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A series of questions and answers related to the assessment and management of various medical-surgical conditions, including heart failure, diabetes complications, urinary tract infections, and stroke. It is designed to help nurses identify and respond appropriately to symptoms and signs, initiate necessary precautions, and administer appropriate medications. A valuable resource for nursing students and professionals seeking to enhance their knowledge and skills in medical-surgical nursing.
Typology: Exams
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Your post-op patient has a Jackson-Pratt (JP) drain in place. How do you ensure
to establish suction Your male patient complains of discomfort while inflating the balloon during insertion of an indwelling urinary catheter. What would be the MOST appropriate action? -
the balloon Your patient has symptomatic anemia but is refusing a blood transfusion for religious
and notify the provider Your patient is admitted with diverticulitis. What type of diet do you expect to be ordered
You were hired to work the medical unit and when you arrive at work the charge nurse has assigned you to the post-surgical unit since they are understaffed. Which is the
Which adaptive equipment would be MOST appropriate to use for a severely contracted patient who is unable to bear weight when transferring from the bed to the chair? -
Which tool should you use to assess pain in you 80-year-old patient with severe
Your patient is admitted from the ED with failure to thrive and advanced dementia. You note he is extremely underweight, appears unbathed for some time, and has a stage 4 pressure injury to his coccyx. You were told in report that he lives at home with family
social worker of your concerns. Your 85-year-old patient with atrial fibrillation fell at home 3 days ago. You notice she has been having several episodes of acute confusion since being admitted to your unit.
Your patient has a temp of 102.3 F, HR 122, and has had 15 mL of urine from the indwelling urinary catheter in the last 2 hours. What is your patient MOST likely
What type of personal protective equipment (PPE) is applied prior to entering a room for
Your patient continues to pull at their IV site located in their left forearm despite verbal reminders and increased observation. The nursing assistant recommends using soft
Your patient was admitted for a hypertensive crisis and has a history of HTN, Parkinson's disease, depression, and alcohol use. On his second hospitalized day, you notice he is more anxious and restless than his baseline. What would be your FIRST
alcohol was.
While in a supine position your patient states, "I'm tired and cannot catch my breath." Physical assessment reveals jugular vein distention and a third heart sound (S3). These
Your new admission presents with a cough, unintentional weight loss, frequent night sweats, and bloody sputum. What type of isolation precautions should you initiate, if
Patients with diabetes are at high risk for complications from damage to what body
If your patient with a known history of diabetes is displaying symptoms of diaphoresis,
Your patient tells you, "I hope I don't die, but if I do I don't want to be brought back.? You notice on her chart and wrist band that she is a full code. What would be the MOST
follow up with provider to ensure the medical record reflects her wishes. Your coworker posted photos on social media from a birthday party they had for her in
Your new patient understands very limited English. How should you communicate with
organization's interpreter services. You are caring for a patient with a history of diabetes mellitus. You walk into the room
Your patient is 4 hours post open appendectomy and has not voided yet. You note his
A patient with peritonitis presents with tachycardia, hypotension, and dehydration. What other assessment finding would you anticipate as part of your physical assessment? -
What is the EARLIEST sign indicating increased intracranial pressure (ICP)? -
In addition to pain, pallor, and pulselessness, a neurovascular assessment also
You received a report on a patient that sustained a right hemisphere CVA 48 hours ago.
