WorksheetsMed surg final study guide
Total questions: 74
Worksheet time: 45mins
The nurse is caring for a pt in sickle cell crisis. What is the rationale for providing warm compression and blanket for this pt?
Sickle cell crisis causes shivering and discomfort.
Heat helps prevent the cells from being sickled
Heat speeds production of new healthy RBCs
Heat prevents vasoconstriction and impaired circulation
The nurse is reviewing the current pt census on a care area, which induvidual is most likely to present with signs or symptoms of sickle cell anemia?
A 1 month old boy who is hispanic
A 5 year old girl who is hispanic
A 1 year old boy who is african american
A 3 month old girl who is african american.
A pt is admitted in sickle cell crisis with symptoms of dyspnea and leg pain. The pt's significant other says, I dont really understand why he is hurting so badly. Which response by the nurse is best?
The pain is due to a disturbance in cellular metabolism.
The bone marrow is expanding with the sickle cells and that causes pain.
Clumping of abnormal RBCs blocks the flow of blood through capillaries.
Bleeding in the joints occurs necuase RBCs are being rapidly destroyed by the bone marrow.
The nurse is caring for a pt with thrombocytopenia. Which activity should be avoided?
Ambulation
Intramuscular injections
Visits from family members
Eating fresh fruits and veggies
An inherited anemia in which the RBCs have a specific mutation that makes the Hgb very sensitive to oxygen changes. _____ ____ ______
(a)
Associated with lack of intrinsic factor in stomach secretions, which is necessary for absorption of vitamin b12. _______ _____
(a)
Aspiration of marrow is done to obtain a specimen that can be viewed under a microscope ____ ______ ______
(a)
Abnormal decrease in the number of platelets
(a)
The nurse is assissting in preparing a pt for transfer to a rehab facility after a stroke. What should the nurse explain as the goal for rehab?
To monitor neurological status
To cure any effects of the stroke
To maximize remaining abilities
To determine the extent of neurological deficits
The nurse is caring for a hospitalized pt who had had a stroke and is waiting to be transferred to a rehab facility. What nursing action can best maximize the pts rehab potential while awaiting transfer?
Teach the pt what to expect at the rehab facility
Keep the pt on bedrest to conserve energy for rehab
Call the physical therapist for bedside rehab until transfer
Turn the pt every 2 hrs to prevent pressure ulcers
A pt comes into the emergency department with symptoms of a stroke. Which medication should the nurse expect may be given to the pt if diagnostic testing confirms an ishemic stroke?
Heparin
Warfarin
Clopidogrel (plavix)
TPA
Which of the following are treatments of migraine headaches?
Prophylactics
NSAIDS
botox injections
Vasoconstrictors
All of these
(a) headaches are a neurological disorder involving brain chemicals and neurological pathways.
The physican prescribes intravenous mannitol for a pt who has a head injury and increased ICP. Which assessment finding indicates to the nurse that the pt is having a therapeutic response to mannitol?
Return of the gag reflex
Increased blood glucose
Increased urinary output
Decreased glasgow coma scale
A pt with a cerebral injury is experiencing ICP. Which intervention should the nurse use to help prevent further increasing ICP?
Avoid touching the pt as much as possible
Provide stimulation such as radio and TV for 12 hr each day
Provide as much nursing care at one time as possible to allow pt to rest
Space nursing care at intervals so that the necessary care is distributed evenly throughout a shift.
The vital signs for a client with a possible head injury were on admission: bp 128/72, pulse 90 bpm, and respirations 66 bpm. Which vital sign and respiration assessment conducted 4 hours later most likely indicates the presence of ICP?
bp 172/68 pulse 42 bpm respiration 10 bpm
bp 160/90 pulse 112 bpm respiration 16 bpm
bp 130/72 pulse 50 bpm respiration 24 bpm
bp 100/70 pulse 120 bpm respiration 30 bpm
The nurse is caring for a pt brought to the emergency department after an automobile accident. THe pt is fully conscious. For what early signs of Increased intracranial pressure (ICP) should the nurse be alert?
Bradycardia
Hypothermia
Pinpoint pupils
Decreased LOC
Flexion posturing, the pt's arms are flexed at the elbow, and the hands are raised towards the chest, and the legs are extended. This posture indicates significant impairment of cerebral functioning. (a)
Extension posturing, both arms and legs are extended and the arms are internally rotated. This posturing indicates damage to the brainstem. (a)
The nurse is caring for a pt who has had a stroke (brain attack). the pt is unable to understand what the nurse is saying and appears fustrated. what term should the nurse use to document this finding?
