Med Surg Practice Exam

Medical-Surgical A 1. 1.ID: 310945742 Which milestone indicates to the nurse successful achievement of young adulthood? o Demonstrates a conceptualization of death and dying. o Completes education and becomes self-su ...

Medical-Surgical A 1. 1.ID: 310945742 Which milestone indicates to the nurse successful achievement of young adulthood? o Demonstrates a conceptualization of death and dying. o Completes education and becomes self-supporting. Correct o Creates a new definition of self and roles with others. Incorrect o Develops a strong need for parental support and approval. Transitioning through young adulthood is characterized by establishing independence as an adult, and includes developmental tasks such as completing education, beginning a career, and becoming self-supporting (B). (A and C) are characteristic of adolescence. Although strong bonds with parents are an expected finding for this age group, the need for support and approval (D) indicates dependency, which is a developmental delay. Awarded 0.0 points out of 1.0 possible points. 2. 2.ID: 310959831 The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia (VT). The client has an implanted automatic defibrillator. What action should the nurse implement? o Prepare the client for transcutaneous pacemaker. o Shock the client with 200 joules per hospital policy. Correct o Use a magnet to deactivate the implanted pacemaker. o Observe the monitor until the onset of ventricular fibrillation. The client must be externally shocked (B) to restore an effective cardiac rhythm. The automatic defibrillator is obviously malfunctioning. (A) will not be effective during ventricular tachycardia, since it is used for asystole. Since the defibrillator is not functioning, (C) is not warranted. The client should be treated immediately to restore cardiac output (D). Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 311013679 How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring? o Positive polarity right shoulder, negative polarity left shoulder, ground left chest nipple line. o Positive polarity left shoulder, negative polarity right chest nipple line, ground left chest nipple line. o Positive polarity right chest nipple line, negative polarity left chest nipple line, ground left shoulder. o Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line. Correct In MCL I monitoring, the positive electrode is placed on the client's mid-chest to the right of the sternum, and the negative electrode is placed on the upper left part of the chest (D). The ground may be placed anywhere, but is usually placed on the lower left portion of the chest. (A, B, and C) describe incorrect placement of electrodes for telemetry monitoring. Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 310950770 Based on the analysis of the client's atrial fibrillation, the nurse should prepare the client for which treatment protocol? o Diuretic therapy. o Pacemaker implantation. o Anticoagulation therapy. Correct o Cardiac catheterization. The client is experiencing atrial fibrillation, and the nurse should prepare the client for anticoagulation therapy (C) which should be prescribed before rhythm control therapies to prevent cardioembolic events which result from blood pooling in the fibrillating atria. (A, B, and D) are not indicated. Awarded 1.0 points out of 1.0 possible points. 5. 5.ID: 310959877 In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing intervention? (Select all that apply.) o Set the infusion pump to infuse the albumin within four hours. Correct o Compare the client's blood type with the label on the albumin. o Assign a UAP to monitor blood pressure q15 minutes. Incorrect o Administer through a large gauge catheter. Correct o Monitor hemoglobin and hematocrit levels. Correct o Assess for increased bleeding after administration. Correct (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). Awarded 0.0 points out of 1.0 possible points. 6. 6.ID: 310944546 A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement?