Med Surg Exam 3 New 2024 Latest Version with All Questions from Actual Past Exam, Exams of Nursing

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Med Surg Exam 3 New 2024 Latest Version with

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What nursing action is essential in order to prevent heat loss through evaporation? a. Apply blankets. b. Move a space heater closer to the client. c. Dry the client with a towel when perspiring. d. Apply a warm cloth to the forehead. ---------- Correct Answer ----------- Answer: c Cognitive Level: Analyze Explanation: Evaporation is the returning of water to the air through vapor. Water on the body's surface can be perspiration (sweat) or water from an outside source, such as a shower. Water evaporation causes a cooling effect. The body normally loses about 500 mL of water per day due to insensible (unnoticed) evaporation. It would be important to dry the client off so that the perspiration does not cause evaporation. Moving a space heater close to the client is not a safe intervention and can cause burns. Applying blankets without drying the client will trap the moisture under the blankets. Applying a warm cloth to the head would not cover the body surface caused by the perspiration. The nurse is preparing to apply a moist dressing to a sacral pressure wound. What is a priority action by the nurse? a. Medicate with analgesics one-half hour prior to the procedure. b. Have the client sign a consent form to perform the procedure. c. Document the procedure so that it won't be forgotten. d. Remove the necrotic tissue with forceps. ---------- Correct Answer ----------- Answer: a Cognitive Level: Apply Explanation: Analgesics provide pain relief and relaxation. The client's cooperation is necessary when applying dressings. Premedicating to minimize pain during the procedure facilitates cooperation and promotes healing. A consent form is not required for a dressing change. The procedure should not be documented until it is complete. The nurse should not remove the necrotic tissue from the wound because it is not within the scope of practice. A client is prescribed hydroxyzine HCL for the treatment of pruritus. What information should the nurse provide to the client? Select all that apply. a. The medication may cause drowsiness. b. Drink water, juice, and other fluids. c. Use sunscreen when exposed to the sun. d. Administer medication on an empty stomach.

e. Discontinue medications 1 week before skin testing. ---------- Correct Answer ----------- Answer: a, b, c Cognitive Level: Apply Explanation: Medications such as hydroxyzine HCL often cause drowsiness. Warn the client not to drive or work around machinery. Alcohol and other sedating drugs potentiate these medications. Urge the client to avoid these. Dry mouth is a common side effect. Encourage the client to drink juices and other fluids, not just water. Sucking on hard candy or ice chips, popsicles, or chewing sugarless gum is helpful. Other side effects may include stomach distress, diarrhea, constipation (administer medication with milk or food), and urinary frequency or retention. The medication should be discontinued 4 days before skin testing. A client developed angioedema after taking lisinopril. What priority nursing action is essential when caring for this client? a. Start an IV. b. Insert an indwelling catheter. c. Apply antipruritic lotion. d. Maintain a patent airway. ---------- Correct Answer ----------- Answer: d Cognitive Level: Analyze Explanation: The priority nursing action is to maintain a patent airway. Without this action, the client will not be able to sustain life. An IV is not an essential action because medication to treat the angioedema may be administered through an endotracheal tube if this is required. An indwelling catheter is not an essential action at this time. Antipruritic lotion is not required in angioedema and is not effective in the treatment. A child has been treated for head lice but has remaining nits attached to the hair shaft. What should the nurse instruct the parent to do? a. Apply petroleum jelly. b. Apply a hair cap to smother them. c. Soak the hair in water. d. Comb the hair with a fine tooth comb. ---------- Correct Answer ----------- Answer: d Cognitive Level: Apply Explanation: Combing the hair with a fine tooth comb is the most effective method of removing nits from the hair shaft. The application of petroleum jelly will not remove the nits. Application of a hair cap will not remove the nits nor will soaking the hair in water. The nurse observes a client with facial burns and suspects smoke inhalation. What observations lead the nurse to suspect this condition? Select all that apply. a. The facial burns b. Singed nasal hairs c. Soot around nares d. Soot-stained sputum e. Report of pain at the burn site ---------- Correct Answer ----------- Answer: a, b, c, d