Dysphagia
Confusion
Receptive aphasia
Expressive aphasia
A pt is diagnosed with diabetic ketoacidosis (DKA) which manifestations should the nurse expect to observe in the pt? Select all that apply.
Dehydration
Hypertension
Flu like symptoms
Kussmauls respirations
Cheyne stokes respirations
A pt is experiencing rapid breathing, fruity odor, lethargy, and weight loss. Laboratory results includ a blood glucose of 720 mg/dl. Which symptom should indicate to the nurse that the pt has type 1 diabetes mellitus?
Thirst
hunger
lethargy
fruity odor
True or False. Pt will be on lifelong hormone replacement therapy after a hypophysectomy?
True
False
After a hypophysectomy which of the following activites should be avoided?
Coughing
Sneezing and nose blowing
straining with bowel movements
all of these
Why do you perform a neurological assessment preoperatively to a hyphophysectomy?
To determine if pt can withstand the procedure
To create a baseline, to compare to after surgery.
To determine if pt can understand the procedure
To determine if a psych counsel is needed prior to procedure
Removal of the pituitary gland.
(a)
A limb threatening condition in which pressure in limb compartments increase. ________ _______
(a)
In severe compartment syndrome, pt may experience the 6 P's. Which of the following are of the 6 P's?
Pain and paralysis
Poikilothermia
parasthesia
Pallor
Pulselessness
If itching occurs under a cast, avoid sticking objects in cast as lesions and tears can happen and result in infections.
True
False
Which of the following are ways to reduce swelling on a pt with a new cast?
Ice cast with leakproof bag/frozen veggies
Elevate extremity above heart
Keep extremity flat with the bed, below the heart
Avoid moving digits
Have pt pump digits 10 times per hour while awake
For a newly applied cast, use your fingers to grasp and move it as needed.
True
False
Which of the following are nursing interventions to use for a pt with an external fixation. Select all that apply.
Monitor for pain every 2-4 hours
Administer analgesics before activites
Use pain relief measures like distraction and guided imagery
Use fracture bedpan as applicable
Used for a severe crushed, splintered, or multiple break fracture. After the fracture is reduced, the surgeon inserts pins into the bone. Pins are held in place by an _______ ______ metal frame to prevent bone movement
(a)
A rapid skeletal muscle tissue breakdown that releases damaged cell contents, such as myoglobin into the bloodstream, which is harmful to the kidneys and can lead to kidney damage.
(a)
The nurse is admitting an 88 year old woman to an extended care facility. Which findings should the nurse consider as normal age related changes of the patients muskuloskeletal system? select all that apply
limb weakness
S shaped curve to back
Loss of 2 inches in height
walks with small shuffleing gait.
Mild pain experiencing in the hands during the mornings.
The daughter of an older female pt with osteoporosis asks what she can do to prevent the development of the disorder as she ages. What should the nurse suggest?
Keep body weight low
Increase oral intake of calcium
Engage in water aerobic activities
Engage in weight bearing exercises
An older adult visiting a wellness clinic reports joint stiffness in the morning. What should the nurse respond to this pt?
The stiffness is due to decreased moisture in joints bones.
As we age, the cartilage in joints gets rough, causing stiffness.
The fluid in your joints gets thinner as you age, and makes joints stiff.
The body makes extra synovial fluid as we age, and that makes joints stiff.
The nurse is assisting a pt recovering from surgery ont he use of an incentive spirometer. Which pt instruction is appripriate?
Do not hold your breath after inhaling
Exhale 5 times before inhaling
Inhale deeply until the target is reached
Exhale deeply until the target is reached
The nurse is contributing to the preoperative pts plan of care. Which pt statement should alert the nurse to plan interventions to help prevent post op complications?
I am 60 years old and in good health
This is my second surgery in 2 years
I have chronic COPD
I have not had anything to eat or drink for 8 hours
A pt recovering from surgery becomes restless, has a drop in bp, increase in heart rate, and is breathing at a rate of 30 per min. Which action should the nurse take first?
Monitor vital signs
Maintain patent airway
Notify patient's family
Ensure HCP is informed
The nurse answers the pt's call light and finds the pt sitting up in bed with a wound evisceration. What action should the nurse take FIRST?
