Med Surg Success Test 1 | Answered with complete solutions
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Med Surg Success
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Med Surg Success
Med Surg Success Test 1 | Answered with complete solutions The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and 4+ pitting ...
The client is admitted to the telemetry unit diagnosed with acute exacerbation of
congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find
when assessing this client?
1. Apical pulse rate of 110 and 4+ pitting edema of feet.
2. Thick white sputum and crackles that clear with cough.
3. The client sleeping with no pillow and eupnea.
4. Radial pulse rate of 90 and capillary refill time <3 seconds.
The nurse is developing a nursing care plan for a client diagnosed with congestive heart
failure. A nursing diagnosis of "decreased cardiac output related to inability of the heart
to pump effectively" is written. Which short-term goal would be best for the client? The
client will:
1. Be able to ambulate in the hall by date of discharge.
2. Have an audible S1 and S2 with no S3 heard by end of shift.
3. Turn, cough, and deep breathe every two (2) hours.
4. Have a pulse oximeter reading of 98% by day two (2) of care.
Reason: Audible S1 & S2 are normal for a heart with adequate output, an audible S3
may indicate left ventricular heart failure
The nurse is developing a discharge-teaching plan for the client diagnosed with
congestive heart failure. Which interventions should be included in the plan? Select all
that apply.
1. Notify health-care provider of a weight gain of more than one (1) pound in a week.
2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside.
3. Instruct client to remove the saltshaker from the dinner table.
4. Encourage client to monitor urine output for change in color to become dark.
5. Discuss the importance of taking the loop diuretic furosemide at bedtime.
The nurse enters the room of the client diagnosed with congestive heart failure. The
client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis.
Which intervention would the nurse implement first?
1. Sponge the client's forehead.
2. Obtain a pulse oximetry reading.
3. Take the client's vital signs.
4. Assist the client to a sitting position.
,The nurse is assessing the client diagnosed with congestive heart failure. Which
signs/symptoms would indicate that the medical treatment has been effective?
1. The client's peripheral pitting edema has gone from 3+ to 4+.
2. The client is able to take the radial pulse accurately.
3. The client is able to perform ADLs without dyspnea.
4. The client has minimal jugular vein distention.
The nurse is assessing the client diagnosed with congestive heart failure. Which
laboratory data would indicate that the client is in severe congestive heart failure?
1. An elevated B-type natriuretic peptide (BNP).
2. An elevated creatine kinase (CK-MB).
3. A positive D-dimer.
4. A positive ventilation/perfusion (V/Q) scan.
The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor
for the client diagnosed with congestive heart failure. Which discharge instructions
should the nurse include?
1. Instruct the client to take a cough suppressant if a cough develops.
2. Teach the client how to prevent orthostatic hypotension.
3. Encourage the client to eat bananas to increase potassium level.
4. Explain the importance of taking the medication with food.
The nurse on the telemetry unit has just received the a.m. shift report. Which client
should the nurse assess first?
1. The client diagnosed with myocardial infarction who has an audible S3 heart
sound.
2. The client diagnosed with congestive heart failure who has 4+ sacral pitting
edema.
3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%.
4. The client with chronic renal failure who has an elevated creatinine level.
An audible S3 indicates left ventricular heart failure and the nurse must assess this
client first because it is an emergency situation
The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a
telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?
1. Assist the client to go down to the smoking area for a cigarette.
2. Transport the client to the intensive care unit via a stretcher.
3. Provide the client going home discharge-teaching instructions.
4. Help position the client who is having a portable x-ray done.
, The charge nurse is making shift assignments for the medical floor. Which client should
be assigned to the most experienced registered nurse?
1. The client diagnosed with congestive heart failure who is being discharged in the
morning.
2. The client who is having frequent incontinent liquid bowel movements and
vomiting.
3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood
pressure of 94/62.
4. The client who is complaining of chest pain with inspiration and a nonproductive
cough.
this client is exhibiting signs and symptoms of shock, the client is becoming unstable &
needs an experienced nurse.
The client diagnosed with congestive heart failure is complaining of leg cramps at night.
Which nursing interventions should be implemented?
1. Check the client for peripheral edema and make sure the client takes a diuretic
early in the day.
2. Monitor the client's potassium level and assess the client's intake of bananas and
orange juice.
3. Determine if the client has gained weight and instruct the client to keep the legs
elevated.
4. Instruct the client to ambulate frequently and perform calf-muscle stretching
exercises daily.
The probable cause of leg cramping is potassium excretion as a result of diuretic
medications. Bananas and orange juice are high in potassium for a patient on diuretics.
The nurse has written an outcome goal "demonstrates tolerance for increased activity"
for a client diagnosed with congestive heart failure. Which intervention should the nurse
implement to assist the client to achieve this outcome?
1. Measure intake and output.
2. Provide two (2)-g sodium diet.
3. Weigh client daily.
4. Plan for frequent rest periods.
Scheduling rest periods allows the client to participate in his or her own care and
addresses a desired outcome.
Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with
a myocardial infarction?
1. Creatine kinase (CK-MB).
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