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WorksheetsMed-Surg Questions 1 for Exam 1 _ 25 questions
Total questions: 25
Worksheet time: 13mins
You are the nurse assigned a post-operative patient who is experiencing severe pain and becoming increasingly agitate.
The patient's V/S are elevated (BP 1140/90, HR 110, RR 24) and they are verbalizing fear and anxiety. Which of the following is the MOST appropriate INITIAL action you should take?
Reassure the patient and try to calm them
Administer the prescribed pain medication
Rationale: The most appropriate initial action is to address the patient's severe pain, as uncontrolled pain can lead to increased agitation, elevated vital signs, and anxiety. Administering the prescribed pain medication will help relieve the pain, which may also help reduce the patient's fear and anxiety. Once pain is managed, further assessment and interventions can be performed as needed.
Notify the physician immediately
Document the patient's V/S and agitation
You are the nurse preparing to discharge (D/C) a patient with a new diagnosis (dx) of choronic kidney disease. The patient expresses confusion about his diet and medication regimen.
Which of the following is your MOST effective strategy to use in order to facilitate the patient's understanding and adherence to the discharge plan?
Rationale:
The most effective strategy is to encourage the patient to ask questions and involve their family members in the teaching process. This approach promotes active participation, allows for clarification of misunderstandings, and provides additional support from family members, which can improve adherence to the discharge plan. Involving family members ensures that the patient has help at home and that everyone understands the dietary and medication requirements, reducing the risk of errors and non-compliance.
Provide the patient with a handout containing all the information
Teach the patient in a one-on-one setting, allowing for questions and clarification
Refer the patient to a dietician for nutritional assessment
Encourage the patient to ask questions and involve their family members in the teaching process
You are the nurse teaching a group of clients about healthy eating habits.
Which of the following statements would be the MOST accurate and culturally sensitive approach to promote healthy eating habits?
You should avoid all processed foods and sugary drinks to maintain a healthy weight.
It's important to eat a variety of foods and choose whole, unprocessed foods whenever possible.
Rationale: This approach encourages balance and inclusivity, respecting cultural food preferences while promoting health. It does not restrict entire food groups and supports making healthier choices within the context of individual and cultural dietary patterns.
You should focus on portion control and eating smaller meals throughout the day.
You should cut out all carbohydrates and focus on protein to loss weight
You are the nurse counseling a patient about the importance of getting regular check-ups and screenings. Which of the following statements would be MOST effective in promoting adherence to preventive care?
You need to get these screenings or you'll regret it later.
Regular check-ups can help catch problems early on and improve your overall health.
Rationale: This statement emphasizes the positive benefits of preventive care, such as early detection and improved health outcomes, which is more likely to motivate patients to adhere to recommended screenings.
You should schedule these screenings right away.
It's your responsibility to get these screenings; I'm not going to push you.
A patient reports experiencing severe pain in their right leg after a recent injury. The pain is described as sharp, throbbing, and increasing with movement. Which of the following is the MOST appropriate initial assessment finding?
Pain level 3/10
V/S are stable
Leg is slightly swollen and bruised
Leg is red and warm to touch
Rationale: Redness and warmth are signs of inflammation or possible infection, which are important initial findings in a patient with severe pain after injury. These symptoms may indicate a more serious underlying condition such as cellulitis or compartment syndrome, requiring prompt medical attention.
You are administering pain medication to a patient who has a history of kidney disease. Which of the following is the MOST important assessment finding to monitor for adverse effects of the medication?
Increased BP
Increased Respiratory Rate
Increased urine output
Decreased kidney function
Rationale: Patients with kidney disease are at higher risk for adverse effects from pain medications, especially those that are renally excreted. Monitoring for decreased kidney function is crucial because further impairment can lead to accumulation of the drug and toxicity.
Place the following perioperative stages in correct order:
A. postoperative
B. preoperative
C. intraoperative
A, B, C
A, C, B
C, A, B
B, C, A
Rationale: The correct order of perioperative stages is: preoperative (before surgery), intraoperative (during surgery), and postoperative (after surgery). Therefore, the sequence is B (preoperative), C (intraoperative), A (postoperative).
You are the pain management nurse on the unit and you observe a patient with complex regional pain syndrome who is not wearing the right-side jacket sleeve. The patient reports intense, right arm pain upon light touch. You recognize this pain as
allodynia
Rationale: Allodynia is pain due to a stimulus that does not normally provoke pain, such as light touch. This is commonly seen in patients with complex regional pain syndrome.
hypoalgia
neuritis
paresthesia
A 45-year-old patient reports pain in the foot, moving up along the calf. He says "My right foot feels like it is on fire."
