To prevent skin breakdown with skeletal traction you should?

Assess the pin insertion site every 8 hours

Repositioning a patient with balanced tension retraction. You should?

Maintain consistent traction tension while repositioning

Dietary factors that may influence the risk of osteoporosis?

Decreased Calcium and vitamin D

What is the priority safety action prior to an MRI?

Ensuring no metal objects on or in patient

Guidelines the nurse should teach for diabetes

Most calories should be derived from carbohydrates.

What action should the nurse recommend in order to promote vitamin D synthesis?

Ensuring adequate exposure to sunlight

What intraoperative change may suggest the presence of anesthesia awareness?

Vital sign changes and client movement

Which intervention will assist in decreasing the client's pain and anxiety following surgery?

Use of guided imagery along with pain medication

A priority for a patient with Type 1 DM

Avoid hot-water bottles and heating pads.

The nurse believes that the amount of drainage on the dressing may be increasing She should

Trace the outline of the drainage

What criteria would support checking blood levels for the diagnosis of diabetes?

FSBS greater than or equal to 126 mg/d

What should the nurse do to prevent dislocation of the new prosthetic hip?

Protect the affected leg from internal rotation

What psychosocial nursing diagnosis should you prioritize with Cushing Syndrome?

Disturbed body image r/t changes in physical appearance

Management of hyponatremia are?

Increase fluid intake, Decrease fluid intake

What activity level would the nurse expect to promote for a patient with hyperparathyroidism?

Ambulation and activity as tolerated

How can the nurse best help the client achieve the goal of maintaining effective oxygenation?

Utilize strategies for promoting diaphragmatic breathing.

What intervention should be included in the care plan of a client with CVL in place?

Change the site dressing whenever it becomes visibly soiled.

