Med Surge Final Exam, Questions and answers, 100% Accurate, Graded A+

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Med Surge Final Exam 1…. A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of following values? Amylase Ratio... nal Amylase is an enzyme that changes complex sugars into simple sugars that can be used by the body. It is produced by the pancreas and salivary glands and released into the mouth, stomach, and intestines to aid in digestion. The amylase level of a client who has acute pancreatitis usually increases within 12 to 24 hr and can remain elevated for 2 to 3 days. 2…. A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis. Which of the following findings in the client's history should the nurse recognize as consistent with a diagnosis of endometriosis? Dysmenorrhea that is unresponsive to NSAIDs. Rational Endometriosis is a condition in which the type of tissue that lines the uterus implants in locations outside the uterus. This typically causes pelvic pain around the time of the menstrual period but can cause pain at other times in the cycle. The discomfort is often unrelieved by the use of NSAIDs. 3…. A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take? Establish a plan of care with the client that sets attainable goals. Rational The nurse should develop a plan of care for this client with mutually set goals. This action invests the client in the rehabilitation process, which encourages feelings of ownership for it, and sees the goals as more attainable4….A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? Large incisions will be made in the eschar to improve circulation. Rational An escharotomy is a surgical incision made to release pressure and improve circulation in a part of the body that has a deep burn and is experiencing excessive swelling. Burn injuries that encircle a body part, such as an arm or the chest, can cause swelling and tightness in the affected area, resulting in reduced circulation. Making surgical incisions into the burned tissue allows the skin to expand, reduces tightness and pressure, and improves circulation. 5….A nurse is caring for a client who has suspected cholecystitis. The nurse should expect the client's urine to appear which of the following colors? Dark and foamy Rational The nurse should expect the client to have dark and foamy urine, which indicates the kidneys are filtering excess bilirubin from the blood. 6….A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication? Erythrocyte sedimentation rate (ESR) Rational Rheumatoid arthritis is a chronic inflammatory disease. ESR is useful in detecting and monitoring tissue inflammation in clients with RA. As the disease improves the ESR decreases. 7….A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching? Drink 3 L of fluid every day.Rational The nurse should instruct the client to drink at least 3 to 4 L of fluid every day to dilute the urine and reduce the risk for stone formation. 8….A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect? Excessive thrombosis and bleeding Rational The nurse should expect excessive thrombosis and bleeding of mucous membranes because both DIC impairs both coagulation and anticoagulation pathways. 9….A nurse is caring for a middle adult client who has just received the diagnosis of endometrial cancer. In taking a nursing history, which of the following manifestations is likely to be reported by this client? Postmenopausal bleeding Rational Endometrial cancer involves cancerous growth of the endometrium (lining of the uterus). The most common manifestation of endometrial cancer is abnormal uterine bleeding, including postmenopausal bleeding and bleeding between normal periods in premenopausal women. 10…A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.) Hypercholesterolemia Hypertension Obesity Smoking 11…A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client? A room with air exhaust directly to the outdoor environmentRational A room with air exhaust directly to the outside environment eliminates contamination of other client-care areas. This type of ventilation system is referred to as an airborne infection isolation room. 12…A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse expect to perform? (Select all that apply.) Assess blood glucose level Assess for neck vein distention Incorrect. Monitor for an irregular heart rate Incorrect. Monitor for postural hypotension Weigh the client daily 13…A nurse is teaching a client about risk factors for osteoporosis. Which of the following factors should the nurse include in the teaching? (Select all that apply.) Sedentary lifestyle Incorrect. Obesity Aging Caffeine intake Secondhand smoke Sedentary lifestyle is correct. Immobility depletes bone. Obesity is incorrect. Women who are obese have a greater capacity for storing estrogen to help maintain acceptable levels of calcium. Aging is correct. Women lose bone due to estrogen depletion after menopause. Caffeine intake is correct. Excessive caffeine intake causes calcium loss in the urine. Secondhand smoke is correct. Smoking is a risk factor for osteoporosis, both active and passive (secondhand) smoking. 14…A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB? Sputum culture for acid-fast bacillus RationalAlthough the Mantoux (skin test) and the chest x-ray may be useful screening tools for TB, the presence of acid-fast bacillus noted in the client's sputum, secretions, or tissues is the only method that can actually confirm the diagnosis. 