stimulant, which would increase the heart rate.
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A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement? Position the head of the bed (HOB) flat. Withhold intravenous fluids. Administer a bolus of IV fluids. Give an antihypertensive medications.
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Give an antihypertensive medications. Most ischemic strokes occur during sleep when baseline blood pressure declines or blood viscosity increases due to minimal fluid intake. Completed strokes usually produce neurologic deficits within an hour, the client's current elevated blood pressure requires antihypertensive medication (D). Positioning the HOB flat (A) decreases venous drainage and contributes to cerebral edema post stroke. Increased blood viscosity during sleep may be related to reduced fluids, so (B) is not indicated. Increasing the vascular fluid volume increases the blood pressure, so (C) is not indicated.
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In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing intervention? (Select all that apply.) a. Set the infusion pump to infuse the albumin within four hours. b. Compare the client's blood type with the label on the albumin. c. Assign a UAP to monitor blood pressure q15 minutes. d. Administer through a large gauge catheter. e. Monitor hemoglobin and hematocrit levels. f. Assess for increased bleeding after administration.
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Set the infusion pump to infuse the albumin within four hours. Administer through a large gauge catheter. Monitor hemoglobin and hematocrit levels. Assess for increased bleeding after administration. (A, D, E, and F) are the correct selections. Albumin should be infused within four hours because it does not contain any preservatives. Any fluid remaining after four hours should be discarded (A). Albumin administration does not require blood typing (B). Vital signs should be monitored periodically to assess for fluid volume overload, but every 15 minutes is not necessary (C). This frequency is often used during the first hour of a blood transfusion. A large gauge catheter (D) allows for fast infusion rate, which may be necessary. Hemodilution may decrease hemoglobin and hematocrit levels (E), while increased blood volume and blood pressure may cause bleeding (F).
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Which client should the nurse recognize as most likely to experience sleep apnea? Middle-aged female who takes a diuretic nightly. Obese older male client with a short, thick neck. Adolescent female with a history of tonsillectomy. School-aged male with a history of hyperactivity disorder.
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Obese older male client with a short, thick neck. Sleep apnea is characterized by lack of respirations for 10 seconds or more during sleep and is due to the loss of pharyngeal tone which allows the pharynx to collapse during inspiration and obstructs air flow through the nose and mouth. With obstructive sleep apnea, the client is often obese or has a short, thick neck as in (B). (A, C, and D) are not typically prone to sleep apnea.
