1 NURSING 250 PROCTORED 1 --- MEDSURG1 2023 -2024 100% verified exam with answers versions available o Answers with rationale 1. A nurse is assessing a client who has left-sided heart failure . Which of the following findings should the nurse expect? a. Bradycardia - more tachycardia cuz of a failing ventricle , SNS is activated to compensate . b. Flushed skin - duskly it wIll look like c. Frothy sputum -Left sided - can be blood tinged d. Jugular vein distention→ Right Rationale: ATI MS: pg. 198 ch 32 pdf Left side: dyspnea, orthopnea, fatigue, pulmonary congestion, frothy sputum, organ failure such as oliguria . Right Side: Jugular vein distention, ascending dependent edema, abdominal distention, polyuria ar rest, liver enlargement , 2. A nurse is assessing a client who is experiencing renal colic from a calculus in left renal pelvis. Identify the area where t he nurse should expect the client to have referred pain. ( Find “hot spots” in the artwork) Pain travels downward to the inguinal area and lower back Renal colic occurs in the kidney area. Referred pain is somewhere that happens in another place other than where the pain should be felt. 2. A nurse is caring for a client who is receiving peritoneal dialysis and notes a decrease in the dialysate flow rate. Which of the following actions should the nurse take? (Select all the apply?). Check answer i read pg 644-647 med surg it’s not so specific p. 370 ch 57 pdf a. monitor the access site for drainage. - to check for sxs of infection. b. Strip the catheter tubing c. Measure the amount of the dialysate outflow d. Raise the client to high fowlers position - they must lie supine e. Position the client to her other side. 3. A nurse is planning to insert an indwelling catheter for a female client. Which of the following actions should thenurse plan to take? Ati video tutorials foley a. Collect urine specimen from the drainage bag 1 hr after insertion b. Raise the head of the bed to 45 degrees prior to insertion c. Secure the catheter to the client's inner thigh d. Attach the bag to the rail of the bed. –under non movable area 6. A nurse is providing teaching for a client who has age-related macular degeneration which of the following information should the nurse include in the teaching a. A possible cause of this problem is long -term lack of dietary protein b. You probably have a Detachment of your retina -vision is like having curtains over eyes c. You probably have noticed a decline in your central vision d. The doctor can perform surgery to correct the start paying the folds in your retina Rationale: ATI MS: PG. 63 Macular degeneration, often called age -related macular degeneration (AMD), is the central loss of vision that affects the macula of the eye. NO cure , happens alot in old people. Sxs: distorted vision, blurred vision, caused by smoking, female, HTN, diet lacking carotene. 2 NURSING 250 PROCTORED 1 --- MEDSURG1 7. A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report? P . 357 ch 55 pdf Med surg a. Platelets 70,000/mm3 - risk of bleed normal range is 150,000 - 300,00 - ABCS is compromised automatically . b. Distended abdomen - expected c. Alkaline phosphatase 125 units/L -norm normal is 30 -120 D. Clay colored stools - bile not on your shit 8. A nurse is preparing to discontinue long -term total parenteral nutrition (TPN) therapy for a client for a client. Thenurse should plan to discontinue the TPN gradually to reduce the risk of which of the following adverse effects? Old med surge docs we used a. Hyperglycemia b. Diarrhea c. Constipation d. Hypoglycemia (Repeat) Since your body is producing enough insulin to take on higher loads, you must taper it down to avoid hypoglycemia with lower concentrations of TPN Abruptly discontinuing TPN will cause rebound hypoglycemia 9. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse plan to take? P . 250 chapter 40 pdf p . 678 lewis a. Administer the unit of packed RBC’s over 1 hr- 2- 4 hr its must be given for 2 -4 hours. older adults b. Obtain the client’s first set of vital signs 1 hr after initiating the transfusion - you get vital signs at the initial first 15 to 30 minutes of the transfusion. c. Initiate venous access with a 21-gauge needle - no more than 19, for a regular adult it is 18 or 20 . d. Use Y tubing with 0.9% sodium chloride when administering the transfusion. Pg 249 10. TOXIC SHOCK SYNDROME - same 11. A nurse is providing discharge teaching to an older adult client who had an exacerbation of COPD. The client is to start fluticasone by metered -dose inhaler. WHich of the following instructions should the nurse include? ( C) p . 132 ch 22 a. Use fluticasone as needed for shortness of breath. - fluticasone used to treat inflammation. b. Limit fluid intake to 1 L per day. - drink plenty to avoid dehydration. 2-3 liters. c. Obtain a yearly influenza immunization. - reduce risk of infection. d. Assist use of pursed -lip breathing. - this is also one of the interventions the nurse does but the question ask about fluticasone. It is a steroid, and we all know steroids decresaes inflammation but also depress our immunue system. So getting a flu shot is priority. 12. A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching? a. “You can cross your legs at the ankles when sitting down.” -avoid flexion contraction b. “Clean the incision daily with hydrogen peroxide.” - soap and water c. “Install a raised toilet seat in your bathroom.” Pg 437 also use straight chairs with arms, abduction pillow between the legs, avoid low chairs, and flexion of hip greater than 90 degrees. NO crossing legs , no turing on operative side. d. “You should use an incentive spirometer every 8 hrs.” - once every hour at least 13. Missing 14. A nurse is caring for a client who is postoperative following a femur fracture. Which of the following findings should the nurse report to the provider immediately ? a. The client reports shortness of breath - embolism ABCS p . 