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NUR242 / NUR 24 2 Exam 3
Medical-Surgical Nursing Concepts
100 % Guarantee passing score of 90% or higher
Consist of 50 Questions with Answers
- The nurse recognizes that a patient with sleep apnea may benefit from which intervention(s)? (Select all that apply.)
A. Weight loss B. Nasal mask to deliver BiPAP C. A change in sleeping position D. Medication to increase daytime sleepiness E. Position-fixing device that prevents tongue subluxation: : ANSWER A, B, C, E
All interventions listed are viable interventions that can be of benefit to patients
who have sleep apnea. Patients should work with their providers of care to determine the severity of their sleep apnea and which specific interventions would be of most importance to them. Encouraging daytime sleepiness is the opposite of the effect needed for this patient.
- Based on the patient's diagnosis, which clinical manifestations would the nurse expect to see when assessing this patient? (Select all that apply.)
A. Bradycardia B. Shortness of breath C. Use of accessory muscles D. Sitting in a forward posture E. Barrel chest appearance: : ANSWER B, C, D, E
The patient with COPD often has a barrel chest appearance, is short of breath, and may use accessory muscles when breathing. These patients tend to move slowly and are slightly stooped. Usually they sit with a forward-bending posture. With severe dyspnea, they exhibit activity intolerance and activities such as bathing and grooming are avoided.
shortness of breath, the first thing that should be done is to increase her oxygen. Once her oxygen is increased, the nurse should note the time and remember to call for stat ABGs in 30 minutes. The patient should then be transferred to the ICU as soon as possible. Once the patient arrives in the ICU, they can administer the one-time dose of Solu-Medrol.
- The nurse immediately checks on the patient and finds that she appears anxious and her vital signs are as follows: ØBlood pressure: 128/84 mm Hg ØHeart rate: 114 (sinus tachycardia) ØRespiratory rate: 24, labored and restless ØTemperature: 99.4° F (axillary) ØO2 saturation: 91% on 40% O2 via trach collar
Which of these findings are cause for concern?: : ANSWER **The BP is within normal range and only slightly elevated. **The temperature is only slightly elevated. **Her heart rate is elevated; the nurse should check the patient's medications to see if she is on a bronchodilator or other medication that could cause her heart rate to increase. The priority concern is the RESTLESSNESS with increased respiratory rate and the decreased oxygen saturation despite the 40% oxygen setting.
- A patient with a history of chronic obstructive pulmonary disease is admit- ted with shortness of breath. Which nursing intervention is most appropriate?
A. Do not administer oxygen. B. Administer oxygen via Venturi mask. C. Use nasal cannula to administer high flow oxygen. D. Administer oxygen at 6L per simple face mask.: : ANSWER B
Oxygen therapy is prescribed at the lowest liter flow needed to manage hypoxemia. A system that delivers more precise oxygen levels (e.g., a Venturi mask) is preferred. Monitor the patient's response to therapy closely to ensure adequate gas exchange and correction of hypoxemia.
- While suctioning a patient, vagal stimulation occurs. What is the appropriate nursing action?
A. Instruct the patient to cough. B. Place the patient in a high Fowler's position. C. Oxygenate the patient with 100% oxygen. D. Instruct the patient to breathe slowly and deeply.: : ANSWER C
dyspnea?
A. "I bought a new pillow so I could prop myself up at night to sleep." B. "I have a productive cough in the morning." C. "I have gained weight since I was here last." D. "The patient is well groomed and is sitting in a tripod position.": : ANSWER A
Patients with COPD, who smoke, may have a productive morning cough. Weight loss often occurs when dyspnea is increased due to the increased metabolic demand. A tripod or orthopneic position is common with COPD and when combined with a disheveled appearance may indicate an increase in dyspnea. Buying a new pillow indicates that the patient must sleep propped up because breathing is worse while lying down. They may not recognize the increased dyspnea and they try to compensate by using multiple pillows in order to rest.
