MEDSURG

107問 • 1年前

問題一覧

A client with peripheral arterial disease complains of leg pain when walking and reports relief when in rest. The nurse's correct intervention for the client will include

Placing patient in semi-fowlers position knees extended

Which of the following activities will constitute to primary hypertension?

Drinking alcoholic beverages of 5-6 cans/day

A patient with a history of Hypertension, admitted due to social withdrawal and decrease ADL. Which to assess first?

Which of the following is appropriate to ask in obtaining the history of a client with mitral valve stenosis?

"Have you experienced any childhood sickness?"

A patient with pacemaker was assigned to the nurse. When does the nurse need to intervene?

"I will avoid sexual intercourse because it might dislodge my pacemaker"

Which is a correct understanding regarding MI?

Weight daily

A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 6.4 mEq/L. Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value?

Tall peaked T waves

A client is diagnosed with varicose veins. A nurse develops a plan of care for the client and includes which client position/activity in the plan?

Bed rest with elevation of the affected extremity

A client is admitted to a medical unit with nausea and bradycardia. The family hands a nurse a small white envelope labeled "heart pill." The envelope is sent to pharmacy and reveals digoxin (Lanoxin). A family member states, "That doctor doesn't know how to take care of my family." The most therapeutic response by the nurse would be

"You are concerned your loved one receives the best care."

How many joules is the maximum electricity output that is needed for defibrillation?

360joules

The client becomes pulseless with a monitored rhythm of ventricular tachycardia ff a motor vehicle accident and a fractured right: The nurse should prepare for:

CPR and Ephinephrine IV push

Discharge teaching for a client with angina includes a complete review of nitroglycerine usage. The nurse tells the client that sublingual nitroglycerine nitroglycerine can be used after the vial has been opened for up to

six months

What advice should the nurse give a client who takes sublingual nitroglycerin tablet without relief of pain?

Take another tablet sublingually

A client is admitted to the hospital with symptoms of left-sided heart failure. The physician prescribes Digoxin (Lanoxin) 0.125 mg daily and a low-sodium diet. When assessing this client, the nurse should expect to find which sign or symptom?

Dyspnea

The physician has prescribed nitroglycerin sublingual tablets as needed for a client with angina. The nurse should tell the client to take the medication:

as soon as he notices signs of chest pain

A client is admitted with sickle cell crisis Upon assessing the client, the nurse would expect to find:

SOB and pain

A client comes to the emergency department complaining of chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction(MI). Which ECG characteristic indicates myocardial injury?

Elevated ST segment

Which of the ff is the most accurate and sensitive cardiac enzyme to confirm MI?

Troponin I and T

What Cardiac enzyme is specific to myocardial damage?

CK MB

The nurse should prepare Mr. Filano for which of the following emergency treatments for cardiac tamponade?

Pericardiocentesis

LANCELOT was admitted to the coronary care unit 1 day ago with an acute myocardial infarction (MI). His vital signs and heart rhythm stabilized during the night, but this morning the nurse has found him cold, pale, diaphroretic and confused. LANCELOT's blood pressure has fallen to 80/60 mm Hg; pulse is thread at 118 beats/minute; and respirations are rapid and shallow at 36 breaths/s minute. Based on these findings, what is the most probable diagnosis?

Cardiogenic shock

After Lancelot's condition has been stabilized in the emergency department, he's admitted to the coronary care unit with a suspected diagnosis of an acute myocardial infarction. Increased serum levels of the isoenzyme CK-MB can be detected how soon after the onset of chest pain?

4-6 hours

When providing care for Mr. Lancelot, the nurse should avoid which route when taking a temperature?

Rectal

A primary nursing care goal for Lancelotis to recognize the life-threatening complication of a myocardial infarction (MI). The major cause of death after an MI is:

Cardiac arrhythmia

Rheumatic fever is commonly associated with a history of infection by which organism?

Group A streptococcus

After a series of laboratory test. It was determined that the client has Mi. which of the following nursing management will the nurse anticipate to give? SATA

ASA, Morphine, Nitroglycerine, Oxygen via nasal cannula, Metoprolol

Which of the following statements is incorrect about pacemakers?

Pulse generator is external and surgically implanted in the subcutaneous pocket below the clavicle

Which of the following conditions will increase the risk of having a large abdominal aortic aneurysm rupture?