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MedSurg2041/Spring2019

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Questions 117

Answers

1
To prevent skin breakdown with skeletal traction you should?
Apply occlusive dressings to the pin sites
Encourage patient to push up with elbows when positioning
Assess the pin insertion site every 8 hours
Encourage the client to perform isometric exercises q shift
2
Which assessment is the nursing priority for a patient with a pleural effusion
Sputum production
Throat discomfort
Shortness of breath
Epistaxis
3
Repositioning a patient with balanced tension retraction. You should?
Place slight additional tension on the traction cords
Release the weights and replace them after positioning
Repostion the bed in stead of the client
Maintain consistent traction tension while repositioning
4
What is not a symptom of diabetes insipidous?
Polyuria
Elevated glucose level
Polyphagia
Polydipsia
5
Dietary factors that may influence the risk of osteoporosis?
Increased Calcium and Vitamin D
Decreased Calcium and vitamin D
Decreased soluble fiber
Increased protein
6
All of the following are pain scales except:
Visual Analog Scale
Numeric Rating Scale
Wong Baker Faces
Glascow Scale
7
What is increased curvature of the thoracic spine?
Scoliosis
Lordosis
Epiphysis
Kyphosis
8
After orthopedic surgery a patient is at highest risk for?
Septic Arthritis
Cellulitis
Osteomyelitis
Sepsis
9
What is the priority safety action prior to an MRI?
Ensuring no metal objects on or in patient
Assessing for nut allergies
Ensurin patient can remain immobile for 3 hours
Assessing for signs and symptoms of active infection
10
What assessment parameter is a priority for DVT prevention?
Range of motion
Hydration status
Family history
Blood pressure
11
Guidelines the nurse should teach for diabetes
Low fat generally indicates low sugar.
Animal fats should be eliminated from the diet.
Most calories should be derived from carbohydrates.
Protein should constitute 30% to of caloric intake.
12
What physical characteristics of Graves disease would the nurse expect to find?
Hair loss
Moon face
Fatigue
Bulging eyes
13
What action should the nurse recommend in order to promote vitamin D synthesis?
Ensuring adequate exposure to sunlight
Taking thyroid supplements as prescribed
Eating a low purine diet
Avoiding weight-bearing exercises
14
uncontrolled hypertension is at risk for developing what health problem?
Glaucoma
Kidney injury
Anemia
Right ventricular hypertrophy
15
What lab value is important to monitor while on diuretics?
The client's red blood cells, hematocrit, and hemoglobin
The client's oxygen saturation level
The client's potassium level
Client's level of consciousness
16
What associated signs and symptoms should the nurse monitor for addisonian crisis?
Bradypnea
Hypothermia
Hypertension
Hypotension
17
Which test confirms osteoporosis?
Bone densitometry
Hip bone radiography
MRI
CT
18
What intraoperative change may suggest the presence of anesthesia awareness?
Bleeding that is beyond what is anticipated
Sudden hypothermia and diaphoresis
Respiratory depression
Vital sign changes and client movement
19
Which intervention will assist in decreasing the client's pain and anxiety following surgery?
Allowing the client to increase activity
Administration of NSAIDs rather than opioids
Use of guided imagery along with pain medication
Use of deep breathing and coughing exercises
20
Complications of uncontrolled hypertension.
Glaucoma
Urinary retention
Aphasia
Retinopathy
21
A priority for a patient with Type 1 DM
Avoid the use of moisturizing lotions.
Dry feet vigorously after each bath.
Examine feet weekly for redness, blisters, and abrasions.
Avoid hot-water bottles and heating pads.
22
The nurse believes that the amount of drainage on the dressing may be increasing She should
Document in medical record
Photograph
Trace the outline of the drainage
Remove and reapply
23
Peripheral neuropathy constitutes a risk for what nursing diagnosis?
Acute confusion
Acute pain
Impaired urinary elimination
Infection
24
What action has the greatest potential to reduce an individual's risk for developing diabetes?
Have blood glucose levels checked annually
Undergo eye examinations regularly
Stop using tobacco in any form
Lose weight, if obese
25
what finding is most closely associated with cholelithiasis?
Decreased serum alkaline phosphatase level
Increased bilirubin
Increased blood urea nitrogen (BUN)
Decreased serum cholesterol
26
When should the patient take Prednisone?
In the morning
At bedtime
At noontime
In the evening
27
What non pharmalogic measures will decrease the bodies needs for insulin
Low stimulation
Adequate sleep
Exercise
Low fat diet
28
Manifestations of Fluid Volume Deficit are?
Dyspnea
Crackles
Weight loss
Weakness
29
The BP is 161/101 mm Hg at two consecutive visits How would this client's BP be def
High normal
Stage 2 hypertensive
Normal
Stage 1 hypertensive
30
A patient has cancer that has metastasized. Which lab test would be elevated?
Creatine
Bilirubin
Alkaline phoshatase
Potassium
31
What criteria would support checking blood levels for the diagnosis of diabetes?