15…A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.) Dyspnea Incorrect. Bradycardia Barrel chest Clubbing of the fingers Incorrect. Deep respirations Rational Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in which they become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to increase the amount of oxygen available to the tissues. Bradycardia is incorrect. With emphysema, the heart rate will increase as the heart tries to compensate for less oxygen to the tissues. Barrel chest is correct. Clients with emphysema lose lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel chest typical of emphysema clients. Clubbing of the fingers is correct. Clubbing results from chronic low arterialoxygen levels. The tips of the fingers enlarge and the nails become extremely curved from front to back. Deep respirations is incorrect. Clients with emphysema lose lung elasticity and have muscle fatigue; consequently, respirations become increasingly shallow. 16…A nurse in an emergency room is caring a the client who sustained partialthickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take? Inspect the mouth for signs of inhalation injuries. Rational Since the client sustained burns to the chest and face, there is a possibility that flames and smoke from the client's burning clothes could have caused aninhalation injury. The nurse should inspect the mouth and throat for soot and swelling. Using the airway, breathing, circulation (ABC) priority-setting framework, is the priority concern at this time 17…A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care? Fresh flowers and potted plants in the room 18…A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan? Avoid foods high in fat. Rational The nurse should instruct the client to follow a low-fat diet to decrease episodes of biliary colic. A client who has chronic cholecystitis has intolerance to fatty foods 19…A nurse is providing preoperative teaching for a client who is scheduled for a gastrectomy. Which of the following information regarding prevention of postoperative complications should the nurse include in in the teaching? Instruct the client about the use of a sequential compression device. Rational The nurse should instruct the client about the use of a sequential compression device to prevent deep-vein thrombosis, a postoperative complication. 20…A nurse is caring for a middle adult female client who reports that her menstrual periods have become irregular and she has been having hot flashes. The nurse should expect the client to have which of the following manifestations associated with early menopause? Dryness with intercourse Rational Menopause, the cessation of a woman's menstrual periods, occurs when the ovaries stop making estrogen. Because of the changes in the vagina, some women can have dryness, discomfort, or pain during sexual intercourse21…During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer? Basal cell carcinoma Rational A basal cell tumor usually begins as a small, waxy nodule with rolled, translucent, pearly borders. Telangiectatic vessels can also be present. As a basal cell tumor grows, it can undergo central ulceration. 22…A nurse is teaching a group of newly license nurses on effective techniques for counseling clients about sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching? Ask about the client's exposure to any past or present STIs. Rational The nurse should assess the client exposure to any past or present STIs and any treatment taken. 23…A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching? Practice effective hand hygiene. Rational Effective hand hygiene—along with immunization, sewer sanitation, and a safe water supply—are the most effective strategies for preventing the transmission of hepatitis A. 24…A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) Increased heart rate Increased blood pressure Increased respiratory rate Incorrect. Increase hematocritIncorrect. Increased temperature Rational Increased heart rate is correct. The nurse should expect the client who has fluid volume excess to have tachycardia and increased cardiac contractility in response to the excess fluid. Increased blood pressure is correct. The nurse should expect the client who has fluid volume excess to have increased blood pressure and bounding pulse in response to the excess fluid. Increased respiratory rate is correct. The nurse should expect the client who has fluid volume excess to have increase in respiratory rate and moist crackles heard in lungs. Increased hematocrit is incorrect. The nurse should expect the client who has fluid volume deficit to have an elevated hematocrit because of hemoconcentration. Increase temperature is incorrect. The nurse should expect the client who has fluid volume deficit to have an increase in temperature due to fluid loss. 25…A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make? It is caused by the lack of production of aldosterone by the adrenal gland. Rational Addison's disease is caused by a lack of production of the adrenocorticotropic hormones (cortisol and aldosterone) by the adrenal gland 26…FLAG A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include? Do not apply heat to the area of irradiation. Rational This instruction will help the client avoid tissue damage. Radiated tissue becomes thinner and might lack tissue receptors that would otherwise alert the client to apotential burn injury. When outdoors in sunlight, the client should wear protective clothing over the area of irradiation. 