of the leg, arm, and face. You are ordered to give digoxin (Lanoxin). Your patients vital signs are: BP 130/70, Temp 97.9F, HR 52, RR 16, O2 Sat 100% on room air. What should you do NEXT? -
Upon entry to your patient's room, you find her sitting in High Fowler's position and complaining of shortness of breath. Her respiratory rate is 34 breaths/min and O2 sat is 84%. Which mode of oxygen delivery would MOST likely reverse these symptoms? -
Your patient is on contact precautions for active MRSA. What proper PPE should you
Your patient recently had a G-tube placed and intermittent enteral feedings have been
Upon entering your patient's room, you note that they are having a seizure. What is your
airway. Your 18-year-old female patient was admitted with dehydration secondary to anorexia nervosa. During your assessment you note she has a flat affect and says, "I just want to
Your patient has a non-productive cough and presence of secretions in his
Your patient takes 5 mg of warfarn (Coumadin/Jantoven) daily and reports having black
Your new patient was admitted with blunt force trauma to the abdomen following a motor vehicle accident (MVA). A NG tube is in place for decompression; however, you note during the assessment that the stomach is rigid and hard during palpation. What
Which of the following nursing diagnoses is MOST important for a patient with chronic
You have a patient going for dialysis. Their medications include lisinopril (Prinivil), ondansetron (Zofran), famotidine (Pepcid), and atorvastatin (Lipitor). Which medication
(Pepcid) What is an early symptom that the patient is developing a complication of heart failure?
You have 4 patients who have high priority needs. One needs to go to surgery, one needs STAT lab draws from a PICC line, another has chest pain rated 8/10, and
Your patient with Hepatitis C exhibits signs of jaundice and a distended abdomen. What procedure would you anticipate being performed by the provider at the bedside for this
A patient on warfarin (Coumadin/Jantoven) has an INR of 6. Which medication would
To reduce the risk of infection and phlebitis in an adult patient with a peripheral IV, what is the MINIMUM duration the catheter should remain in place before ROUTINE
You are caring for a patient post lobectomy with a chest tube in place for drainage.
to cough and deep breathe. What patient population is the pneumococcal vaccine, PPSV23 indicated for? -
Your patient with stave IV terminal lung cancer continues to experience increasing pain as each day passes. What would you anticipate the provider ordering for this patient? -
The provider gives you a telephone order to explain a surgical procedure to your patient
the provider that explaining the procedure is outside the nurse's scope of practice. The patient has diltiazem HCl (Cardizem CD) ordered and is requesting the capsule be
it is a slow-release medication that cannot be opened or crushed." Your 72-year-old male patient is admitted for colon cancer related complications and has a history of CHF, stroke, and a recent knee replacement. Based on your patient's risk assessment, you determine he is at risk for venous thromboembolism (VTE). What
You receive a provider's order that is not consistent with evidence-based practice. What
Your patient's morning labs revealed a hemoglobin level of 6.3 and hematocrit of 18.
Your 68-year-old patient is a Type 1 diabetic with a history of schizophrenia and exhibits signs and symptoms of tardive dyskinesia. What long-term medication is associated
olanzapine, quetiapine, ziprasidone, aripiprazole, paliperidone, lurasidone, chlorpromazine, fluphenazine, haloperidol, perphenazine Your 80-year-old patient is being discharged home post CVA. She lives alone, yet still requires assistance with ADLs. What referral is MOST appropriate to ensure her needs
Central Telemetry calls and tells you your patient is experiencing bradycardia. What is
patient and take vital signs. Your patient is currently under 1:1 observation for suicide precautions. He states he needs to have a bowel movement and would like some privacy to use the bathroom.
arms' length view of you at all times for your safety, including while using the bathroom." A female patient requests a female nurse to provide care for her based on her religious
Your patient is a 40-year-old female with a recent history of hair loss, extremely dry skin, a nd a 20-point weight loss in the last 3 weeks. She also exhibits occasional episodes of tremors in her upper extremities. What condition do these symptoms MOST
Insulin lispro (Humalog) is orders via sliding scale a.c. for your patient with diabetes.
min before the meal arrives Which of the following would be used as part of the preop procedure to prevent
Two days after surgery, your 72-year-old patient is showing signs of agitation and confusion, which is not his baseline. The severity fluctuates throughout the day. His medications include hydromorphone (Dilaudid), amlodipine (Norvasc), alprazolam (Xanax), and carbidopa-levodopa (Sinemet). What condition do you MOST likely
Your new patient admitted for cholecystitis expresses she has a history of anxiety disorder. She is feeling panicked and does not think she can handle staying in the
The provider orders and IV infusion of D5W 1000 mL to infuse over the next 6 hours.