High Blood Pressure

Mr. Boruto's severe left-sided heart failure will lead to a decreased in the total amount ejected per minute. This quantity is known as:

Cardiac output

The doctor prescribes dopamine (Intropin) to improve Mr. Boruto's hemodynamic status. The nurse knows that this drug is prescribes to:

Increase cardiac output and stroke volume

What should you expect if the pacemaker is experiencing a battery failure?

Dizziness and lightheadedness

Which of the following is true of cardioversion?

The electrical shock is applied during the R-wave

Hinata is a student nurse who have been suspected to have a mitral valve prolapse (MVP) during the annual physical examination of students enrolled in x university. She was referred to a cardiologist for further work-up. You are assigned to take care of her. As a nurse, which of the following do you expect to be manifested by Hinata as an early sign of Mitral valve prolapse during your physical assessment?

Systolic click of the valve leaflet as a result of the ballooning of the left atrium

The BEST approach in assessing the EARLY sign of MITRAL valve prolapse is through

auscultation

When an individual.is suffering from MVP like Hinata you should emphasize to her to AVOID the following, EXCEPT

Light exercises

A nurse assists a physician in performing a liver biopsy. After the biopsy the nurse plans to place the client in which of the following positions?

A right side-lying position with a small pillow or folded towel under the puncture site

The client is undergoing radiation therapy to treat lung cancer. Following the treatment, the nurse notes erythema on the client's chest and neck, and the client is complaining of pain at the radiation site. The nurse interprets this assessment data as

A superficial injury to tissue from the radiation

The nurse is instructing the client to perform a testicular self-examination. The nurse tells the client

That the best time for the examination is after a shower

The community health nurse conducts a health promotion program regarding testicular cancer to community members. The nurse determines that further information needs to be provided if a community member states that which of the following is a sign of testicular cancer?

Alopecia

The client reports to the nurse that when performing testicular self-examination, he found a lump the size and shape of a pea. The most appropriate response to the client is which of the following?

"That's important to report even though it might not be serious."

The nurse is preparing a client for a mammography. The nurse tells the client

To avoid the use of deodorants, powders, or creams on the day of the test

The nurse administers chemotherapeutic drugs to a client with cancer. What side effect are MOST common?

nausea and vomiting

The client requests information about the adverse effects of Vincristine. The nurse tells him all of the following, except?

You won't lose any hair

Oral radioactive iodine is prescribed as a mode of treatment for a client with thyroid cancer. The nurse understands the mechanism of this treatment and includes which of the following action in the care plan?

Flushing urine in the toilet twice

A client with cervical cancer is prescribed with an internal radiation implant. When caring for this client, the nurse should observe which of the following actions?

Place precaution signs on the client's room

The community health nurse is instructing a group of female clients about breast self-examination. The nurse would instruct the client to perform the examination

1 week after menstruation begins

Ino Yamanaka, age 46, is admitted to the medical-surgical flow with anemia, shortness of breath, weakness, pallor, and bone pain. She'll soon undergo bone marrow aspiration. Her while blood cell count is 90,000/ul. Ino is very anxious about the procedure. To help allay her anxiety, the nurse describes the procedure. How is a bone marrow aspiration best described?

"A small amount of marrow is taken from the posterior iliac crest and analyzed."

Acute myeloblastic leukemia is diagnosed. Which abnormal test result would the nurse anticipate in patients with leukemia?

Leukocyte count of 90,000/ul.

Mrs. Yamanaka begins chemotherapy treatment that includes methotrexate (Folex). Allopurinol (Zyloprim) is also prescribed to:

Inhibit uric acid synthesis that is caused by tissue destruction from chemotherapy

During Mrs. Yamanaka's chemotherapy regimen, which is important to include in her plan of care?

Tell her to avoid crowds and infected individuals

When caring for Ino, the nurse would anticipate transfusing packed red blood cells (RBCs) for;

Pallor, Fatigue and weakness

Nurse Jiraya is assigned in the Oncology Unit handling patients with breast cancer. A 40 year old client, with a history of breast conserving surgery, axillary node dissection and radiation therapy, calls the clinic to report that her arm is red, warm to touch, and slightly swollen. Which of the following actions should the nurse suggest?

Elevate the arm on two pillows

Menarche at 13 years

The patient's relative asked nurse Jiraya how often she should perform BSE. The nurse's best response would be:

"Every month, 5 to 7 days after menses start."

Induction therapy: Anti-leukemic agent, what is the purpose?