Random plasma glucose greater than 150 mg/
Random plasma glucose greater than 126 mg/dl
FSBS greater than or equal to 126 mg/d
FSBS greater than 116 mg/dl on two separate occasions
32
What should the nurse do to prevent dislocation of the new prosthetic hip?
Have the client reposition himself independently
Keep the hip flexed placing pillows under the client's knee
Protect the affected leg from internal rotation
Keep the affected leg in a position of adduction
33
Manifestations of Hyponatremia are?
Dry mucosa
Increased salivation
Increased blood pressure
Constipation
34
What are risk factors for osteoporosis?
High alcohol intake low body mass
Female, small frame
Male, diabetes, high protein
Recurrent infections and use of NSAIDS
35
Causes of hypokalemia are?
Constipation
Hyponatremia
Hypoglycemia
Nausea vomiting diarrhea
36
Cholecystitis pain radiates where?
Right flank
Right upper qudrant
Mid epigastric
Right lower quadrant
37
What psychosocial nursing diagnosis should you prioritize with Cushing Syndrome?
Disturbed body image r/t changes in physical appearance
Decisional conflict r/t treatment options
Powerlessness r/t disease progression
Spiritual distress r/t changes in cognitive function
38
Malignant hyperthermia causes
Metabolic alkalosis
Metabolic acidosis
Respiratory acidosis
Respiratory alkalosis
39
What is a potential complication of a laporascopic cholecystectomy?
Wound evisceration
Bile duct injury
Decubitus ulcer
Diabetic coma
40
Management of hyponatremia are?
Discourage dietary sodium
Increase fluid intake
Weight q.o.d
Decrease fluid intake
41
Goal of multi-modal analgesia is to:
Increasing the risk of adverse effects
Higher doses lower side effects
Lower doses lower side effects
Using only a single agent
42
What is the first assessment that the nurse should perform on this newly post op pt?
Core body temperature
Heart rate and rhythm
Airway patency
Skin integrity
43
What activity level would the nurse expect to promote for a patient with hyperparathyroidism?
Out of bed to chair twice a day
Bedrest with bathroom privileges
Complete bedrest
Ambulation and activity as tolerated
44
How can the nurse best help the client achieve the goal of maintaining effective oxygenation?
Utilize strategies for promoting diaphragmatic breathing.
Teach the client to perform airway suctioning.
Develop an appropriate exercise program.
Administer supplementary oxygen by simple face mask.
45
After a thyroidectomy how should the nurse best position the client for comfort and safety?
Supine with roll supporting neck
Sidelying with one pillow
Semi fowlers two pillows
Semi fowlers no pillow
46
The priority information that the nurse should provide to the anesthetist during the visit?
Number of pregnancies
Last bowel movement
Difficulty falling asleep
Latex allergy
47
What intervention should be included in the care plan of a client with CVL in place?
Aspirate blood from the device once daily to test pH.
Passive range-of-motion exercises to prevent venous stasis.
Apply antibiotic ointment to the insertion site twice daily.
Change the site dressing whenever it becomes visibly soiled.
48
What laboratory finding would you not expect with hyperosmolar hyperglycemic syndrome?
Ca 9.4
Na 137
glucose 660mg/dl
Ph 6.7
49
Which patient is at most risk for hepatitis B?
Co worker of infected person
Secretary working in a hospital
Infant born to infected mother
Patient who smokes heroin
50
Acute pain includes all the following except:
specific injury
can last a lifetime
recent onset
surgical procedure
51
what intervention should the nurse prioritize to reduce the client's risk of a DVT
Maintain the head of the bed at 45 degrees or higher.
Encourage oral fluid intake.
Encourage early ambulation.
Perform passive range-of-motion exercises every 8 hours.
52
Complications of gallstones?
Atrophy of gallbladder
Acute pancreatitis
Gallbladder cancer
Gangrene of gallbladder
53
Postoperative issues the nurse anticipate for a patient who drinks 2 bottles of wine daily
Nonadherence to prescribed treatment s/p surgery
Alcohol withdrawal syndrome from anethesia
Increased risk for postoperative complications
Increased risk for allergic reactions
54
A patient is diagnosed with hypothyroidism. "Which symptom do you expect?
Fatigue
Palpitations
Bulging eyes
Flushed skin
55
What are basic survival skills to a client newly diagnosed with type 1 diabetes?
Signs and symptoms of diabetic nephropathy
Effects of surgery and pregnancy on blood sugar levels
Recognition of hypoglycemia and hyperglycemia
Management of diabetic ketoacidosis
56
The nurse should educate the patient to use the incentive spirometer
Every 8 hours/10 breathes
Every 2 hours/10 breathes
Every four hours/ 10 breathes
Every hour/10 breathes
57
Sign or symptom associated with Addisons?
Moon face
Hypertension
Muscle weakness
Truncal obesity
58
What factor should the nurse identify as possibly contributing to a decrease in cardiac output?
An increase in preload related to ambulation
Change in position from standing to sitting
A pulse oximetry reading of 94%
A heart rate of 54 bpm
59
Continuous wheezes during inspiration and expiration. This finding is most suggestive of what?
Pneumonia