He reports that the pain started yesterday and he has no prior history of injury or falls. Which pain assessment components has he reported?
Rationale: The patient describes the location of pain (foot and calf), the quality of pain ("feels like it is on fire"), and the duration (started yesterday). These are key components in pain assessment to help guide diagnosis and management.
Location, quality, duration
Aggravating and alleviating factors
Intensity, temporal characteristics, and functional impact
Exacerbation with associated signs/symptoms
A client admitted two days ago with a lung resection accidentally pulls out the chest tube. Which of your actions
indicate understanding of chest tube management?
Order a chest X-ray (CXR)
Reinsert the tool
Cover the insertion site with a vaseline gauze
Rationale: Covering the insertion site with a vaseline gauze creates an occlusive dressing, which helps prevent air from entering the pleural space and causing a pneumothorax. This is the immediate nursing action to protect the patient after accidental chest tube removal.
Call the doctor
A patient with a history (Hx) of hypertension (HTN) is admitted to the hospital experiencing chest pain and shortness of breath (SOB). The patient is experiencing dyspnea and has an elevated BP of 180/110. Which of the following actions should you take first?
Administer STAT dose of nitroglycerin
Assess the patient's oxygen saturation (SaO2 or SpO2) and respiratory rate
Administer a beta blocker to lower the patient's BP
Elevate the head of the patient's bed to facilitate breathing
Rationale: Elevating the head of the bed is a rapid, non-invasive intervention that can immediately help improve the patient's breathing and oxygenation by reducing pressure on the lungs and facilitating chest expansion. This is a priority action in a patient with acute dyspnea and chest pain, as it can provide quick relief while further assessment and interventions are prepared.
You are the nurse caring for a patient hospitalized with excessive fluid build-up around the heart. The patient is being discharged one on the following medications: ASA 81 mg PO, atenelol 50 mg PO, torsemide 10 mg PO twice daily, and lisinopril 20 mg PO. Which potential side effects from these medications should you teach the client requires priority notification to the healthcare provider (HCP)?
Rationale: Achy muscles at night may indicate myopathy or rhabdomyolysis, which can be a serious side effect of some cardiac medications, especially if the patient is also on diuretics or ACE inhibitors. This symptom requires prompt evaluation by the healthcare provider to prevent complications. The other options, while important, do not require immediate notification unless they worsen or are accompanied by other symptoms.
Achy muscles at night
Depression and anxiety
Ecchymosis of the arms and hands
HR consistently 60 - 68 beats/minute
You are the nurse discussing types of surgery with a group of nursing students. You explain that surgery done to restore function to a body part is called
ablative
diagnostic
palliative
reconstructive
Rationale: Reconstructive surgery is performed to restore function or appearance to a body part that has been damaged or impaired. This type of surgery aims to improve physical function, which distinguishes it from other types such as ablative (removal), diagnostic (to determine the cause of symptoms), or palliative (to relieve symptoms without curing).
You are caring for a patient who is scheduled for elective surgery to remove rectal polyps. You know that this type of surgery is classified by urgency as
emergent
urgent
elective
Rationale: Elective surgeries are those that are planned in advance and are not urgent or emergent. Removal of rectal polyps is typically scheduled ahead of time and does not require immediate intervention, making it an elective procedure.
optimal
You are preparing a patient for surgery, offering education and support. You know that this is the ________ phase of perioperative nursing.
Rationale: The preoperative phase involves all the activities that occur before surgery, including patient assessment, education, and emotional support. This phase is crucial for preparing the patient physically and psychologically for the surgical procedure.
preoperative
intraoperative
interoperative
postoperative
You are working as an operating room nurse and follow the standards and guidelines set by the Association of PeriOperative Registered Nurses (AORN). You know that these standards and guidelines are based on the
best available evidence from research and expert opinion
Rationale: AORN standards and guidelines are developed using the best available evidence from research and expert consensus to ensure safe and effective perioperative nursing practice.
preferences and values of individual surgeons and nurses
policies adn procedures of each health care facility
feedback and satisfaction of patients and families
As a nurse, you know that the reason for understanding and using the nursing process is that it is
rules by each healthcare facility for the guidance of nurses who work in that facility.
a systematic problem-solving method encompassing all components necessary to care for patients.
Rationale: The nursing process is a structured, evidence-based approach that helps nurses assess, diagnose, plan, implement, and evaluate patient care. It ensures comprehensive and individualized care, making it essential for effective nursing practice.
a way of legitimizing the nursing profession and placing nurses on an equal footing with the pure sciences.
a unidimensional, static, linear approach used to guide nurses as they make clinical judgments.