- The nurse is assessing a patient with a chest tube following a pneumonec- tomy. Which assessment finding requires intervention?
A. Bandage around the posterior tube is loose. B. 2 cm of water is in the second chest tube chamber.
C. The water in the water seal chamber rises and falls with inhalation/exhala- tion. D. Bubbling present in the water seal chamber when the patient coughs.: : ANSWER A
After lung surgery, two tubes, anterior and posterior, are used. Dressings around the wound should not be loose. The wounds should be covered with airtight dressings.
- A home health patient with a history of asthma is having shortness of breath. The nurse discovers that the peak flowmeter indicates a peak expi- ratory flow (PEF) reading that is in the red zone. What is the priority nursing action?
A. Call 911 immediately. B. Take the patient's vital signs. C. Notify the patient's prescriber. D. Repeat the PEF reading to verify the results.: : ANSWER A A PEF reading in the red zone indicates a range that is 50% below the patient's personal best PEF reading and indicates serious respiratory obstruction requiring 911 or rapid response. Offer medications and stay with the patient. Repeating the
D. Blood glucose: : ANSWER B
All of the patient's vital signs are abnormal. However, the most important one to report immediately is her increased respirations (and decreased oxygen saturation). Even though a diagnosis has not been confirmed, it is very important to address these problems. The patient is experiencing tachypnea.
- After consulting with the provider, the following orders are received: Full liquid diabetic diet IV fluids 1000 mL .9 NS at 60 mL/hr Oxygen at 2 L per nasal cannula Blood cultures × 3 and urinalysis Tylenol grain × every 4 hour for temperature above 101º F Cefazolin (Ancef) 1 g IVP every 8 hour
Which of the provider's orders should the nurse implement first? A. IV fluids 1000 mL .9 NS at 60 mL/hr B. Oxygen at 2 L per nasal cannula C. Blood cultures and urinalysis D. Cefazolin (Ancef) 1 g IVP every 8 hour: : ANSWER B
All of the provider's orders are very important. However, the most important one is oxygen therapy. Hypoxia is often seen with pneumonia, so it is very important that supplemental oxygen is started as soon as possible. IV fluids should be started to enhance pulmonary toileting, and the laboratory should be notified to draw the needed blood cultures. UAP can obtain the specimen for urinalysis. The blood cultures and the UA should be obtained before the IVP Ancef is administered.
- The nurse understands that which of the following is the most common symptom of pneumonia in the older adult patient?
A. Fever B. Cough C. Confusion D. Weakness: : ANSWER C
The older adult with pneumonia often has weakness, fatigue, lethargy, confusion, and poor appetite. Fever and cough may be absent, but hypoxemia is usually present. The most common manifestation of pneumonia in the older adult patient is confusion from hypoxia rather than fever or cough.
Oxygen dissociates with the hemoglobin molecule based on the need for oxygen to perfuse tissues. Under normal conditions, 50% of hemoglobin molecules completely dissociate their oxygen molecules when blood perfuses tissues that have an oxygen tension (concentration) of 26 mm Hg. This is considered a "normal" point at which 50% of hemoglobin molecules are no longer saturated with oxygen.
- Which assessment finding does the nurse interpret that is associated most closely with lung disease?
A. Cough B Dyspnea C. Chest pain D. Sputum production: : ANSWER A
Cough is a main sign of lung disease. Dyspnea (difficulty in breathing or breathless- ness) is a subjective perception and varies among patients. A patient's feeling of dyspnea may not be consistent with the severity of the presenting problem. Sputum production may be associated with coughing and indicate an acute or chronic lung
condition. Chest pain can occur with other health problems, as well as with lung problems.
- A patient in the ED has been experiencing upper abdominal pain after meals for the past 2 months. She also notices that when she takes a nap or sleeps at night, she has pain. Eating seems to decrease pain. She has been taking OTC antacids with some relief.