Increase remission of all manifestations of the disease

Chichay's mother states to the nurse, "It's hard to see Chichay with no hair he had such lovely soft blond hair." The best response for the nurse is:

This is temporary, Ned will re-grow new hair in 3-6 months, but it may be a different color and/ or texture.

A 55-year-old client, who is suspected of having colorectal cancer, is admitted to the C.I. After taking the history and vital signs, the physician does which tests as a screening for colorectal cancer?

Proctosigmoidoscopy

The following are risk factors for colorectal cancer, EXCEPT:

High fat, high fiber diet

To confirm his impression of colorectal cancer, the attending doctor will require which diagnostic study?

Carcinoembryonic antigen

What is the most common complication of mastectomy which the nurse should prevent?

Lymphedema

After surgery, the client is treated with a combination therapy protocol that includes doxorubicin (Adriamycin) to prevent metastases. Realizing the potentially toxic effects of this drug, the nurse should observe for and immediately report:

Occurrence of dysrhythmias

TNM classifications stands for?

Tumor, Nodes, Metastasis

A 51-year-old male is admitted for complaints of rectal bleeding, abdominal pain, weight loss and change in bowel habits. Nurse Kakashi is aware that these are manifestation of colon cancer. The physician prescribes radiation therapy and chemotherapy. Nurse Kakashi knows that radiation therapy is used to treat colon cancer before surgery. Which of the following is the effect of radiation therapy? It

Reduces the size of the tumor

The patient undergoes radiation therapy. Nurse Lawrence noted that the patient's white blood cell (WBC) count is severely depressed. The PRIORITY nursing intervention would be to

Place the patient in a private room and maintain strict aseptic technique for all procedures

Nurse Kakashi is aware that chemotherapy should only be administered by nurses who have taken special courses in administering chemotherapy and who are highly skilled. Before the nurse gives the prescribed dose of a chemotherapeutic agent, the nurse should do which of the following:

Verify the dose, drug, and schedule with another trained nurse

Nurse Kakashi assesses the patient receiving chemotherapy. Select the signs and symptoms that would require further evaluation.

Large areas of ecchymosis in various sites on the body

Ms. Sakura, an oncology nurse assists in the care of a 49-year-old female client diagnosed with breast cancer Ms. Sakura understands that the risk factors for the development of breast cancer include the following EXCEPT:

Breast feeding

The client asks Ms. Sakura what part of the breast cancer is usually found. Based on her knowledge, the nurse says that most malignant tumors occur in the ________ of her breast.

upper, outer quadrant

The physician orders a modified radical mastectomy right. The client returns to her room after the surgical procedure. Which of following position will the nurse place the right arm of the client?

Elevate on pillows with client's hand higher than her elbow, her elbow higher than her shoulder

The nurse further explains to the client that a normal local tissue response to radiation is:

Redness of the surface tissue

The nurse in the burn unit is assigned to a patient with 2° burn. Which of the following is a correct assessment finding for the Client?

Erythematous with blisters

A patient with Acne vulgaris is taking Isotretinoin(Accutane). Which is a correct teaching made by the nurse?

It worsens with exposure to sunlight

A patient with scabies was placed under the care of the nurse. What should the nurse expect to see?

Thread-like lesions

A child weighing 27 kg is admitted to the burn unit with 3rd-degree burns to the chest, face, and extremities. During the acute phase (i.e. first 48 hours) of a major burn injury, which assessment findings should the nurse immediately report?

Urinary Output of 150 ml in 8 hours

Upon assessment of a burn victim, the nurse finds reddened skin with mild edema. Thin-walled blisters are present, and the patient complains of pain. These assessment findings are indicative of which types of burn injury?

Superficial partial thickness

A 37-year-old man is seen in the outpatient clinic for treatment of psoriasis. The nurse should anticipate which of the following findings in this man?

Discolored nails

The physician prescribes coal tar preparations as part of the treatment plan for a man who has psoriasis. The nurse should include which statement in the teaching plan for this client?

Avoid sunlight immediately after the treatment

An adult's shirt catches on fire and is now in flames. He panics and runs into his neighbor's yard. Which of the following interventions is appropriate? Select all that apply:

Rolling him on the ground

A 78-year-old man is admitted with severe flame burns resulting from smoking in bed. The nurse can expect his room environment to include

Strict isolation techniques and policies

A 60-year-old farmer presents with a diagnosis of basal cell epithelioma. The lesion would most likely be described as

Dome shaped, shiny with a well-defined border.