Explanation: For joint stiffness and discomfort, hydrotherapy and warm heat are helpful to alleviate the discomfort. Cool compresses will cause more stiffness in the joints. Adequate nutrition and maintaining weight can help with arthritic pain in the future but is not an immediate remedy. A client suffered a stroke that affected the left side of the body. What nursing action will assist with the prevention of contractures of the lower extremities? a. Apply heat to the extremities. b. Position the client as if standing. c. Apply sequential compression devices to the lower extremities. d. Stand the client on both feet several times a day. ---------- Correct Answer ----------- Answer: b Cognitive Level: Apply Explanation: Positioning clients as if they are standing while in the bed will help prevent contractures and foot drop. Applying heat will not prevent contractures. Applying sequential compression devices will assist with the prevention of thrombophlebitis. The client may not be ready for aggressive physical therapy and standing at this time could cause falls. A client is having symptoms associated with an alteration in muscle function. What diagnostic tests should the nurse prepare the client for? Select all that apply. a. Creatine kinase b. Electromyelogram c. Lumbar puncture d. Muscle biopsy e. Electrocardiogram ---------- Correct Answer ----------- Answer: a, b, d Cognitive Level: Apply Explanation: Tests of muscle function and/or disorders include the blood level of creatine kinase, electromyogram (measurement of electrical activity of muscle tissue), and muscle biopsy. Neither a lumbar puncture nor an electrocardiogram are tests for muscle function. A client is experiencing residual limb pain following a surgical amputation to the right lower extremity below the knee. What action by the nurse would help alleviate the pain? a. Have the client "move" the missing limb. b. Apply ice packs to the residual limb. c. Have the client discuss feelings of loss. d. Present reality and do not support the delusion of sensation. ---------- Correct Answer ----------- Answer: a Cognitive Level: Analyze Explanation: Reassure clients that residual limb pain generally disappears in time. For pain relief, tell clients to "move" the missing limb. By activating the damaged nerves leading to the amputated limb, clients usually feel great relief. Ice packs to the limb may

cause vasoconstriction and tissue damage. It is important to encourage clients who seem to be disturbed and uneasy following amputation to discuss their feelings; however, this will not alleviate physical pain. The client is not delusional or having hallucinations. The nurse is caring for a client who has had a lower extremity amputation. What intervention by the nurse will best prevent hip contractures? a. Change drains using aseptic technique. b. Elevate the foot of the bed. c. Inspect the limb for signs of infection. d. Do not place a pillow under the residual limb. ---------- Correct Answer ----------- Answer: d Cognitive Level: Apply Explanation: To prevent hip contractures, do not place pillows under the residual limb when the client is on the back. Changing drains will not having any bearing on the status of hip fractures. Elevating the foot of the bed will decrease edema but not prevent contractures. Inspecting the limb for signs of infection will not prevent contractures but will prevent sepsis. The nurse is caring for a client postoperatively who has had cervical decompression. What statements by the client should the nurse immediately report to the primary care provider? Select all that apply. a. Reports of discomfort when moving b. Reports of change in sensation of arms c. Difficulty breathing d. Difficulty moving arms e. No bowel movement for 2 days ---------- Correct Answer ----------- Answer: b, c, d Cognitive Level: Analyze Explanation: Reports of change in sensation of arms, difficulty breathing, and difficulty moving arms are indications of possible nerve damage and should be reported immediately. Reports of discomfort when moving are common and do not indicate a complication. Not having a bowel movement in 2 days is not an indication that a complication is present; however, the client may need added roughage in the diet as well as a stool softener. A client is diagnosed with arthritis and wants to maintain an active lifestyle. What exercises should the nurse recommend to the client? Select all that apply. a. Swimming b. Jumping rope c. Bicycling d. Running e. Slow walking ---------- Correct Answer ----------- Answer: a, c, e Cognitive Level: Apply