mL/hr You are assigned a new admission and note a Braden score of 11 after completing your assessment. Which interventions would be MOST appropriate based on your
low airloss mattress. Your patient may have tuberculosis TB) and is placed in airborne precautions. What test
Your patient starts to complain of difficulty breathing while laying down, and states that he has been coughing up pink sputum. While performing your assessment, you notice jugular vein distention and coarse crackles in both lungs on auscultation. What
You received a patient post op transurethral resection of the prostate (TURP). Which of
Your patient with C. diff (Clostridioides difficile) has a family member about to leave the
Your patient has a diagnosis of urinary tract infection (UTI) and is currently taking medication that has recently made her urine reddish-orange. Which of the following
(Pyridium) Your patient is taking digoxin (Lanoxin) and has a potassium level of 3.0. How might this
You are preparing to hang 1 unit PRBC's to administer to your patient. The patient states, "I don't take blood products." What is the MOST appropriate response? -
the provider of your decision." An older adult patient arrives on the unit looking emaciated, disheveled, and with soiled clothes. The patient claims that his daughter cares for him at home. What would you
You just left your patient's room with her husband at bedside. You then receive a phone call from someone states that she is your patient's mother and demands updates about
consent to release information to her mother. The provider orders Heparin 4 units/kg SQ. Your patient weighs 176 pounds. How many
What diagnostic finding would support a diagnosis of deep vein thrombosis? -
You are caring for a combative 85-year-old male with a history of dementia, CHF, UTI, and anemia. The family states he appears to be more confused than his baseline. What
cultures, CBC A patient has recently been diagnosed with terminal cancer. Her responses are caustic
her feelings, understanding this is expected in the grieving process.
You notice your patient who recently had a stroke is coughing intermittently during
aspirating. A patient with acute diverticulitis is MOST likely to complain of abdominal pain with what
Which of the following is MOST important in preventing a catheter associated urinary
the catheter The provider orders a Heparin infusion of 900 units/hr. Your IV medication on hand has 25,000 units of Heparin in 500 mL of D5W. How many mL/hr will you infuse? -
Your patient has developed a productive cough and fever. The provider is suspecting
precautions What medication would you anticipate to be ordered for a patient who has a LDL > 200
Fifteen minutes after starting a blood transfusion, the patient complains of lower back
Your patient had a transurethral resection of the prostate (TURP) 24 hours ago. What
What condition (not medication related) might cause an elevation in the patients PT/INR
Your patient admitted for small bowel obstruction has been vomiting for the last 3 days. What electrolyte imbalance would you expect to be associated with this patient? -
As you are walking down the hallway you overhear your colleague discussing her personal family issues with a patient. What would be the MOST appropriate response? -
maintaining professional boundaries with patients. Your patient, who has soft wrist restraints for safety (non-violent), is working with the occupational therapist at the bedside. The nursing assistant enters and says, "The
know when the therapy session is finished and I will re-apply them." Your patient suddenly develops signs and symptoms of shortness of breath, restlessness, tachypnea, hemoptysis, and decreased oxygen saturations despite being
The dosage of which drug must be tapered down slowly to prevent acute adrenal
Your patient with CHF states, "I can still eat the same food, I just have to weight myself everyday." Based on this statement, which nursing diagnosis would be appropriate? -
patient arrives on unit. you do an assessment and notice lice in her hair. what is your
facility code procedure
Cancer treatment options: Safety precautions for a sealed radiation implant -
■ Place the client in a private room away from other clients when possible. ■ Place appropriate sign on the door warning of the radiation source. ■ Wear a dosimeter film badge that records personal amount of radiation exposure.
■ Limit visitors to 30-min visits, and have visitors maintain a distance of 6 ft from the source. ■ Visitors and health care personnel who are pregnant or under the age of 16 should not come into contact with the client or radiation source. ■ Keep a lead container in the client's room if the delivery method could allow spontaneous loss of radioactive material. Tongs are available for placing radioactive material into this container. ■ Precautions listed above should be carried out at home if the client is discharged during therapy. ◯ Client Education ■ Inform client of the need to remain in an indicated position to prevent dislodgement of the radiation implant. ■ Instruct the client to call the nurse for assistance with elimination. ■ Instruct client and family about radiation precautions needed in the health care and home environments.