The burn client is receiving treatments of topical mafenide acetate (Sulfamylon) to the site of injury. The nurse monitors the client, knowing that which of the following indicates that a systemic effect has occurred?

Hyperventilation

Mafenide acetate (Sulfamyion) is given to the client with a burn injury. When applying the medication, the client complains of local discomfort and burning. Which of the following is the most appropriate nursing action?

Inform the client that this is normal

Nurse Tsunade assists in the care of a 25 year old make who is admitted in the emergency department for burns in the chest, abdomen, right arm land right leg. Nurse Tsunade is aware that fluid shifts occur during the emergent phase of a burn injury. This shifting is due to fluid moving from what space? From

Vascular to interstitial space

Nurse Tsunade understands that fluid shift results from an increase of which of the following?

Permeability of capillary walls

Which of the following fluid and electrolyte imbalance would Nurse Tsunade anticipate that the patient would be particularly susceptible to in the emergent phase of burn care?

Hyperkalemia

Shikamaru has just been diagnosed with Addison's Disease. Which of the following are classic symptoms of this adrenal deficiency?

Anorexia, hyperkalemia, hypermentation, decrease stress tolerance

Mr. Sai is a Type 1 DM. He is on NPH 35 units and Regular Insulin 10 units subq every am and pm. Which of the following choices is the best rationale for this insulin prescription?

This schedule best reflects the insulin peaks your own pancreas would create in response to your daily food intake

A male teenager was wheeled in the ED for a stab wound. The ED nurse suspects that the kidneys may have been injured The nurse assesses the patient for complications, Which are the most common complications? Urinary leakage Delayed bleeding from damage Abscess formation Paralytic Ileus Renal failure

2 and 3

A male teenager was wheeled in the ED for a stab wound. The ED nurse suspects that the kidneys may have been injured The nurse knows that with renal trauma, further complications may occur such as: 1.Secondary hemorrhage due to infection 2.Renal artery stenosis 3.Renal atrophy 4.Hypotension 5.Hydronephrosis

1,2,3,5

The nurse assesses the patient to determine the extent of injury. Which of the ff signs is a cardinal sign of renal trauma?

hematuria

The nurse monitored the client undergoing plasmapheresis (removing antibody-antigen complexes from circulation). Which of the ff reactions should the nurse observe?

Transfusion reactions

The goal for treatment for respiratory acidosis is to improve ventilation. Which of the ff measures is appropriate for client with COPD experiencing respiratory acidosis?

Spirometers

Roger, a patient who has just undergone a subtotal gastrectomy, is under the care of Nurse Anderson. The nurse is closely monitoring his nasogastric tube drainage as part of the postoperative care. What color should Nurse Anderson expect the nasogastric tube drainage to be for approximately 12 to 24 hours following the surgery?

Dark brown.

Mercedes calls you to her room to report extreme pain on her left wrist and hand. Her hand is swollen and when you removed the I.V. dressing, you saw a red streak along the vein pathway and a bluish discoloration around the I.V. puncture site. Which of the following will you do AFTER you have stopped the infusion?

Remove the peripheral catheter and apply dressings.

The physician prescribed that the intravenous infusion be resumed. A 20-gauge catheter in the inner aspect of the patient’s right forearm was inserted and the fluid infusion was resumed at 125 mg per hour. When patient’s condition has been stabilized, you planned for preventive measures to prevent similar incidents. Which of the following guidelines will you question?

When checking sites, remove tape to visualize the entire peripheral catheter and vein pathway.

When administering theophylline to the patient, what PRIORITY drug-induced adverse reaction should you monitor as a nurse?

Restlessness

A patient consulted the clinic because of psoriasis. Suzuki understands that psoriasis is:

a chronic inflammatory skin disorder

Which of the following characteristic lesions will Suzuki expect to observe on the patient with psoriasis?

Well demarcated regions of erythematous plaques that shed thick silvery white flakes

Another patient consulted the clinic because of a band-like pattern of painful vesicular lesions on her anterior thigh. Physician’s diagnosis is herpes zoster. Which of the following data in the patient’s history will Suzuki consider as a precipitating factor?

Post radiation therapy for a thyroid problem

100

Acyclovir (Zovirax) was prescribed for the patient with herpes zoster. After having instructed the patient regarding action and administration of the drug, which of the following responses of the patient would require re-instruction?

“It kills the virus, so recurrence is remote.”

Astignars random QS

Kyla Angelique Son · 19問 · 1年前

Astignars random QS