e. Do you drink alcohol? ---------- Correct Answer ----------- Answer: b, c, d Cognitive Level: Analysis Explanation: Wrinkles occur due to the loss of elastic fibers and collagen in the skin. The dermis also thins. The loss of oil (sebum) also contributes to wrinkling, with oilier skin wrinkling less. Cigarette smoking has been linked to a more rapid destruction of elastic fibers, and can lead to the development of wrinkles at a younger age. Exposure to sun and genetics can also play a part in wrinkling. Moisturizer and alcohol intake are not linked to premature wrinkling. A client lacks the DNA-repair enzyme that helps reverse UV damage. What should the nurse be sure to include with information related to this lack of enzyme? a. Wear sunglasses when outdoors. b. Avoid any activities that involve the outdoors. c. Apply aloe vera after a sunburn. d. Closely check skin for new or changes in moles. ---------- Correct Answer ----------- Answer: d Cognitive Level: Apply Explanation: The skin contains DNA-repair enzymes that help reverse UV damage. If the genes for these enzymes are absent, or if the DNA is damaged, the person is more susceptible to skin cancer, the most dangerous form of which is malignant melanoma. It is important for the client to check for the development of any new mole formation or to note changes in a present mole. Wearing sunglasses with UV protection is important in the prevention of cataracts. Using aloe after a sunburn will help decrease the pain but does not relate to a lack of DNA-repair enzyme. A client informs the nurse that a bookshelf fell on the client's toe and the toenail fell off. The client asks the nurse when to expect the toenail to regrow. What is the best response by the nurse? a. "You will not have regrowth of that toenail." b. "You should have a new nail in about 3 months." c. "You should have a new nail in about 12 to 18 months." d. "The nail will be back in about 2 weeks." ---------- Correct Answer ----------- Answer: c Cognitive Level: Apply Explanation: A fingernail lost through trauma takes about 3 to 5 months to regrow, and a toenail takes about 12 to 18 months to regrow. A nail will continue to regrow as long as the live cells in the nail bed remain undamaged. There is nothing in the scenario that indicates damage to the nail bed. What is the part of the tooth that is considered part of the integumentary system? -------- -- Correct Answer ----------- enamel T/F Nails are considered part of the integumentary system. ---------- Correct Answer ----------- True

What does the body do to assist in ridding the body of waste? ---------- Correct Answer -- --------- perspire The outermost layer of the skin is known as the _____________? ---------- Correct Answer ----------- epidermis The product of desquamation ,________________________, is the waterproof barrier and the actual protector of the body. ---------- Correct Answer ----------- keratin The ____________, is relatively waterproof and provides a barrier against light, heat, bacteria, and other foreign substances. ---------- Correct Answer ----------- stratum corneum The innermost layer of the epidermis, composed of living cells is called the _____________. ---------- Correct Answer ----------- stratum basale basal layer stratum germinativum Name one of the three types of cells that are also present in the basale. ---------- Correct Answer ----------- merkel melanocytes langerhans' cells The epidermis has no blood supply, this is called ____________. ---------- Correct Answer ----------- avascular Indicators of aging include ______________ ---------- Correct Answer ----------- wrinkling loss of SQ fat atrophy of glands Deeper in the dermis are sweat glands also called_______________. ---------- Correct Answer ----------- sudoriferous glands Also referred to as the hypodermis, ______________lies beneath the dermis and above a layer of muscle. ---------- Correct Answer ----------- subcutaneous tissue Name one of the 3 pigments which forms normal skin color ---------- Correct Answer ----- ------ melanin carotene hemoglobin _____________are individuals born without the ability to produce melanin. ---------- Correct Answer ----------- albino

Medical term for removal of dead, deviated, contaminated tissue, foreign materials, or eschar? ---------- Correct Answer ----------- debridement Which graft is the skin taken from the person themselves? ---------- Correct Answer ------ ----- autograft Type of edema which involves deeper dermal and subcutaneous tissues? ---------- Correct Answer ----------- angioedema What is the other name for atopic dermatitis? ---------- Correct Answer ----------- eczema Clients with eczema should be instructed to use soaps that are ____________. ---------- Correct Answer ----------- less alkaline Small, flesh colored, brown, or yellow papules caused by HPV? ---------- Correct Answer ----------- warts Most common topical treatment for impetigo ---------- Correct Answer ----------- bactroban mupirocin retapamulin altabax What is the importance of sebum? ---------- Correct Answer ----------- prevents drying Scabies inspections should include _________________and must include? ---------- Correct Answer ----------- search the body Which test would the nurse do to diagnose abnormal areas of pigmentation in the skin? ---------- Correct Answer ----------- Wood's light If a client spilled boiling water on their arm, what would the nurse expect to see? ---------