27…A nurse is teaching a newly licensed nurse about the purpose of a CA 125 test. Which of the following statements should the nurse include in the teaching? A CA 125 test is used to monitor a client's progress during treatment of ovarian cancer. Rational CA 125 tests are useful in monitoring progress during and after treatment of ovarian cancer 28…A nurse is teaching a client about the seven warning signs of cancer. Which of the following signs should the nurse include as manifestations of cancer? (Select all that apply.) A non-healing sore Incorrect. Bloating Change in bowel pattern Change in moles Nagging cough 29…A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? Heart rate Rational When a client's circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore, the nurse should identify a decrease in heart rate as in indication of adequate fluid replacement 30…A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects? Bleeding from the gums RationalBleeding from the gums is directly related to myelosuppression due to inhibited bone marrow production of blood cells and platelets. 31…A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency? Cold and numb numbness distal to the fistula site Pallor and numbness distal to the fistula site are possible indicators of venous insufficiency and should be immediately reported to the provider. 32…A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include? Basal cell carcinoma has a low incidence of metastasis. Rational Basal cell carcinoma is a localized lesion that seldom metastasizes. 33…A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times? As soon as the nurse can prepare the client and the administration set Rational The nurse should infuse the blood as soon as possible and complete the procedure within 4 hr. 34…A nurse is teaching self-management to a client who has hepatitis B. Which of the following Instructions should the nurse include in the teaching? Rest frequently throughout the day. Rational Limiting activity is usually recommended until the symptoms of hepatitis have subsided. The nurse should recommend the client rest frequently throughout the day to reduce the metabolic demands upon the liver and decrease energy demands.35…A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority? CD4-T-cell count 180 cells/mm3 Rational A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely immunocompromised and is at high risk for infection. Therefore, this value is the priority for the nurse to report to the provider 36…A nurse is instructing a client how to decrease the nausea associated with chemotherapy and radiation. Which of the following statements indicates an understanding of the teaching? I will eat foods that are served at room temperature. Rational The nurse should instruct the client to eat foods served at room temperature or chilled. Foods served hot may contribute to nausea. 37…A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include? Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. Rational The nurse should instruct the client to avoid activities that increase intraocular pressure. Therefore, the nurse should instruct the client to avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week following surgery. 38…A nurse is teaching about adverse effects of anastrozole with a client who has advanced breast cancer and is postmenopausal. Which of the following adverse effects should the nurse recommend the client report to the provider? Musculoskeletal pain Rational The client who is experiencing musculoskeletal pain should notify the provider. Musculoskeletal pain is a common adverse effect that affects 50% of clients that is possibly caused from estrogen deprivation39…A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect? Decreased serum calcium level Rational A decreased serum calcium level is an expected finding for FES, although the reason for this finding is unknown. 40…A client is receiving treatment for stage IV ovarian cancer and asks the nurse to discuss her prognosis. The client plans to have aggressive surgical, radiation, and chemotherapy treatments. Which of the following prognoses should the nurse discuss with the client? Poor Rational At this advanced stage, the prognosis for ovarian cancer is poor. Ovarian cancer is the leading cause of death from female reproductive cancers. Survival rates are low because it is not often discovered until its late stages. 41…A nurse is providing teaching to a client who has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. Which of the following instructions should the nurse include in the teaching? Artificial lubrication can be used to treat vaginal itching and dryness. Rational The nurse should instruct the client that atrophic vaginal changes occur due to the loss of estrogen postoperatively and can also cause pain and dryness during sexual intercourse. Artificial lubricants can reduce the manifestations associated with diminished mucous production. 42…A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program? Establish the ability to communicate effectively. RationalA CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication. 43…A nurse is teaching a client about the causes of osteoporosis. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis? Thyroid hormones Rational Long-term use of synthetic thyroid hormone, such as levothyroxine, can accelerate bone loss. 44…A nurse is teaching a newly licensed nurse about gynecological examination. Which of the following information should the nurse include in the teaching? The urethral orifice is assessed by separating the labia minora. Rational The urethral orifice, clitoris, and vaginal orifice are examined for lesions, inflammation, and discharge by separating the labia minora. 