Notify the HCP immediatly
Apply gentle pressure over the wound
Place the pt in low fowlers
Cover the wound with sterile saline soaked towels
If the pt doesn't comply with fluid and food restriction prior to surgery, what is the best action?
Carefully monitor the pt during surgery for signs of aspiration
Get orders to pump pt stomach prior to procedure
Notify HCP, and post-pone the procedure
Refer pt to a different HCP
Foods and fluids are restricted before surgery to prevent the risk of (a)
Bathing and skin cleaning are usually performed prior to surgery to reduce the risk of surgical site infections.
true
false
(a) is the viscera spilling out of the abdomen
The nurse is preparing to initiate a tube feeding through a patients nasogastric (NG) tube. Prior to initiating this feeding what should the nurse use to irrigate the tube?
Sterile water
Normal saline
Cranberry juice
Carbonated water
The nurse is caring for a patient whose NG tube, attached to low intermittent suction to decompress a bowel obstruction, is not draining. After checking placement, which action should the nurse take?
Advance the NG tube 2 inches.
Change the suction setting to high.
Reinsert the NG tube in the other nare.
Irrigate the NG tube with 30 milliliters of normal saline
The nurse is auscultating bowel sounds and hears two bowel sounds over 5 minutes. How should the nurse document this finding?
Absent bowel sounds
Normal bowel sounds
Hypoactive bowel sounds
Hyperactive bowel sounds
A patients Levin NG tube inserted for decompression of the bowel, which is connected to low intermittent suction, is not draining. The patient reports feeling full, uncomfortable, and nauseous. After verifying tube placement, what action should the nurse take next?
Provide an antiemetic.
Remove the nasogastric tube.
Notify the physician immediately.
Gently irrigate tube with normal saline.
The nurse is reinforcing teaching with a patient who had a large portion of the stomach removed. Which patient statement indicates understanding of why the patient will need to receive vitamin B12 for life?
Sickle cell anemia
Pernicious anemia
Iron-deficiency anemia
Acquired hemolytic anemia
The nurse is caring for a patient with gastroesophageal reflux disease (GERD). Which patient statement indicates a need for nutritional instruction?
I should drink milk, as it is the perfect food.
Nutrition can affect health positively or negatively.
Excessive intake of a nutrient can interfere with others.
Classes of nutrients are carbohydrates, fats, proteins, vitamins, minerals, and water.
A patient is recovering from a Billroth I procedure and has a nasogastric Levin tube set to low intermittent suction. As the patient turns in bed, the Levin tube is partially pulled out. Which action should the nurse take?
Notify the registered nurse (RN)
Irrigate the tube.
Advance the tube
Place suction on continuous.
The nurse is providing care to a patient 3 days after a Billroth I procedure. About which observation should the nurse be most concerned?
Pulse 58 beats per minute
Incisional pain score 4 on a 1 to 10 scale
Patient becomes tearful while viewing the incision
Reports of abdominal cramping shortly after eating
The nurse is caring for a patient who has developed esophagitis from gastroesophageal reflux disease (GERD). For which additional complication should the nurse anticipate providing care to this patient?
Laryngospasm
Bronchospasm
Barretts esophagus
Aspiration pneumonia
The nurse is caring for a patient who complains of nausea related to gastric cancer. Which supplement should the nurse suggest?
Ginger
Lemon
Butterscotch
Black licorice
The nurse is collecting data from a newly admitted patient. Which finding should the nurse identify as a risk factor for constipation?
The patient does not like milk or milk products
The patient has had hemorrhoids for the past 5 years.
The patient had part of the stomach removed 10 years ago because of ulcers
The patient has a history of breast cancer treated with chemotherapy 3 years ago.
The nurse is contributing to a patients plan of care. For which patient would the nursing diagnosis of Risk for Constipation be most appropriate?
A 37-year-old taking NSAIDs for bursitis
A 59-year-old taking narcotics for chronic pain control
A 74-year-old taking antibiotics for a urinary tract infection
A 67-year-old taking anticoagulant therapy for a history of deep vein thrombosis
The nurse is contributing to the plan of care for a patient with gluten enteropathy (celiac disease). What should the nurse recommend be eliminated from the diet of the patient?