Pleurisy
Emphysema
Asthma
60
What action has the potential to reduce an individual's risk for developing diabetes?
Lose weight, if obese
Undergo eye examinations regularly
Stop using tobacco in any form
Have blood glucose levels checked annually
61
A patient with a perforated gastric ulcer will be scheduled for surgery?
As soon as all the elective surgeries have been completed
Within 24 hours
Within the next week
Without delay because the bleed is emergent
62
Which is not a side effect of Analgesic Medication
Hypotension
Diarrhea
Nausea and vomiting
Sedation
63
A gerontologic patient is having a hip replacement. Which intervention is priority?
Use of a pressure relieving mattress
Use a foley catheter until discharge
Total parenteral nutrition
Prophylactic antibiotics
64
What assessment finding would suggest that the client is experiencing bronchospasm?
Slow, deliberate respirations and diaphoresis
Fine or coarse crackles on auscultation
Reduced respiratory rate or lethargy
Wheezes or diminished breath sounds on auscultation
65
Signs and symptoms of pancreatic necrosis?
Increased abd girth decreased LOC
Abdominal pain unrelived by opiods
Fever, tachycardia, hypotension
Sudden increase in random blood sugars
66
What is the best way to assess for jaundice?
Assess the skin folds
Assess the eyes
Asess the right upper quadrant
Assess the urine
67
Complications of an ERCP?
Gallbladder gangrene
Acidosis and hypoglycemia
Perforation and bleeding
Hyperglycemia
68
What is an expected urinalysis finding for diabetes insipidus?
Highly dilute urine
Albumin in the urine
Glucose in the urine
Leukocytosis in urine
69
Which of the following is an open surgical drain
Wound Vac
Penrose drain
Hemovac
Jackson Pratt
70
Which criterion determines when the nurse should allow the client to drink fluids?
Ability to demonstrate deep inspiration
Absence of nausea
Oxygen saturation of ³92%
Presence of a cough and gag reflex
71
What food would be the best source of iodine for the body?
Eggs
Table salt
Red meat
Shellfish
72
70-year-old obese client who has been admitted s/p colon resection at risk for?
Falls
Hyperglycemia
Infection
Azotemia
73
What assessment findings are most consistent with this peripheral neurovascular dysfunction?
Pain, diaphoresis, and erythema
Pain, diaphoresis, and erythema
Absence of feeling, capillary refill of 5 secs,d cool skin
Hot skin with a capillary refill of 1 to 2 seconds
74
Unintended leakage of a vesicant to surrounding tissue is?
Thrombophlebitis
Infiltration
Hematoma
Extravasation
75
How should the nurse best position a patient who has undergone a thyroidectomy
HOB elevated 30 degrees no pillow
Supine with small roll supporting neck
Sidelying one pillow under head
Semi fowler withhead supported on two pillows
76
Manifestations of Fluid Volume Overload are
Decreased heart rate
Poor skin turgor
Weight gain
Decreased blood pressure
77
What is the order of the nursing process?
Assess, implement, plan evaluate
Evaluate, plan, implement assess
Assess, plan, implement, evaluate
Implement assess, evaluate plan
78
Fluid is lost through all systems except
Kidneys
Lungs
Skin
Liver
79
What non pharmacologic can help control blood sugar for Type 2 DM?
Two meals a day
Exercise 30 mins 3 to 5 days a week
Adequate sleep
Exercise 30mins a week
80
After administering a preoperative medication to the client, what should the nurse do?
Encourage light ambulation.
Place the bed in a low position with the side rails up.
Take the client's vital signs every 15 minutes.
Tell the client that he will be asleep
81
Dietary modifications for HTN include:
Reduced intake of protein and carbohydrates
Reduced intake of fat and sodium
Increased intake of potassium, vitamin B12, and vitamin D
Increased intake of calcium and vitamin D
82
Wound dehiscence with evisceration occurs. What should be the nurse's first response?
Place previous position and call the physician.
Assess the client's blood pressure and pulse.
Place saline-soaked sterile dressings on the wound.
Pull the dehiscence closed using gloved hands.
83
What teaching should a patient receive with a plaster cast?
The cast will feel cool to touch for the first 30 minutes.
The cast will only have full strength when dry.
The cast should be tight fitting
The cast should be supported on a board while drying
84
Interventions to reduce potential for vomiting reduce the risk of what surgical complication?
Hypoxia
Hypothermia
Impaired skin integrity
Malignant hyperthermia
85
A patient is unusually restless following surgery. The nurse should:
Page the client's physician.
Assess the client's oxygen levels.
Administer antianxiety medications.
Initiate a social work referral.
86
What is digital gangrene a sign of?
Varicose veins
Coronary artery disease
Raynaud phenomenon
Arterial insufficiency
87
A patient is hyperventilation what would you expect the ABG to reflect?
Respiratory Alkalosis
Metabolic Alkalosis
Metabolic Acidosis
Respiratory Acidosis
88
National patient safety goal related to the operating room
Reduce the risk of fire
Reduce health care associated infection
Reduce patient misidentification
Reduce patient falls
89
