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Medical-Surgical LPN/RN Assessment 1ShiftKey Answered with rationales and Graded A+ Latest 2024
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Medical-Surgical LPN/RN Assessment 1ShiftKey Answered with rationales and Graded A+ Latest 2024
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Medical-Surgical LPN/RNAssessment 1ShiftKey
1. A patient with chronic obstructive pulmonary disease (COPD) is admitted to the
hospital with increased shortness of breath. What is the most appropriate initial
nursing intervention?
A. Administer bronchodilators
B. Provide supplemental oxygen
C. Encourage deep breathing exercises
D. Perform chest physiotherapy
Answer: B. Provide supplemental oxygen
Rationale: The initial intervention for a patient with COPD experiencing increased
shortness of breath is to ensure adequate oxygenation. Supplemental oxygen can
help alleviate hypoxia and improve breathing.
2. Which of the following signs is most indicative of hypovolemic shock?
A. Bradycardia and hypertension
B. Tachycardia and hypotension
C. Hyperthermia and bradycardia
D. Bradycardia and hyperthermia
Answer: B. Tachycardia and hypotension
Rationale: In hypovolemic shock, the body typically exhibits tachycardia (increased
heart rate) and hypotension (low blood pressure) as compensatory mechanisms in
response to reduced blood volume.
3. A patient is scheduled for a laparoscopic cholecystectomy. What is an essential
preoperative teaching point for this procedure?
A. Avoid eating solid foods for 24 hours before surgery
,B. Inform the patient that they will need to remain on bed rest for 2 days
postoperatively
C. Explain that there may be shoulder pain due to gas used during the procedure
D. Advise the patient to discontinue all medications 1 week before surgery
Answer: C. Explain that there may be shoulder pain due to gas used during the
procedure
Rationale: During a laparoscopic cholecystectomy, carbon dioxide gas is used to
inflate the abdomen, which can cause referred shoulder pain postoperatively. It's
important to inform the patient about this potential side effect.
4. Which laboratory value should a nurse monitor closely for a patient receiving
heparin therapy?
A. Hemoglobin
B. Platelet count
C. Prothrombin time (PT)
D. Activated partial thromboplastin time (aPTT)
Answer: D. Activated partial thromboplastin time (aPTT)
Rationale: Heparin therapy affects the coagulation pathway monitored by the aPTT.
It is essential to monitor aPTT to ensure that the patient is within the therapeutic
range and to adjust the dosage as needed.
5. A patient with diabetes mellitus is being treated for a foot ulcer. Which
assessment finding would most likely indicate a need for immediate intervention?
A. Redness and warmth around the ulcer
B. Presence of a small amount of purulent discharge
C. Absence of pedal pulses
D. Edema in the surrounding area
,Answer: C. Absence of pedal pulses
Rationale: The absence of pedal pulses may indicate impaired blood flow and can be
a sign of severe arterial insufficiency or other vascular issues. This warrants
immediate intervention to prevent further complications.
6. A patient with heart failure is experiencing dyspnea and edema. Which of the
following interventions is most appropriate to manage these symptoms?
A. Increase fluid intake
B. Administer diuretics as prescribed
C. Encourage the patient to lie flat
D. Restrict sodium intake
Answer: B. Administer diuretics as prescribed
Rationale: Diuretics are used to manage symptoms of heart failure by reducing fluid
overload, which helps alleviate dyspnea and edema.
7. Which symptom is most characteristic of a deep vein thrombosis (DVT)?
A. Fever and rash
B. Redness and warmth of the affected limb
C. Shortness of breath and chest pain
D. Nausea and vomiting
Answer: B. Redness and warmth of the affected limb
Rationale: Redness, warmth, and swelling of the affected limb are classic signs of
DVT. Other symptoms may also include pain in the leg, especially when walking.
8. A patient is recovering from a total hip replacement. Which of the following
interventions is essential to prevent complications?
A. Encourage the patient to sit cross-legged
, B. Instruct the patient to keep the affected leg in an adducted position
C. Advise the patient to use an elevated toilet seat
D. Encourage the patient to perform passive range-of-motion exercises
Answer: C. Advise the patient to use an elevated toilet seat
Rationale: Using an elevated toilet seat helps prevent hip dislocation by reducing the
need for the patient to bend their hip excessively, which is important in the
postoperative period.
9. Which vital sign change would most likely indicate the need for immediate
assessment in a postoperative patient?
A. Temperature of 99.5°F (37.5°C)
B. Heart rate of 110 beats per minute
C. Blood pressure of 120/80 mmHg
D. Respiratory rate of 16 breaths per minute
Answer: B. Heart rate of 110 beats per minute
Rationale: An elevated heart rate, especially in the postoperative period, can indicate
potential complications such as hypovolemia, infection, or pain. This warrants
immediate assessment.
10. A patient with renal failure is receiving dialysis. What is a priority nursing
consideration for this patient?
A. Monitor blood glucose levels closely
B. Assess for signs of hyperkalemia
C. Encourage high-protein intake
D. Administer antibiotics as prescribed
Answer: B. Assess for signs of hyperkalemia
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