Assessments are performed every hour for the first 24 hr and every 1 to 4 hr thereafter following initial trauma to monitor neurovascular compromise related to edema and/or the immobilization device. Nursing Actions ☐ Monitor neurovascular status and assess pain. ☐ Apply ice for 24 to 48 hr. ☐ Handle a plaster cast with the palms, not fingertips, until the cast is dry to prevent denting the cast. ☐ Avoid setting the cast on hard surfaces or sharp edges. ☐ Prior to casting, the area is cleaned and dried. Tubular cotton web roll is placed over the affected area to maintain skin integrity. The casting material is then applied. ☐ After cast application, position the client so that warm, dry air circulates around and under the cast (support the casted area without pressure under or directly on the cast) for faster
drying and to prevent pressure from changing the shape of the cast. Use gloves to touch the cast until it is completely dry. ☐ Elevate the cast above the level of the heart during the first 24 to 48 hr to prevent edema of the affected extremity. ☐ If any drainage is seen on the cast, it should be outlined, dated, and timed, so it can be monitored for any additional drainage. ☐ Older adult clients have an increased risk for impaired skin integrity due to the loss of elasticity of the skin and decreased sensation (comorbidities). Acute Kidney Injury and Chronic Kidney Disease: Over the counter medications -
calcium into the kidney cells, maintain cell integrity, and increase glomerular filtration rate (GFR).Avoid administering antimicrobial medications (e.g., aminoglycosides and amphotericin B), NSAIDs, angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers, and IV contrast dye, which are nephrotoxic. ◯ Digoxin (Lanoxin), a cardiac glycoside, increases contractility of the myocardium and promotes cardiac output. ■ Monitor digoxin laboratory levels due to slow excretion of the medication with CKD. ■ Administer digoxin (Lanoxin) after receiving dialysis. ◯ Sodium polystyrene (Kayexalate) to increase elimination of life-threatening serum potassium, which may cause dangerous cardiac dysrhythmias and peaked T waves. ■ Restrict sodium intake. Sodium polystyrene contains sodium and can cause fluid retention and hypertension, a complication of CKD. ◯ Erythropoietin alfa (Epogen, Procrit) to stimulate production of red blood cells, given for anemia ◯ Ferrous sulfate (Feosol), an iron supplement to prevent severe iron deficiency. ◯ Aluminum hydroxide gel (Amphojel) ■ Taken with meals to bind phosphate in food and stop phosphate absorption. ■ Take 2 hr before or after digoxin. ◯ Furosemide (Lasix), a loop-diuretic administered to excrete excess fluids. ■ Avoid administering to a client who has end-stage kidney disease. ■ Clients may also receive thiazide diuretics, potassium-sparing diuretics, and osmotic diuretics.
■ Medications such as carvedilol (Coreg) and metoprolol (Lopressor) may be used to improve the condition of the client who has sustained increased levels of sympathetic stimulation and catecholamines. This would include clients who have chronic heart failure. ■ Nursing considerations ☐ Monitor BP, pulse, activity tolerance and orthopnea. ☐ Check orthostatic blood pressure readings. ■ Client Education ☐ Instruct the client to weigh daily. ☐ Advise the client to regularly check BP. ☐ Tell the client to follow the provider's instructions on increasing medication dosage.
