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Saunders practice questions
Med-Surg III (NSG 233)
Herzing University
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PRACTICE QUESTIONS
- A postcardiac surgery client with a blood urea nitrogen (BUN) level of 45mg/dL and a serum creatinine level of 2/dL has a total 2-hour urine output of 25 mL. The nurse understands that the client is at risk for which?
A. Hypovolemia B. Acute kidney injury C. Glomerulonephritis D. Urinary tract infection
- The nurse is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do which to enable the client to best tolerate the ambulation?
A. Provide the client with a walker. B. Remove the telemetry equipment. C. Encourage the client to cough and deep breathe. D. Premedicate the client with an analgesic before ambulating.
- A client is wearing a continuous cardiac monitor, which begins to alarm at the nurse’s station. The nurse sees no electrocardiographic complexes on the screen. The nurse should do which first?
A. Call a code blue. B. Call the health care provider. C. Check the client status and lead placement. D. Press the recorder button on the ECG console.
- The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply.
A. Administering oxygen B. Inserting a Foley catheter C. Administering furosemide (Lasix) D. Administering morphine sulfate intravenously E. Transporting the client to the coronary care unit F. Placing the client in a low Fowler’s side-lying position
The nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. The client has a short burst of ventricular tachycardia (VT), followed by ventricular fibrillation (VF). The client suddenly loses consciousness. Which intervention should the nurse do first? A. Go to the nurse’s station quickly and call a code. B. Run to get a defibrillator from an adjacent nursing unit. C. Call for help and initiate cardiopulmonary resuscitation (CPR). D. Start oxygen by cannula at 10L/minute and lower the head of the bed.
The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse?
A. Blood pressure B. Status of airway C. Oxygen flow rate D. Level of consciousness
- To use an external cardiac defibrillator on a client, which action should be performed to check the cardiac rhythm?
A. Holding the defibrillator paddles firmly against the chest B. Applying the adhesive patch electrodes to the skin and moving away from the client C. Connecting standard electrocardiographic electrodes to a transtelephonic monitoring device D. Applying standard electrocardiographic monitoring leads to the client and observing the rhythm
- The nurse is assisting in caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention?
A. Limiting movement and abduction of the left arm B. Limiting movement and abduction of the right arm C. Assisting the client to get out of bed and ambulate with a walker D. Having the physical therapist do active range of motion to the right arm
- A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. The nurse understands that a life- threatening complication of this condition is which?
A. Pneumonia B. Pulmonary edema C. Pulmonary embolism D. Myocardial infarction
- A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. The nurse should check the client for which next?
A. Smoking history B. Recent exposure to allergens C. History of recent insect bites D. Familial tendency toward peripheral vascular disease
ANSWERS & RATIONALES
1. B
Rationale: The client who undergoes cardiac surgery is at risk for acute kidney injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Kidney injury is signaled by a decreased urine output and increased BUN and creatinine levels. The client may need medications to increase renal perfusion and could need peritoneal dialysis or hemodialysis.
D Rationale: The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery, because analgesia will promote rest, decrease myocardial oxygen consumption caused by pain, and allow better participation in activities such as coughing, deep breathing, and ambulation.
C Rationale: Sudden loss of electrocardiographic complexes indicates ventricular asystole or possible electrode displacement. Checking of the client and equipment is the first action by the nurse.
A, B, C, D Rationale: Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler’s position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to accurately measure output. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client’s response to treatment is successful.
C Rationale: When ventricular fibrillation occurs, the nurse remains with the client and initiates CPR until a defibrillator is available and attached to the client. Options A, B and D are incorrect.
B Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway is the priority.
7. B
Rationale: The nurse or rescuer puts two large adhesive patch electrodes on the client’s chest in the usual defibrillator position. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds. The machine then indicates if it is necessary to defibrillate. Although automatic external defibrillation can be done transtelephonically, it is done through the use of patch electrodes (not standard electrocardiographic electrodes) that interact via telephone lines to a base station that controls any actual defibrillation. It is not necessary to hold defibrillator paddles against the client’s chest with this device.
B Rationale: In the first several hours after insertion of either a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgment. The nurse helps prevent this complication by limiting the client’s activities.
C Rationale: Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension.
A Rationale: The mixture of arterial and venous manifestations (Claudication and phlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger’s disease). This is a relatively uncommon disorder, characterized by inflammation and thrombosis of smaller arteries and veins. This disorder is typically found in young men who smoke. The cause is unknown but is suspected to have an autoimmune component.
B Rationale: Raynaud’s disease responds favorably to the elimination of nicotine and caffeine. Medications such as calcium channel blockers may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is very important. However, moving to a warmer climate may not necessarily be beneficial because the symptoms could still occur with the use of air conditioning and during periods of cooler weather.
B Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Wheezes, rhonchi, and diminished breath sounds are not associated with pulmonary edema.
Saunders practice questions
Course: Med-Surg III (NSG 233)
University: Herzing University
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