While preparing to conduct the nursing history and assessment on a patient transferred from the ED, you discover that the family believe the patient to be a questionable historian due to cognitive impairment. Based on this information, you initially begin the interview by
reviewing the ED chart.
contacting the admitting physician.
directing questions to family members.
establishing a line of communication by the patient.
Rationale: Even if the patient is considered a questionable historian due to cognitive impairment, it is important to first attempt to establish communication and assess the patient's ability to participate in their own care. This respects patient autonomy and ensures that any information provided directly by the patient is considered before relying on secondary sources such as family or medical records.
A patient with pneumonia presents with the following arterial blood gas results:
pH 7.32, PaCO2 50 mm/Hg,
HCO3 24 mEq/L, PaO2 80 mm/Hg.
Which of the following imbalances is present?
Rationale: The pH is below normal (acidemia), PaCO2 is elevated (indicating hypoventilation), and HCO3 is normal. This pattern is consistent with respiratory acidosis, where the primary disturbance is increased CO2 due to impaired gas exchange, as seen in pneumonia.
Respiratory acidosis
Metabolic acidosis
Respiratory alkalosis
Metabolic alkalosis
You show the best understanding of the LEGAL importance of the patient's chart when stating
"It is acceptable to change your nurses notes the next day if you realize that you documented the wrong assessment results."
"Patient charts are carefully protected from unlawful
access by inappropriate individuals or institutions."
"A chart is a document that shows proof that the patient received care that met expected standards."
Rationale: The patient's chart serves as a legal record of the care provided. It is used to demonstrate that the care met professional and legal standards, and can be referenced in legal proceedings to verify that appropriate care was given.
"The patient has a legal right to the information contained in the chart but not the original documentation itself."
A cigarette vendor came to the ED after she fell onto the ground and injured her left leg. She is noted to be tachycardic and tachypneic. Painkillers were administered to decrease her pain. She suddenly started complaining that she is still in pain and now experiencing muscle cramps, tingling, and paresthesia. ABG results are
pH 7.6, PaO2 120 mm/Hg
PaCo2 31 mm/Hg, HCO3 25 mm/L
What does this mean?
Rationale: The ABG shows a high pH (alkalosis), low PaCO2 (indicating respiratory cause), and normal HCO3. This means the alkalosis is due to respiratory causes and is uncompensated, as the HCO3 has not changed. The symptoms of muscle cramps, tingling, and paresthesia are consistent with alkalosis.
Respiratory Alkalosis, Uncompensated
Respiratory Acidosis, Partially Compensated
Metabolic Alkalosis, Uncompensated
Metabolic Acidosis, Partially Compensated
Which of the following is NOT the responsibility of the Scrub Nurse in the OR?
Positioning the patient
Assisting with gowning/gloving the surgeon
Handing surgical instruments to the surgeon
Assisting with application of surgical drapes
A female patient who speaks little English has emergency gallbladder surgery. Which Nursing action would best help this patient understand wound care instruction during discharge?
Asking frequently if the patient understands the instruction
Asking an interpreter to relay the instructions to the patient
Writing out instructions for a family member to read to the patient
Demonstrating the procedure to the patient and her family and having the patient return the demonstration
Rationale: Demonstrating the procedure and having the patient perform a return demonstration ensures understanding regardless of language barriers. This method allows the nurse to directly assess the patient’s comprehension and ability to perform wound care, which is especially important when verbal communication may be limited. Involving the family also provides additional support and clarification.
As the medication nurse, you realize that you must stay especially alert for adverse effects when administering medications to a male geriatric patient. What is the factor that makes geriatric patients have adverse drug effects?
Faster drug clearance
Aging-related physiological changes
Rationale: Aging-related physiological changes, such as decreased renal and hepatic function, altered body composition, and changes in receptor sensitivity, can affect how drugs are metabolized and eliminated, increasing the risk of adverse drug effects in geriatric patients.
Increased amount of neurons
Enhanced blood flow to the GI tract
The physician orders Heparin 7,500 units subcutaneously (subq) every 6 hrs.
The vial reads 10,000 units per mL.
How much should you give per each dose?
Rationale: To determine the volume to administer, divide the ordered dose (7,500 units) by the concentration available (10,000 units/mL):
7,500 units ÷ 10,000 units/mL = 0.75 mL. Therefore, you should give 0.75 mL per dose.
(a)