The client inquires about the normal function of pleural fluid. What should the nurse describe?
allows for full expansion of the l
It lubricates the movement of the thorax and lungs.
It limits lung expansion within the thoracic cavity.
prevents the lungs from collapsing
90
Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure?
Can be performed with conscious sedation
Approach allows complete removal of gallbladder
Can be performed in a clinic setting
Poses fewer surgical risks than an open procedure.
91
What interventions increase the risk of DVT
Teds
Dehydration
Early ambulation
Venodyne boots
92
what sign or symptom that would suggest peripheral neuropathy?
Persistently cold feet
The presence of a tingling sensation
Pain that does not respond to analgesia
Acute pain, unrelieved by rest
93
Positive Trousseau sign is a manifestation of
Hyperkalemia
Hypocalcemia
Hypercalcemia
Hyponatremia
94
A brain (B-type) natriuretic peptide (BNP) is elevated which diagnosis due you suspect?
Heart failure
Valve dysfunction
Pleurisy
Cardiomyopathy
95
A patient with diabetes is receiving foot care instructions. What is the priority instruction
Dry feet vigorously after each bath
Avoid hot water bottles and hot baths
Examine feet weekly for abrasions, infections
Avoid use of moisturizing lotions
96
What is a normal change expected in the aging heart of an older adult?
Decreased connective tissue in the SA and AV node
Widening of the aorta
Decreased left ventricular ejection time
Thinning and flaccidity of the cardiac values
97
Which hepatitis has an immunization for prevention?
Hepatitis C
Hepatitis A
Hepatitis D
Hepatitis B
98
What is a complication during a central line placement?
Pneumothorax
Pleural effusion
Atelectasis
Ateletectasis
99
A patient is hypoventilating what would the ABG reflect?
Metabolic Acidosis
Respiratory Acidosis
Metabolic Alkalosis
Respiratory Alkalosis
100
When should the nurse start to teach incentive spirometry to a patient?
Pre op
Discharge
Post op
Intra op
101
The pt is in stage II (the excitement stage) of anesthesia. Appropriate intervention is:
Encourage the client to express feelings.
Restrain the client.
Stroke the client's hand.
Rub the client's back.
102
Signs and symptoms of hepatitis?
Weight gain
Decreased bilirubin
Night sweats
Clay colored stools
103
A nurse notes a pt frequently coughing with meals. Which assessment should the RN complete?
Inspect the client's tongue and mouth.
Obtain a sputum sample.
Assess the client's nutritional status.
Perform a swallowing assessment.
104
which of the following clients as having the highest risk for chronic pancreatitis?
A 39-year-old man with chronic alcoholism
An 18-year-old man who is a weekend binge drinker
A 45-year-old obese woman with a high-fat diet
A 51-year-old woman who smokes 1 ppday
105
Clinical manifestations of hypernatremia are:
Decreased temperature
Seizures
Decreased HR and BP
Moist mucous membranes
106
How should the nurse best position a client who has leg ulcers that are venous in origin?
knees bent to 45-degree angle and supported with pillows
Elevate the lower extremities
legs flat and straight
Dangle legs over the side of the bed
107
Signs and symptoms of DKA?
Concentrated urine
Moist mucous membranes
Fruity breathe
Glucose 180mg/dl
108
What is a sign of compartment syndrome?
Capillary refill less than 2 secs
Pulseless
Pain with active ROM
Erythema
109
What guideline applies to periods of illness in a diabetic client?
Eat three substantial meals a day, if possible.
Do not eliminate insulin when nauseated and vomiting.
Reduce food intake and insulin doses in times of illness.
Report elevated glucose levels greater than 150 mg/dL
110
What are the most likely complications for the client who has had pancreatic surgery?
Proteinuria and hyperkalemia
Malabsorption and hyperglycemia
Weight loss and hypoglycemia
Hemorrhage and hypercalcemia
111
What intervention is most likely to prevent asthma exacerbations among these clients?
Ensuring that clients keep their immunizations up to date
Utilize alternative therapies in asthma management
Carrying a corticosteroid rescue inhaler at all times
Recognizing and avoiding asthma triggers
112
What finding is associated with cholelithiasis?
Increased bilirubin
Increased lipase
Increased lipase
Increased alk phos
113
A priorty assessment for a patient with pancreatitis and parenteral nutrition?
Fluid output
Oral intake
Blood glucose level
BUN and creatine
114
Signs and symptoms of malignant hyperthermia are?
Heart rate less than 40
Heart rate greater than 120
Heart rate less than 60
Heart rate greater than 140
115
What sign or symptoms is most closely associated with Addisons disease
Muscle weakness
Moon face
Hypertension
Obesity
116
Pain in lower legs that increases with walking and decreases with rest?
Coronary artery disease (CAD)
Raynaud disease
Arterial embolus
Intermittent claudication
117
Where should the nurse best palpate the PMI?
Midline between the xiphoid process and the left nipple
Left MCL line of the chest at the level of the nipple
Two to three centimeters to the left of the sternum
Left MCL line of the chest at the fifth intercostal space

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