45…FLAG A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? Abnormally prominent U wave Rational Although U waves are rare, their presence can be associated with hypokalemia, hypertension and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip for a flattened T wave, prolonged PR interval, prominent U wave, or ST depression. 46…A nurse is assessing a client who reports numbness and pain in his right palm, index finger, and middle finger. The client reports working with a keyboard most ofthe time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request that the client perform? Hold the wrist at a 90-degree flexion. Rational Carpal tunnel syndrome is the compression of the median nerve at the wrist. The condition is common in people who perform repetitive motions of the hand and wrist, such as typing. Tapping over the median nerve at the wrist may cause pain to shoot from the wrist to the hand, and bending the wrist at a 90-degree flexion will usually result in numbness, tingling, or weakness 47…A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation? Avoid foods prepared with tap water. Rational To decrease the risk for acquiring viral hepatitis, clients should prepare foods with purified water. 48…A nurse is providing teaching to a client about the manifestations of uterine prolapse. Which of the following statements by the client should indicate to the nurse a need for further teaching? Feces can be present in the vagina. Rational The presence of feces in the vagina is a manifestation of a genital fistula. This statement indicates a need for further teaching. 49…A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? Cover the wound with a moist, sterile gauze dressing. RationalThe client's wound has dehisced, or opened along the suture line, and is now draining. The primary clinical objective in managing a dehisced wound is to keep it clean and moist, and manage any exudate. The nurse's priority action therefore is to cover the wound with a moist, sterile, saline-soaked gauze dressing 50…A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? Serosanguineous Rational Watery red drainage should be documented as serosanguineous. 51…A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate? Before the examination, your provider will give you a sedative that will make you sleepy. Rational This therapeutic response appropriately addresses the client's concerns. The client is seeking information and this response provides the client with accurate information. It can also lead to further discussion about the procedure. 52…A nurse is teaching a client about preventing osteoporosis. Which of the following statements by the client indicates a need for further teaching? I will reduce my intake of vitamin K-rich foods. Rational Vitamin K is necessary for bone health. The nurse should instruct the client to increase her intake of vitamin K-rich foods—such as green, leafy vegetables—to promote bone health 53…A nurse is selecting a qualified staff member to double check a blood label with a client ID bracelet prior to infusing a unit of blood. The nurse should identify that which of the following persons is qualified? Oncology nurseRational The nurse should ask another nurse or a provider to double check the blood label and client ID prior to an infusion. 54…A nurse is caring for a client who is scheduled to have a magnetic resonance imaging (MRI) scan. The client asks the nurse what to expect during the procedure. Which of the following statements should the nurse make? An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner. Rational The nurse should instruct the client that many clients report being disconcerted by the loud thumping and humming noises produced by the scanner, and for that reason, earplugs are offered to reduce the discomfort 55…A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level? Reduce the client's intake of protein. Rational Ammonia is formed in the gastrointestinal tract by the action of bacteria on protein. Limiting dietary protein intake can assist with decreasing the client's ammonia level. Protein is necessary for healing, so strict limitation of dietary protein is not recommended. 56…A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations? Cheyne-Stokes respirations Rational Cheyne-Stokes respirations (CSR) are characterized by a rhythmic increase (to the point of hyperventilation) and decrease (to the point of apnea) in the rate and depth of respiration. CSR are common respiratory alterations seen in clients who are unconscious, comatose, or moribund (approaching death).57…A nurse is caring for a client scheduled to receive external radiation to the neck for cancer of the larynx. During a pre-treatment exam, the nurse explains to the client that the most likely side effect would be Dysphagia. Rational Radiation therapy does not hurt while it is being given. But the side effects that people may get from radiation therapy can cause pain or discomfort. Only the area of treatment is affected by the radiation, so dysphagia (trouble swallowing) would be an expected side effect. Other possible side effects include hoarseness, xerostomia (dry mouth), loss of taste, and skin redness 58…A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's threechamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse ta [Show More]

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