• Correct Answer ----------- pink or red blisters Excessive sebaceous discharge that forms large scales or cheese like plugs on the body is called ---------- Correct Answer ----------- seborrhea The client with full thickness burns over 30% of the body should be on a diet high in ______________________. ---------- Correct Answer ----------- calories and proteins What is the degree of burn that includes the epidermis, dermis, and subcutaneous fat? - --------- Correct Answer ----------- third degree Name one of the ways the nurse can determine that fluid and electrolyte treatment has been successful after a burn. ---------- Correct Answer ----------- Urine output 45mL/hr HR 100 bpm Systolic B/P 110 mm H

What ointment can be used on first degree burns when changing dressings? ---------- Correct Answer ----------- bacitracin _________________injuries occur if the burn victim was in a closed area with the fire and smoke. ---------- Correct Answer ----------- smoke inhalation More than ______________of the bones in the body are found in the hands, wrist, feet, and ankles. ---------- Correct Answer ----------- half A baby has approximately _____________bones at birth ---------- Correct Answer -------- --- 306 Another example of long bone besides the femur is_______________ ---------- Correct Answer ----------- tibia radius humerus Name another example of short bone? ---------- Correct Answer ----------- tarsals ankles carpals Name one of the bones of the middle ear are__________________. ---------- Correct Answer ----------- malleus incus stapes The hollow inner part of most bones is the ---------- Correct Answer ----------- marrow Damage to the growth plate in a limb will cause ______________of growth resulting in a shorter bone. ---------- Correct Answer ----------- cessation Joints that are fixed joints, also called sutural ligaments, are______________. ---------- Correct Answer ----------- synarthroses Joints that are freely movable also known as synovial joints are called______________. ---------- Correct Answer ----------- diarthroses Type of joint that allows movement only in one plane, flexion and extension, is called______________ ---------- Correct Answer ----------- hinge joint A _____________joint consists of a bone pivoting or turning within a bony or cartilaginous ring. ---------- Correct Answer ----------- pivot

Most painful form of arthritis, it is likely related to autoimmune distruction of joints. -------- -- Correct Answer ----------- rheumatoid Lab tests for gout would show elevated ---------- Correct Answer ----------- uric acid A disorder which causes a chronic hardening of connective tissue ---------- Correct Answer ----------- scleroderma A _______________generally involves damage to the muscles and sometimes to the attached tendon. ---------- Correct Answer ----------- strain A ______________is any break or crack in a bone. ---------- Correct Answer ----------- fracture When a _________________, removed, after the fracture is healed, the skin may appear dry and scaly. ---------- Correct Answer ----------- cast What is the acronym for a surgical procedure that is used to repair a fracture? ---------- Correct Answer ----------- ORIF Damage from an external fixation device can cause _____________pressure, causing damage to nerves and vessels. ---------- Correct Answer ----------- neurovascular An infection of the bone is called ---------- Correct Answer ----------- osteomyelitis The sudden blockage of one or more arteries by a piece of foreign material. ---------- Correct Answer ----------- embolism The most common embolism in young people ---------- Correct Answer ----------- fat embolism Damage to a blood vessel can result in____________, a medical emergency which can result in shock. ---------- Correct Answer ----------- hemorrhage Surgical procedure to relieve compartment syndrome is called_____________. ---------- Correct Answer ----------- fascitomy How do you know that your pt with burns has had enough fluids and electorlytes? -------- -- Correct Answer ----------- Urine output 45mL/hr HR 100 Systolic BP 110 mg H T/F Client education about arthritis includes exercise daily, do low-impact exercises, apply heat over the joints ---------- Correct Answer ----------- True

A pt with puritus should be taught ---------- Correct Answer ----------- Wash new clothes before wearing Wear cotton gloves at night Shower after swimming Name a factor that contributes to skin cancer? ---------- Correct Answer ----------- Age over 40 Fair skin Light hair and eyes What protects the heart, lungs, liver, and gives support to the shoulders? ---------- Correct Answer ----------- thoracic cage What is responsible for a cold sweat? ---------- Correct Answer ----------- apocrine glands What keeps skin from drying out? ---------- Correct Answer ----------- sebum What is the term for loss of hair R/T hereditary factors? ---------- Correct Answer ----------