Which assessment factor puts the patient at risk for peptic ulcer disease? A. Weight loss of 35 pounds B. Use of NSAIDs to control arthritis pain C. GERD 4 years ago D. Use of prednisone (Deltasone) for inflammation: : ANSWER B
Peptic ulcer development is associated primarily with NSAID use and bacterial infections with H. pylori.
- Which diagnostic results support the diagnosis of peptic ulcer disease? (Select all that apply.) A. Low hemoglobin B. Low WBC level C. Low hematocrit D. Positive for H. Pylori bacteria
PPI, such as lansoprazole (Prevacid), and two antibiotics, such as metronidazole (Flagyl) and clarithromycin (Biaxin).
- As the patient prepares for discharge, the nurse provides education about behaviors that reduce symptoms and aggravate peptic ulcers.
Which teaching does the nurse provide? (Select all that apply.) A. Sit upright 30 to 60 minutes after meals. B. Spices should be added to food to enhance flavor. C. A vagotomy will be needed in the future. D. Extreme vomiting should be reported to your physician. E. H. pylori can be a concern in patients with peptic ulcers. F. The goal of initial intervention is to control symptoms and prevent further complications.: : ANSWER A, D, E, F
Patients should avoid spicy foods because they irritate the ulcer and gastric tissue. A vagotomy is associated with GI bleeds.
- A 64-year-old patient with a history of arthritis and hypertension is admit- ted with progressive epigastric cramping, dyspepsia, nausea, and dark sticky stools for 2 days. Which order should the nurse question?
A. IV fluids, normal saline at 125 ml/hr
B. Guaiac stool sample ´ 2 C. Naproxen (Naprosyn) 500 mg twice daily D. Stool sample for bacterial testing: Answer: C
Rationale: Long-term NSAID use creates a high risk for acute gastritis. Naproxen is an NSAID that may be used to treat arthritis. Other risk factors for acute gastritis include alcohol, caffeine, and corticosteroids. IV fluids may or may not be needed to replace any fluids or blood lost from the patient's gastritis. Stool guaiac is nonspecific but may be ordered to confirm blood in the stool, and a stool sample may be used to test for the presence of Helicobacter pylori infection. However, it is not as accurate as blood or breath tests.
- What is the nursing priority in the management of a patient with an active upper GI bleed?
A. Obtain vital signs. B. Apply oxygen by nasal cannula. C. Type and crossmatch the patient for blood products. D. Notify the physician.: Answer: A
B. Walks 20 minutes once daily C. Frequently takes NSAIDs for pain D. Consumes foods with calcium supplementation: : ANSWER C
Some drugs can cause GERD, such as oral contraceptives, anticholinergic agents, sedatives, nonsteroidal antiinflammatory drugs (NSAIDS) such as ibuprofen, ni- trates, and calcium channel blockers. The possibility of eliminating those drugs causing reflux should be explored with the health care provider. Maintaining a normal weight , performing daily exercise, and taking supplements with food are not risk factors for developing GERD
- Which nursing intervention is the priority in the care of a patient with a hiatal hernia?
A. Providing nutrition education B. Promoting regular exercise C.Providing medication education D. Instructing the patient on signs and symptoms of intestinal strangulation-
: ANSWER A
The most important role of the nurse in caring for a patient with a hiatal hernia is health teaching, specifically nutrition management to include weight loss. Education for prescribed medications is an important nursing function, as well as education for signs and symptoms of infection if the patient has a rolling hiatal hernia.
- A patient in the ED has been experiencing upper abdominal pain after meals for the past several months. She reports pain after napping or sleeping at night. She has been taking OTC antacids with some relief. The nurse un- derstands that which assessment finding places the patient at risk for peptic ulcer disease?
A. GERD 4 years ago B. Weight loss of 35 lbs C. Use of NSAIDs to control arthritis pain D. Recent discontinuation of prednisone (Deltasone): : ANSWER C
Peptic ulcer development is associated primarily with nonsteroidal anti- inflammatory drug (NSAID) use and bacterial infections with Helicobacter pylori.