■ Short-acting beta2 agonists, such as albuterol (Proventil, Ventolin) provide rapid relief. ■ Cholinergic antagonists (anticholinergic medications), such as ipratropium (Atrovent), block the parasympathetic nervous system. This allows for the sympathetic nervous system effects of increased bronchodilation and decreased pulmonary secretions. These medications are long acting and are used to prevent bronchospasms. ■ Methylxanthines, such as theophylline (Theo-24), relax smooth muscles of the bronchi. These medications require close monitoring of serum medication levels due to narrow therapeutic ranges. Use only when other treatments are ineffective. ■ Nursing Considerations ☐ Monitor the client's serum levels for toxicity when taking theophylline. Side effects will include tachycardia, nausea, and diarrhea. ☐ Watch the client for tremors and tachycardia when taking albuterol. ☐ Observe the client for dry mouth when taking ipratropium. ■ Client Education ☐ Encourage the client to suck on hard candies to help moisten dry mouth while taking ipratropium. ☐ Encourage client to increase fluid intake, report headaches, or blurred vision. ☐ Monitor heart rate. Palpitations can occur, which may indicate toxicity of ipratropium.
water. ● Instruct clients to complete the prescribed course of antimicrobial therapy, even though symptoms may resolve before the full course is completed Antiseptics: Inform clients that urine will have a brownish discoloration. ● Encourage clients to administer with food if GI symptoms occur. ● Instruct clients to complete the prescribed course of antimicrobial therapy, even though symptoms may resolve before the full course is completed. ● Recommend that clients avoid crushing tablets because of the possibility of tooth staining. ● Instruct clients to avoid nitrofurantoin while pregnant (can cause infant birth defects). Fluoroquinolones: Ciprofloxacin is available in oral and intravenous forms. ◯ Discontinue other IV infusions or use another IV site when administering IV ciprofloxacin. ● Decrease doses of ciprofloxacin in clients who have renal dysfunction. ● Intravenous ciprofloxacin should be administered in a dilute solution slowly over 60 min in a large vein. ● For inhalation anthrax infection, ciprofloxacin is administered every 12 hr for 60 days. ● Instruct clients to complete the prescribed course of antimicrobial therapy, even though symptoms may resolve before the full course is completed. Gastrointestinal Therapeutic Procedures: Calculating Infusion Volume of TPN -
concentration [20% to 50%] of dextrose), lipids/essential fatty acids, protein, electrolytes, vitamins, and trace elements. Standard IV bolus therapy is typically less than or equal to 700 calories/day. Basic guidelines regarding when to initiate TPN ☐ A weight loss of 7% body weight and NPO for 5 days or more ☐ A hypermetabolic state The flow rate is gradually increased and gradually decreased to allow body adjustment (usually no more than a 10% hourly increase in rate).
Pressure Ulcers, Wounds, and Wound Management: Signs of Wound Healing -
◯ The inflammatory stage begins with the injury and lasts 3 to 6 days. Initial care involves the following. ■ Controlling bleeding with vasoconstriction and retraction of blood vessels, and with clot formation. ■ Delivering oxygen, white blood cells, and nutrients to the area via the blood supply. ◯ The proliferative stage lasts the next 3 to 24 days. Effects to the wound include: ■ Replacing lost tissue with connective or granulated tissue. ■ Contracting the wound's edges. ■ Resurfacing of new epithelial cells. ◯ The maturation or remodeling stage involves the strengthening of the collagen scar and the restoration of a more normal appear TYPE OF HEALING CHARACTERISTICS WOUND TYPE Primary intention › Little or no tissue loss › Edges approximated, as with a surgical incision › Heals rapidly › Low risk of infection › No or minimal scarring Secondary intention › Loss of tissue › Wound edges widely separated (pressure ulcers, open burn areas) › Longer healing time › Increase for risk of infection › Scarring Tertiary intention › Widely separated › Deep › Spontaneous opening of a previously closed wound › Risk of infection › Extensive drainage and tissue debris › Closed later › Long healing time
◯ Some clients report transient symptoms, such as visual disturbances, dizziness, slurred speech, and a weak extremity.
