Question 1

Lisa, the nurse on duty, is preparing to discharge a client newly diagnosed with diabetes mellitus. The client states, " I should eat a candy bar or cup of ice cream every time I feel shaky, hungry, or nauseated." Which of the following is Lisa's best response?

Accepted Answer

The candy bar and ice cream may have too much glucose and fat, potentially leading to hyperglycemia. In addition, the fat may delay glucose absorption. Immediate absorption of glucose is needed in hypoglycemia.

Question 2

Mr. Tuxen, a 66-year-old black American, was brought by his wife to the Emergency Department because he is increasingly confused and is coughing blood. His medical diagnosis is cirrhosis of the liver. While assessing Mr. Tuxen, the nurse understands that the correct technique when doing abdominal assessment is:

Accepted Answer

The correct sequence when doing abdominal examination is inspection, auscultation, percussion, and palpation. The least invasive is done first and the most uncomfortable is done last.

Question 3

Thrombus formation is a danger for all postoperative clients. The nurse should act independently to prevent this complication by:

Accepted Answer

Performing active-assistive leg exercises. Inactivity causes venous stasis, hypercoagulability, and external pressure against the veins, all of which lead to thrombus formation. Early ambulation or exercise of the lower extremities reduces the occurrence of this phenomenon.

Question 4

The nurse is providing discharge teaching for a client's family member on the administration of enoxaparin (Lovenox). Which action by the family member would indicate an understanding of the administration procedure for the drug?

Accepted Answer

Lovenox is an anticoagulant medication that is administered via the subcutaneous route. The medication is injected at the anterior lateral abdominal wall (ALAW), usually once or twice a day, or as directed by the physician. The administration site is changed for every injection, between right and left ALAW, to prevent bruising and bleeding.

Question 5

The nurse is developing a plan for Mrs. Ramos, a 38-year-old housewife, who is going home with a new diagnosis of heart failure. The nurse is teaching Mrs. Ramos to monitor fluid status. Which of the following is the best instruction?

Accepted Answer

Daily weight is the most sensitive indicator of changes in fluid status. It is more accurate for a client at home than urine output. Fluid restriction may be recommended for a client with advanced heart failure, but it is not a method of monitoring fluid status. The client should never adjust the dose of his or her medications.

Question 6

Which client is at greatest risk for developing hypertension?

Accepted Answer

African-American men are at greatest risk of developing hypertension; and this client is a smoker, which is a considered a major risk factor. While all the other clients have contributing factors to hypertension, smoking is still considered the major risk factor for hypertension.

Question 7

Situation: Jenny, 43 years old, has consulted her family physician because she has been experiencing chest pains, intolerance to heat, nervousness, dizziness, frequent headaches, and palpitations during the past three months. The doctor diagnosed her with pheochromocytoma. The most important assessment that the nurse should carry out with regards to Jenny's condition is:

Accepted Answer

Pheochromocytoma is a tumor of the adrenal medulla that causes an increase secretion of catecholamines that can elevate the blood pressure.

Question 8

Arnold Swanson, who had a myocardial infarction 2 days ago, has been complaining to the nurse about issues related to his hospital stay. The best initial nursing response would be to:

Accepted Answer

Refocus the conversation on his fears, frustrations, and anger about his condition. This provides the opportunity for the client to verbalize feelings underlying behavior and can be helpful in relieving anxiety. Anxiety can be a stressor that can activate the sympatho-adrenal response, causing the release of catecholamines that can increase cardiac contractility and workload that can further increase myocardial oxygen demand.

Question 9

The client is admitted with metabolic acidosis secondary to diabetic ketoacidosis (DKA). Understanding metabolic acidosis, the nurse should choose which of the following as the priority nursing diagnosis?

Accepted Answer

DKA is associated with excessive urine output, dehydration, and hypokalemia, placing the client at risk for decreased cardiac output and cardiac dysrhythmias. Choice A is false regarding output and does not address the metabolic pattern. Choices C and D may apply to the client, but are not the priority needs; in addition, Choice C will resolve as the DKA is treated.

Question 10

A 45-year-old client with leg ulcers and arterial insufficiency is admitted to the hospital. The nurse understands that leg ulcers of this nature are usually caused by:

Accepted Answer

Decreased arterial flow is a result of vasospasm. The etiology is unknown. It is more problematic in colder climates or when the person is under stress. Hyperemia occurs when the vasospasm is relieved.

Question 11

A client who had a Billroth I procedure is beginning to eat solid foods. The nurse should assess the client for the development of dumping syndrome by determining the presence of which of the following?