457 chapter 71 b. The client has a temperature of 38.1 C (100.5F) c. The clients incision is red and warm d. The client reports incision pain 3 NURSING 250 PROCTORED 1 --- MEDSURG1 15.A A nurse is planning care for a client who Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action? P . 290 ch 46 pdf a. Place the client in a protective environment b. Obtain a stool specimen with gloves→ CONTACT ISO c. Clean surfaces with chlorhexidine -bleach D. Wash hands with alcohol -based hand rub. 16. A nurse is setting up a sterile field before performing a dressing change on client who is postoperative. Which of the following actions should the nurse plan to take to maintain the sterile field? (select all the apply) a. Grasp 2.5 cm (1 in ) of the outer edge to open the surgical wrap - 1 inch form broder is always non sterile so its ok to touch it . b. Select a work surface at the nurses waist level - body mchiancis . c. Apply sterile gloves before opening the pack - sterile package must be opened first before donning sterile gloves d. Open the first flap of the sterile package toward the nurse's body - must be AWAY first , then sides , then TOWARDS the nurse . e. Place a surgical pack with a sterile drape on the work surface. 17.A A nurse is caring for a client who has acute appendicitis. Which of the findings is the priority to the provider? Ch 23 p . 143 PEDIATRICS pdf also p 944 lewis a. Nausea - has not burst b. Flank pain - normal c. Fever - has not burst d. Rigid abdomen - muscles contract because it exploded - can lead to rupture and infection also HR ELEVATED, shallow and rapid respirations, pulse is weak. . 18.A A nurse is caring for a client who is receiving radiation. The client reports nauseas since the therapy was initiated. Which of the following considerations should the nurse include when planning the clients meals? P . 583 ch 91 also ch 16 p 269 of the lew is book a. Offer frequent, high -carbohydrate meals - several small meals a day is preffered. b. Offer highly seasoned foods - you want COLD , dry , foods. Cooking stimulates odors that lead to nausea. c. Offer a snack prior to radiation therapy - several small meals a day is recommended. d. Offer hot beverages with meals - hot foods can stimulate nausea. Beverage with meals leads to nausea. 19. A nurse is caring for a client who is receiving mechanical ventilation. Which of the following interventions should the nurse implement? (D) page 208-209 not sure which answer Empty water from the ventilator tubing daily . ( -INFECTION CONTROL: water that collects in the ventilator tubing can create a breeding ground for bacteria which may lead to VAP. Suction the client’s airway every 4 hr.(Suction every 2 hr and as needed. p.157 ) Maintain the client in supine position. (should reposition pt to help with secretions) Perform oral care every 2 hr.( you do oral care but not every 2hrs ) 20. A nurse in an emergency department is assessing a client who has cirrhosis of the liver. Which of the following is a priority finding? ( C) a. Palmar erythema b. Spider angiomas c. Mental confusion (RM 10 Ch.55 p.359 pdf - too much bilirubin in the blood went to the brain and now caused mental encephalopathy) d. Yellow Sclera 21. A nurse is preparing to administer bumetanide to a client who has heart failure. Which of the following assessment findings should indicate effectiveness of the medication a. Bowel sounds present in 4 quadrants on auscultation b. Alert and oriented to time place and person 4 NURSING 250 PROCTORED 1 --- MEDSURG1 c. Lung sounds clear - it is Bumex d. Apical pulse 80 Rationale: MS RM 10 Ch.32 p.198 -9 23. A nurse is caring for a client who has hypertension and has a new prescription for lisinopril . The nurse should consult with the provider about which of the following medication in the client's medication administration record? a. Potassium chloride ** found on medscape b. evothyroxine c. Acetaminophen d. Metformin Rationale: Pharm RM 7.0 Ch.20 p.151; Hyperkalemia is a complication for Lisinopril; avoid any salt substitutes containing K+. 24. A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan or care? a. Avoid use of anticoagulants - use it b. Place pillow under client knees - stasis danger c. Discourage leg exercises while in bed - you need it d. Apply compression stocking in lowerextremities Rationale: It’s common post -op, also, resume regular activity after 4-6 wks. 25. What interferes with warfarin therapy a. Potatoes (Potassium) Oranges (Vit C) b. Bananas (Potassium) c. Cauliflower - Huge Vitamin K remember veggies Rationale: Avoid any interaction with Vitamin K when on anticoagulant therapy, and dark, leafy veggies (or just any veggies) are THE source for it. 26. A nurse is administering furosemide 80 to a client with pulmonary edema. Which of the following assessment findings indicates the nurse that the medication is effective? P , 144 ch 19 pharm pdf a. Elevation in BP b. Adventitious breath sounds c. Weight loss of 1.8 kg (4lb) in the past 24 hr d. Respiratory rate of 24/min 27.A A nurse is caring for a client who has Cushing’s disease. Which of the following findings should the nurse expect? Ch 80 page 518 a. Weight loss b. Hyponatremia - increased c. Hyperglycemia d. Hypercalcemia - DECREASED ERRYTHANG is UP except K+/Ca+, both HYPO 28. A nurse is monitoring a client who has receiving 2 units packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction? (MS RM 10.0 Ch.40 p.250 : chills, fever, low-back pain, tachycardia, flushing, hypotension, chest tightening or pain, tachypnea, nausea, anxiety, hemoglobinuria, and an impending sense of doom) a. Back pain b. Bradycardia - should be tachycardia c. Hypertension - hypotension it will cause. d. Chills