Red meats
Milk and milk products
Fresh fruits and vegetables
Wheat, rye, oats, and barley
The nurse is caring for a patient who is being screened for diverticulosis. Which patient statement indicates understanding of conditions that predispose to diverticulosis?
Colon cancer.
Chronic diarrhea.
Chronic constipation.
Diet high in red meats.
The nurse is teaching a patient with diverticulosis how to avoid complications. Which patient statement indicates that teaching has been effective?
I will avoid milk and milk products.
I should avoid very hot and spicy foods.
I will increase fluids and fiber in my diet.
I should cook vegetables thoroughly before eating.
A patient with liver failure and esophageal varices is prescribed to receive vasopressin. What should the nurse realize is the purpose for this medication?
To promote portal circulation
To reduce ammonia buildup and encephalopathy
To constrict vessels causing bleeding in esophageal varices
To maintain blood pressure in a patient with hypotension related to bleeding varices
The nurse is caring for a patient with esophageal varices. Which symptom should alert the nurse to possible bleeding?
Asterixis
Dark amber urine
Hard formed stool
Blood-streaked emesis
The nurse is reinforcing teaching provided to a patient with esophageal varices. Which activity should the patient be taught to avoid?
Lifting heavy objects
Participating in aerobic activities
Eating concentrated carbohydrates
Rising suddenly from a reclining position
The nurse is collecting data for a patient with acute pancreatitis. Which laboratory test result should the nurse expect?
Decreased serum lipase
Elevated serum amylase
Elevated serum albumin
Decreased serum ammonia
The nurse is caring for a patient recovering from a cardiac catheterization with a right femoral artery entry site. Which action should the nurse take?
Ambulate every 2 hours.
. Position knees with 40-degree bend.
. Avoid movement of right leg as ordered.
Perform passive range of motion of right leg hourly.
The nurse reviews the cardiac catheterization procedure with a patient scheduled for the test in 2 hours. Which patient statement indicates that teaching has been effective?
I know the room will be very warm.
Most people feel drowsy during the procedure.
The table may move while the test is being done
I should expect a cool sensation throughout my body when they inject the dye.
The nurse is caring for a patient who had a cardiac catheterization using the left femoral site for entry. Which data is most important for the nurse to monitor?
Pupil reaction
Left pedal pulse
Orientation status
Right foot sensation
A patient is being instructed about a Holter monitor. Which statement indicates that the patient knows what to do a symptom occurs while wearing a Holter monitor?
Call an ambulance.
Notify the physician.
Take an apical pulse.
Push the event button.
A patient will be wearing a Holter monitor for 2 days. What should the nurse instruct the patient about bathing while wearing the monitor?
Take a sponge bath.
You may take a tub bath.
Take a shower with the monitor on.
Remove the monitor before showering.
The nurse is collecting data from a patient who has mitral stenosis. For which condition should the nurse assess in the patients history?
Meningitis
Scarlet fever
Rheumatic fever
Rheumatoid arthritis
The nurse is reinforcing teaching provided to a patient with aortic stenosis. Which statement indicates that the patient correctly understands what happens in aortic stenosis?
There is impaired emptying of the left ventricle.
There is impaired emptying of the right ventricle.
There is backflow of blood into the left ventricle.
There is backflow of blood into the right ventricle.
While collecting data on a patient with aortic stenosis the nurse monitors for signs of heart failure. What is the nurse monitoring for heart failure as a complication of aortic stenosis?
Cardiac workload is increased from reduced cardiac output.
Cardiac workload is decreased from reduced cardiac output.
Cardiac workload is increased from increased cardiac output.
Cardiac workload is decreased from increased cardiac output.
The nurse is providing discharge teaching for a patient with mitral stenosis. What should the nurse include in this teaching?
The medications you will be taking make your blood thicker, so you are at risk for small clots to form.
It is important that you increase your fluid intake and take iron supplements so that your body can make enough blood for your heart to pump around.
Your blood is rushing through your heart so fast that it may not give your heart enough oxygen and you may have something called angina, or heart pain.
Because of your heart condition, the blood flow through your heart is slower and blood may tend to pool in certain areas, which might allow tiny clots to form.
A patient with acute pericarditis has a nursing diagnosis of Pain related to the inflammatory process. What nursing action should the nurse recommend?
Restrict fluids to 500 mL per day.
Teach the patient to take shallow, rapid breaths.
Provide anti-inflammatory medication as ordered.
Have the patient cough and deep breathe hourly while awake
