Question 1

Michelle, a 24-year-old intern, was diagnosed with mitral stenosis. Aside from noticing a murmur during the physical examination, the nurse may also find:

Accepted Answer

Mitral stenosis results in enlargement of the left atrium which over time, increased pulmonary pressure and jugular vein distention. Dyspnea on exertion and syncope on exertion are associated with aortic valve abnormalities (choices A and C). Angina is associated with aortic stenosis (Choice D).

Question 2

The nurse is caring for Mrs. Guzman, a 47-year-old Filipina broker, on the 3rd postoperative day after coronary artery bypass (CABG) surgery. Because an important nursing diagnosis for post-CABG clients is ineffective breathing pattern, what is the best plan by the nurse?

Accepted Answer

Incentive spirometry and deep breathing are the preferred techniques for lung expansion with these clients. Vigorous coughing is discouraged for post-CABG clients because it may increase intrathoracic pressure and cause instability in the sterna area (Choice A). Premedication before ambulation (Choice C) will facilitate activity intolerance, not effective breathing pattern; auscultating lungs (Choice D) will detect adventitious lung sounds resulting from the ineffective breathing pattern, but it is not an action to encourage effective breathing pattern

Question 3

The nurse is preparing to defibrillate a pulseless adult client. Which action demonstrates safe, appropriate use of defibrillator?

Accepted Answer

Defibrillation is the delivery of an electrical current to deporalize a critical mass of myocardial cells. Prior to defibrillation of a client, a verbal communication of an impending shock must be made to ensure that everyone is clear of contact with the client. Contact with client, bed, or equipment during the delivery of the shock could result in electrical injury to the person involved.

Question 4

Which of the following findings in a client awaiting abdominal aortic aneurysm repair would you report immediately to the physician?

Accepted Answer

The primary symptom of a dissecting aneurysm is sudden, severe pain. Abdominal dissections commonly cause back pain. The other responses don't address this emergency.

Question 5

Which of the following disorders is characterized by a sudden drop in blood glucose, followed by rebound hyperglycemia caused by gradual and excessive administration of insulin?

Accepted Answer

The Somogyi phenomenon is characterized by a sudden fall in blood glucose, followed by a rebound hyperglycemia caused by the gradual excessive administration of insulin. Diabetes insipidus isn't related to insulin administration. Diabetic ketoacidosis and HHNS aren't characterized by this phenomenon.

Question 6

Following a thyroid scan with radioactive iodine for a thyroid nodule, the nurse should plan for:

Accepted Answer

No radiation precautions are necessary after injection of radioactive iodine that will be used for thyroid scan. Choice B pertains to radium implants. Choice C may be employed to when radioactive iodine therapy is utilized to control and reduce hypersecretion by the thyroid (hyperthyroidism). Choice D is not an example of normal radiation therapy policy.

Question 7

Because aldosterone is the major mineralocorticoid secreted by the adrenal cortex, which fluid and electrolyte imbalance should the nurse anticipate with decreased secretion of this hormone?

Accepted Answer

The primary fluid and electrolyte imbalances in Addison's disease are hyponatremia, hypovolemia, and hyperkalemia. These imbalances are caused by decreased aldosterone secretion. Calcium levels are not affected by this condition.

Question 8

The nurse would be correct in saying that the two common causes of primary hypothyroidism are:

Accepted Answer

The most common cause of hypothyroidism is excess thyroid tissue destruction due to radioactive iodine therapy for hyperthyroidism. Spontaneous hypothyroidism is believed to be due to autoimmune response. Several studies have revealed a high incidence of antibodies for thyroid antigen in clients with spontaneous atrophy (Choice B). Other, less common causes include surgical removal (Choice C), Hashimoto's thyroiditis, overuse of antithyroid drugs (Choice D), and pituitary tumors or insufficiency that decrease the circulating levels of the thyroid-stimulating hormone.

Question 9

A patient is hemorrhaging from multiple trauma sites. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms except:

Accepted Answer

Hypertension. In hypovolemia, one of the compensatory mechanisms is activation of the sympathetic nervous system that increases the RR & PR and helps restore the BP to maintain tissue perfusion, but not cause a hypertension. The SNS stimulation constricts renal arterioles that increases release of aldosterone, decreases glomerular filtration, and increases sodium and water re-absorption that leads to oliguria.

Question 10

The doctor orders for a glycosylated hemoglobin test for a client with diabetes. The client asked you what the purpose of this test is. You explained that glycosylated hemoglobin is used:

Accepted Answer

Glycosylated hemoglobin reflects the average blood glucose over the life of the red blood cells, usually 4 months. This test is not a ration of hemoglobin to glucose content, nor is it helpful in diagnosing anemia. The time frame of 6 months is too long.