Accepted Answer

Symptoms of dumping syndrome can occur within 5 minutes to 3 hours after eating and include nausea, vomiting, tachycardia, diaphoresis, abdominal pain, diarrhea, syncope, and hyperactive bowel sounds.

Question 12

The client returns to the nursing unit following a pyelolithotomy for removal of a kidney stone. A Penrose drain is in place. Which of the following actions would the nurse include in the client's postoperative plan of care?

Accepted Answer

Frequent dressing changes around the Penrose drain are required to protect the skin against breakdown from the urinary drainage. If urinary drainage is excessive, an ostomy pouch may be placed over the drain to protect the skin. A Penrose drain is not irrigated. Weighing the dressings is not necessary. Placing the client on the affected side will prevent a free flow of urine through the drain.

Question 13

After her gastrectomy, actress Sandra Newton asks the nurse when the nasogastric tube will be removed. The nurse responds ______________.

Accepted Answer

The nasogastric tube is removed after bowel sounds have been reestablished (generally around the third day) and after the client has passed flatus or stool. Choices A and C are incorrect because they do not include the return of bowel sounds. Before removal, the tube is frequently clamped for 2 to 4 hours - not 2 days (Choice D) - to test the client's tolerance. Gastric residue is measured after this period. If it is more than 100ml, the nasogastric tube is left in place. Likewise, if the client experiences any pain, nausea, vomiting, or distention during this period, the tube is left in. If no symptoms occur and there is minimal amount of gastric residue, the tube is removed.

Question 14

Mr. Chandler has trouble remembering to rotate his sites for insulin injections. In the past week he has self-injected into the right abdomen, left abdomen, right upper arm, left thigh, and right thigh. Into which site should he self-inject his insulin next?

Accepted Answer

He is due for an injection in the left upper arm owing to the site rotation.

Question 15

Julie Johnson is receiving total parenteral nutrition (TPN). The nurse reviews the following lab values:
Glucose = 72 mg/dL
Chloride = 98 mg/dL
Sodium = 138 mEq/L
Potassium = 3.0 mEq/L
Based on the nurse's review of the lab values, which nursing action is appropriate?

Accepted Answer

A normal potassium level is in the range of 3.5-5.0 mEq/L. A client with a potassium of 3.0 mEq/L is hypokalemic. Hypokalemia can result in excitability of cardiovascular, neuromuscular, and gastrointestinal function. The physician should be notified and the need for potassium replacement discussed.

Question 16

Marcus Pinel, 43-years-old, is brought back to the nursing unit following a thyroidectomy. Which of the following methods should the nurse use to assess for bleeding?

Accepted Answer

Palpate the back of the neck and shoulders for evidence of bleeding. The danger of hemorrhage is greatest during the first 24 hours following thyroid surgery. The tendency is for blood to flow down at the sides and posteriorly if hemorrhage occurs in the area of the neck. Inspecting the dressings for signs of hemorrhage may not reveal bleeding (Choice A). Changing dressings immediately after surgery is not appropriate (Choice B). A drop in hemoglobin may be a clue to bleeding, but is not the best initial assessment action (Choice C).

Question 17

Mr. HP recently undergone a colostomy. During his first day post-operative, the nurse does not find any measurable fecal drainage from the colostomy. What should the nurse do?

Accepted Answer

Continue the current plan of care because the colostomy is expected not to function for 2 days or more (48 to 72 hours) after surgery. The drainage that is expected at this time is only mucous and serosanguinous, thus the doctor need not be notified and the stoma should not be irrigated at this time.

Question 18

Lanie, the new day-shift nurse, is developing a health promotion program for intestinal health. Which of the following pieces of information should the nurse include in the program?

Accepted Answer

Diverticular disease is virtually known in cultures where highly refined foods are not available. The other statements are false.

Question 19

For which complication of thyroidectomy would the nurse monitor?

Accepted Answer

Respiratory obstruction, hemorrhage, tetany, and laryngeal nerve injury are the major complications following thyroid surgery. Hypocalcemia, not hypercalcemia (Choice A), is a complication resulting from damage to the parathyroid glands during surgery. Serum T₄ will be decreased or absent, not elevated (Choice C), and the client will need replacement therapy because no thyroid hormone is secreted once the total thyroid gland is removed. Choice D is not related to thyroidectomy.

Question 20

A client receiving heparin sodium asks the nurse how the drug works. Which of the following points would the nurse include in the explanation to the client?

Accepted Answer

It prevents the conversion of factors that are needed in the formation of clots. Heparin is an anticoagulant. It prevents the conversion of prothrombin to thrombin. It does not dissolve a clot.

Quiz 1: Medical Surgical