◯ These symptoms may indicate a transient ischemic attack (TIA), which can be a warning of an impending stroke. ◯ Antithrombotic medication and/or surgical removal of atherosclerotic plaques in the carotid artery can prevent the subsequent occurrence of a stroke. ● Objective Data ◯ Physical Assessment Findings ■ Symptoms will vary based on the area of the brain that is deprived of oxygenated blood. ☐ The left cerebral hemisphere is responsible for language, mathematics skills, and analytic thinking. ☐ Symptoms consistent with a left-hemispheric stroke include the following: X Expressive and receptive aphasia (inability to speak and understand language respectively) X Agnosia (unable to recognize familiar objects) X Alexia (reading difficulty) X Agraphia (writing difficulty) X Right extremity hemiplegia (paralysis) or hemiparesis (weakness) X Slow, cautious behavior X Depression, anger, and quick to become frustrated X Visual changes, such as hemianopsia (loss of visual field in one or both eyes)
timing (diastolic versus systolic) help determine the valve involved. Murmurs are graded on a scale of I (very faint) to VI (extremely loud). Arthroplasty: Assessing a Client Using a Continuous Passive Motion Machine -
to promote motion in the knee and prevent scar tissue formation. CPM is usually placed and initiated immediately after surgery. CPM provides passive range of motion from full extension to the prescribed amount of flexion. The prescribed duration of its use should be followed, but it should be turned off during meals.
Dos/Don'ts
› Use elevated seating/raised toilet set. › Avoid flexion of hip greater than 90º. › Use straight chairs with arms. › Avoid low chairs. › Use an abduction pillow, or a pillow, if prescribed, between the client's legs while in bed (and with turning, if restless, or is in an altered mental state). › Do not cross a client's legs. › Externally rotate a client's toes. › Do not internally rotate a client's toes.
pillows. Avoid neck extension. Invasive Cardiovascular Procedures: Postoperative Care Following a Coronary Artery
◯ Nursing Actions ■ Maintain patent airway and adequate ventilation. ☐ Monitor respiratory rate and effort. ☐ Auscultate breath sounds. Report crackles. ☐ Monitor SaO2. ☐ Document ventilator settings. ☐ Suction as needed. ☐ Assist with extubation. ■ Encourage the client to splint the incision while deep breathing and coughing. ■ Dangle and turn the client from side to side as tolerated within 2 hr following extubation. Assist the client to a chair within 24 hr. Ambulate the client 25 to 100 ft by first postoperative day. ■ Consult respiratory services to aid in recovery and client education. ■ Consult case management services to initiate discharge planning: need for home oxygen therapy, transfer to tertiary care facility. ■ Continually monitor client's heart rate and rhythm. Treat dysrhythmias per protocol. ■ Maintain an adequate circulating blood volume. ☐ Monitor blood pressure. X Hypotension may result in graft collapse. X Hypertension may result in bleeding from grafts and sutures. X Titrate IV drips (dopamine [Intropin], dobutamine [Dobutrex], milrinone [Primacor], sodium nitroprusside [Nipride]) per protocol to control blood pressure and/or increase cardiac output.
☐ Monitor hemodynamic pressures, and monitor catheter placement. Observe waveforms and markings on catheter. ☐ Monitor the client's level of consciousness. Assess neurological status every 30 to 60 min until the client awakens from anesthesia, then every 2 to 4 hr, or per facility policy. ☐ Notify the surgeon of significant changes in values. ■ Monitor chest tube patency and drainage. ☐ Measure drainage at least once an hour. ☐ Volume exceeding 150 mL/hr could be a sign of possible hemorrhage and should be reported to the surgeon. ☐ Avoid dependent loops in tubing to facilitate drainage. ■ Ass
◯ For all acid-base imbalances, it is imperative to treat the underlying cause. ◯ Respiratory acidosis: Oxygen therapy, maintain patent airway, and enhance gas exchange (positioning and breathing techniques, ventilatory support, bronchodilators, mucolytics). ◯ Respiratory alkalosis: Oxygen therapy, anxiety reduction interventions, and rebreathing techniques. ◯ Metabolic acidosis: Varies with causes (if DKA, administer insulin; if related to GI losses, administer antidiarrheals and provide rehydration; if serum bicarbonate is low, administer sodium bicarbonate [1 mEq/kg]). ◯ Metabolic alkalosis: Varies with causes (if GI losses, administer antiemetics, fluids, Acute Kidney Injury and Chronic Kidney Disease: Nephrostomy Tube Insertion -
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