Question 11

A client was diagnosed with hyperparathyroidism. The nurse explains that because of his condition, he is at risk for having:

Accepted Answer

Fractures can result from hyperparathyroidism because the condition causes the release of calcium from bone into blood, resulting in demineralization of the bones.

Question 12

Contractures are among the most serious long-term complications of severe burns. If a burn is located on the upper torso, which nursing measure would be least effective to help prevent contractures?

Accepted Answer

Helping the client to rest in the position of maximal comfort would be most effective to help prevent contractures. Mobility and placing the burned areas in their functional position can help prevent contracture deformities related to burns. Pain can immobilize a client as he seeks the position where he finds less pain and provides maximal comfort, but this approach can lead to contracture deformities and other complications.

Question 13

The nurse explains to a client that bronchitis is characterized by:

Accepted Answer

The basic pathophysiological changes associated with chronic bronchitis are hypertrophy of the mucous glands lining the bronchi and the production of increased amounts of mucus (sometimes thick and difficult to expectorate) that tend to narrow the airway and trap air distal to the mucus. Bronchoconstriction and edema of the bronchial walls are characteristic of asthma. Exudates in the alveoli and increasing lung stiffness are consistent with pneumonia.

Question 14

Which finding below would indicate the most effective response to asthma medications?

Accepted Answer

If medication used to relax and dilate bronchioles is effective, effective gas exchange will be manifested by an improved PEFR because air will be able to freely enter and leave the lungs and normal gas exchange will take place. Peak expiratory flow rate refers to the amount of air inspired. If the PEFR is below the amount of air inspired, it means that air is trapped in the alveoli and bronchioles because of bronchial spasms and blockage by accumulated secretions, this prevents proper exchange of oxygen and carbon dioxide and leads to hypoxia and acidosis.

Question 15

Emergency treatment for an acute asthmatic attack is Adrenaline 1:1000 given hypodermically. This is given to:

Accepted Answer

Relax the bronchial smooth muscle. An acute asthmatic attack is characterized by severe bronchospasm, which can be relieved by the immediate administration of bronchodilators. Epinephrine is an adrenergic agent that causes bronchial dilation by relaxing the bronchial smooth muscles.

Question 16

Mr) KA is a client with tracheostomy in the neurology ward. As part of your routine care, you will perform suctioning because of the presence of secretions. It is important to follow which correct technique?

Accepted Answer

Hyperoxygenate the client before and after suctioning. This is to prevent hypoxia. The safe wall suction pressure range for an adult is 80 to 120 mmHg (120 to 150 mmHg with tubing occluded). The nurse should advance the catheter into the tracheostomy without occluding the Y- port to minimize mucosal trauma and aspiration of the client's oxygen. The nurse should use intermittent suction in the airway for up to 10 to 15 seconds.

Question 17

Auscultation of a client's lungs reveals rales (crackles) in the left posterior base. The nursing intervention is to:

Accepted Answer

Although crackles often indicate fluid in the alveoli, they may be related to hypoventilation and will clear after a deep breath or a cough. It is, therefore, premature to impose fluid (Choice B) or activity (Choice D) restrictions. Inspection for edema (Choice C) would be appropriate after re-auscultation.

Question 18

A client undergoes below the knee amputation following a vehicular accident. Three days postoperatively, the client is refusing to eat, talk, or perform any rehabilitative activities. The best initial nursing approach would be to:

Accepted Answer

Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving. The withdrawal provides time for the client to assimilate to what has occurred and integrate the change in the body image. Acceptance of the client's behavior is an important factor in the nurse's intervention.

Question 19

Rhoda Miller has returned to the clinic 72 hours following a tuberculin skin test with an induration of about 5 to 6 mm at the administration site. She is visibly upset and states, "I can't believe I have TB!" Which statement by the nurse is appropriate?

Accepted Answer

An induration of 5 to 9 mm resulting from a tuberculin skin test is indicative of close contact with an individual infected with mycobacterium tuberculosis. The client with this finding will be prescribed isoniazid for 6 to 12 months as prophylaxis against development of active TB. History of diabetes is not related to a false positive tuberculin skin test. The nurse should demonstrate a calm, supportive, and informing manner with this client.

Question 20

In developing the care plan for a client with pulmonary mycobacterium tuberculosis, what primary precaution should be included?

Accepted Answer

Use of special mask to avoid inhaling infected airborne droplets. Mycobacterium tuberculosis is transmitted via airborne droplets so use of a properly fitted particulate filter mask is indicated to prevent its spread. The other options do not represent methods of preventing airborne transmission.

Quiz 1: Medical Surgical Nursing Practice