• alopecia What disease process is the result of melanocytes that stop making melanin? ---------- Correct Answer ----------- vitiligo What gives body structures such as skin, its color? ---------- Correct Answer ----------- melanin What should the nurse do if the client has cyanosis? ---------- Correct Answer ----------- monitor O2 level What diet should the pt with full thickness burns be on? ---------- Correct Answer ----------
• high calorie and protein Name a skin graft that comes from the persons own skin? ---------- Correct Answer ------- ---- autograft Name the test which is used to determine decrease in skin pigment? ---------- Correct Answer ----------- Wood's light What is the degree of the burn that goes through the epidermis, dermis, and sub-q fat? - --------- Correct Answer ----------- third degree Name a topical ointment that can be put on first-degree burn ---------- Correct Answer --- -------- bacitracin Name the vertebrae that allows the head to turn ---------- Correct Answer ----------- axis

CBC

Name a disorder associated with low calcium intake. ---------- Correct Answer ----------- osteoporosis A nurse is assessing a client who is receiving oxygen via partial rebreather mask at 10 L/min. When auscultating the client's lungs, the nurse should monitor for which of the following findings as an indication of oxygen toxicity? ---------- Correct Answer ---------- Crackles A nurse is caring for a client who requires oxygen therapy. The nurse should identify that which of the following types of oxygen delivery systems can deliver the highest oxygen concentration? ---------- Correct Answer ---------- Nonrebreather mask A nurse in a long-term care facility is planning care for a client who is to receive oxygen at 4 L/min via nasal cannula. Which of the following interventions should the nurse include in the plan of care? ---------- Correct Answer ---------- Provide the client with oral care every 8 hours A nurse is caring for a client who is 1 hour postoperative following an open cholecystectomy with general anesthesia. The nurse should monitor for which of the following findings as an indication of hypoxia? ---------- Correct Answer ---------- cyanotic mucus membranes A nurse is planning care for a client who requires an exact concentration of oxygen. Which of the following oxygen delivery systems should the nurse include? ---------- Correct Answer ---------- Venturi mask A nurse is caring for a client who has chronic kidney disease (CKD). Which of the following actions should the nurse take to manage fluid overload? ---------- Correct Answer ---------- Obtain the client's blood pressure at least every 4 hours. A nurse is caring for a client who has chronic kidney disease (CKD). The client suddenly develops restlessness and dyspnea, and the nurse auscultates crackles in the client's lungs. Which of the following actions should the nurse take first? ---------- Correct Answer ---------- Place the client in high-Fowler's position A nurse is assessing a client who has chronic kidney disease (CKD). Which of the following findings should the nurse identify as a manifestation of the early stages of CKD? ---------- Correct Answer ---------- Polyuria A nurse is caring for a client who has chronic kidney disease (CKD) and has developed Kussmaul respirations. The nurse should identify that the client is experiencing which of the following acid-base imbalances? ---------- Correct Answer ---------- Metabolic acidosis

A nurse is caring for a client who has chronic kidney disease (CKD). The nurse should monitor the client for which of the following manifestations of fluid overload? ---------- Correct Answer ---------- Increased blood pressure A nurse is preparing to administer acetaminophen 1,000 mg PO every 12 hr for a client who has arthritic pain. The nurse should monitor the client for which of the following adverse effects? ---------- Correct Answer ---------- Hepatotoxicity A nurse is caring for a client who has a left hip fracture and is prescribed a morphine IV bolus as needed for pain. The nurse should monitor the client for which of the following adverse effects? ---------- Correct Answer ---------- Sedation A nurse is assessing a client's pain. Which of the following questions should the nurse ask the client to assess the quality of pain? ---------- Correct Answer ---------- "What does your pain feel like?" A nurse is preparing to administer hydrocodone to a client who reports throbbing pain following a back injury. The nurse should document the client is experiencing which of the following types of pain? ---------- Correct Answer ---------- Somatic A nurse is caring for a client who has a fractured humerus and received an opioid medication intravenously 1 hour ago for pain. Which of the following questions should the nurse ask to determine the intensity of the client's pain at this time? ---------- Correct Answer ---------- "On a scale from 0 to 10, how do you rate your pain?" Stable angina ---------- Correct Answer ---------- predictable and consistent pain from exertion which can be relieved by rest and/or nitroglycerin Unstable angina (preinfarction angina or crescendo angina) ---------- Correct Answer ---- ------ sxs increase in frequency and severity; may not be relieved with rest or nitroglycerin Intractable/refractory angina ---------- Correct Answer ---------- severe incapacitating chest pain Variant angina (Prinzmetal's angina) ---------- Correct Answer ---------- pain at rest with reversible ST-segment elevation; thought to be caused by coronary artery vasospasm Silent ischemia ---------- Correct Answer ---------- objective evidence of ischemia (EKG changes with a stress test), no chest pain s/s of angina ---------- Correct Answer ---------- - choking, tightness, viselike, heavy sensation

• apprehension (impending death)
• retrosternal pain radiates to jaw, arm, shoulder, neck

Total cholesterol level ---------- Correct Answer ---------- <200 mg/dL HDL levels ---------- Correct Answer ---------- >40 for males and >50 for females LDL levels ---------- Correct Answer ---------- <100 mg/dL (<70 for very high risk) Triglyceride levels ---------- Correct Answer ---------- <150 mg/dL Treatment for high cholesterol (hyperlipidemia) ---------- Correct Answer ---------- statins Patient education for MONA ---------- Correct Answer ---------- - Morphine: reduces pain, regulates SNS (which decreases oxygen demand from the heart)

• Oxygen: improves oxygenation of heart tissue and reduces pain
• Nitroglycerin: dilates blood vessels and increases blood flow to heart
• Aspirin: thins blood PCI ---------- Correct Answer ---------- Percutaneous coronary intervention (placement of a catheter and stent in a coronary artery to open the artery; balloon angioplasty) Complications r/t PCI ---------- Correct Answer ---------- - MI
• hematoma/bleeding
• retroperitoneal hematoma
• arterial occlusion
• pseudoaneurysm formation or arteriovenous fistula formation
• acute kidney injury PTCA (percutaneous transluminal coronary angioplasty) complications ---------- Correct Answer ---------- - hematoma at femoral artery insertion site
• embolism
• kidney injury from contrast dye
• bleeding
• thrombus formation
• stroke
• infection CABG ---------- Correct Answer ---------- coronary artery bypass graft
• one or more procedures may be performed using various veins and arteries
• left internal thoracic artery used frequently because of its functional longevity
• saphenous vein - also used as bypass graft CABG complications ---------- Correct Answer ---------- - hypovolemia/hypervolemia
• persistent bleeding
• cardiac tamponade
• hypothermia
• hypotension
• tachyarrhythmias or bradycardia

• cardiac failure
• MI/stroke
• infection
• pulmonary, kidney, or hepatic complications Post MI education ---------- Correct Answer ---------- - stop exercise/activity if chest pain occurs, palpitations, or dyspnea
• do not exceed target HR VTE (venous thromboembolism) prophylaxis ---------- Correct Answer ---------- - antiembolic stockings or sequential compression devices
• pharmacologic agents (antiplatelets) Pneumonia prophylaxis ---------- Correct Answer ---------- - incentive spirometry
• turn, cough, deep breathe
• early mobility Risk factors of COPD ---------- Correct Answer ---------- - exposure to tobacco smoke
• secondhand smoke
• increased age
• occupation exposure (i.e., dust, chemicals)
• exposure to indoor and outdoor air pollution
• genetic abnormalities, deficiency of alpha 1-antrypsin
• RN should emphasize need to reduce exposure to inhaled toxins Clinical manifestations of COPD ---------- Correct Answer ---------- - chronic cough and sputum
• dyspnea
• weight loss
• increased work of breathing (using accessory muscles)
• respiratory insufficiency and infection
• barrel chest
• bronchospasm (wheezes or dim LS) Assessment and diagnosis of COPD ---------- Correct Answer ---------- - spirometry (ratio FEV1 to vital force with and without bronchodilator)
• ABGs
• chest x-ray
• chest CT (for differential dx)
• always review dx tests Management of COPD ---------- Correct Answer ---------- - risk reduction
• oxygen therapy
• bronchodilators (SABA and LABA)
• corticosteroids
• other medications: antitussives, abx, antimucolytics