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Med Surg 2 : Exam 1

Terms in this set (125)

The nurse instructor is teaching a group of nursing students about adventitious heart sounds. The instructor explains that auscultation of the heart requires familiarization with normal and abnormal heart sounds. What would the instructor tell these students a ventricular gallop indicates in an adult?
Heart failure
A client has undergone cardiac catheterization and will be discharged today. What information should the nurse emphasize during discharge teaching?
Avoid heavy lifting for the next 24 hours.
The nurse is completing a cardiac assessment. Upon auscultation, the nurse hears a grating sound using the diaphragm of the stethoscope. How will the nurse best document this finding?
Friction rub
Within the heart, several structures and several layers all play a part in protecting the heart muscle and maintaining cardiac function. The inner layer of the heart is composed of a thin, smooth layer of cells, the folds of which form heart valves. What is the name of this layer of cardiac tissue?
Endocardium
A nurse is caring for a dying client following myocardial infarction. The client is experiencing apnea with a falling blood pressure of 60 per palpation. Which documentation of pulse quality does the nurse anticipate?
Thready pulse
The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include?
"Do not bend at the waist, strain, or lift heavy objects for the next 24 hours."
The nurse is reviewing the results of the patient's echocardiogram and observes that the ejection fraction is 35%. The nurse anticipates that the patient will receive treatment for what condition?
Heart failure
A 52-year-old female patient is going through menopause and asks the nurse about estrogen replacement for its cardioprotective benefits. What is the best response by the nurse?
"Current evidence indicates that estrogen is ineffective as a cardioprotectant; estrogen is actually potentially harmful and is no longer a recommended therapy."
After a physical examination, the provider diagnosed a patient with a grade 4 heart murmur. When ausculatating a murmur, what does the nurse expect to hear?
Loud and may be associated with a thrill sound similar to (a purring cat).
During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure?
wheezes with wet lung sounds
The nurse is reviewing the morning laboratory test results for a client with cardiac problems. Which finding is a priority to report to the health care provider?
K+ 3.1 mEq/L
The client is admitted for a scheduled cardiac catheterization. On the morning of the procedure, while assessing the client's morning laboratory values, the nurse notes a blood urea nitrogen (BUN) of 34 mg/dL and a creatinine of 4.2 mg/dL. What priority reason will the nurse notify the healthcare provider?
The client is at risk for renal failure due to the contrast agent that will be given during the procedure.
The nurse is caring for a client who is scheduled for a transesophageal echocardiogram. What nursing intervention is a priority after the procedure?
Keep the head of the bed elevated 45 degrees and keep NPO until return of the gag reflex.
The clinic nurse caring for a client with a cardiovascular disorder is performing an assessment of the client's pulse. Which of the following steps is involved in determining the pulse deficit?
Count the heart rate at the apex.
You are doing an admission assessment on a client who is having outpatient testing done for cardiac problems. What should you ask this client during your assessment?
Have you had any episodes of dizziness or fainting?"
During an initial assessment, the nurse measures the client's apical pulse and compares it to the peripheral pulse. The difference between the two is known as pulse:
deficit
The nurse is caring for a client on a monitored telemetry unit. During morning assessment, the nurse notes abnormal ECG waves on the telemetry monitor. Which action would the nurse do first?
Assess the client.
The balloon on the distal tip of a pulmonary artery catheter is inflated and the pressure is measured. What is the term for the measurement obtained?
pulmonary artery wedge pressure
The nurse is assessing a patient who reports feeling "light-headed." When obtaining orthostatic vital signs, what does the nurse determine is a significant finding?
A heart rate of more than 20 bpm above the resting rate
What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse?
contractility
The nurse is assessing vital signs on a client who is 3 months status post myocardial infarction (MI). While the healthcare provider is examining the client, the client's spouse approaches the nurse and states "We are too afraid he will have another heart attack, so we just don't have sex anymore." What is the nurse's best response?
"The physiologic demands are greatest during orgasm and are equivalent to walking 3 to 4 miles per hour on a treadmill."
The nurse is assessing a client taking an anticoagulant. What nursing intervention is most appropriate for a client at risk for injury related to side effects of medication enoxaparin?
Report any incident of bloody urine, stools, or both.
You are evaluating the expected outcomes on a client who is recovering from a cardiac catheterization. What is an expected outcome that you would evaluate?
The client and family understands the discharge instructions.
You are monitoring the results of laboratory tests performed on a client admitted to the cardiac ICU with a diagnosis of myocardial infarction. Which test would you expect to show elevated levels?
Enzymes
Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for pumping blood to all the cells and tissues of the body?
left ventricle
The nurse is caring for an elderly client with left-sided heart failure. When auscultating lung sounds, which adventitious sound is expected?
Crackles
The nurse cares for a client in the emergency department who has a B-type natriuretic peptide (BNP) level of 115 pg/mL. The nurse recognizes that this finding is most indicative of which condition?
heart failure
The nurse cares for a client with clubbing of the fingers and toes. The nurse should complete which action given these findings?
Obtain an oxygen saturation level.
The nurse is administering a beta blocker to a patient in order to decrease automaticity. Which medication will the nurse administer?
Metoprolol
Which of the following terms refers to a muscular, cramp-like pain in the extremities consistently reproduced with the same degree of exercise and relieved by rest?
Intermittent claudication
A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time?
ineffective peripheral tissue perfusion related to venous congestion
What are the symptoms a nurse should assess for in a patient with lymphedema as a result of impaired nutrition to the tissue?
Ulcers and infection in the edematous area
The nurse is caring for a patient with venous insufficiency. What should the nurse assess the patient's lower extremities for?
Ulceration
The nurse is educating a patient with chronic venous insufficiency about prevention of complications related to the disorder. What should the nurse include in the information given to the patient? (Select all that apply.)
-Avoid constricting garments.
- Elevate the legs above the heart level for 30 minutes every 2 hours.
-Sleep with the foot of the bed elevated about 6 inches.
When assessing a client with cellulitis of the right leg, which finding should the nurse expect to observe?
Red, swollen skin with inflammation spreading to surrounding tissues
A nurse is teaching a client who will soon be discharged with a prescription for warfarin (Coumadin). Which statement should the nurse include in discharge teaching?
"Don't take aspirin while you're taking warfarin."
Which of the following are characteristics of arterial insufficiency?
Diminished or absent pulses
A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities?
Participate in a regular walking program.
A patient is suspected to have a thoracic aortic aneurysm. What diagnostic test(s) does the nurse anticipate preparing the patient for? (Select all that apply.)
- Computed tomography
-Transesophageal echocardiography
-X-ray
A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection?
Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute
A client with systemic lupus erythematosus (SLE) complains that his hands become pale, blue, and painful when exposed to the cold. What disease should the nurse cite as an explanation for these signs and symptoms?
Raynaud's disease
The nurse teaches the patient with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes
a vasospasm.
Which of the following is accurate regarding Raynaud's disease?
Episodes may be triggered by unusual sensitivity to cold.
Which of the following are risk factors for venous disorders of the lower extremities?
Obesity
A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by
forcing blood into the deep venous system.
What should the nurse do to manage the persistent swelling in a patient with severe lymphangitis and lymphadenitis?
Teach the patient how to apply an elastic sleeve
As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client?
Demonstrate how to apply and remove elastic support stockings.
Which of the following is the most effective intervention for preventing progression of vascular disease?
Risk factor modification
A nurse is teaching a patient newly diagnosed with arterial insufficiency. Which of the following terms should the nurse use to refer to leg pain that occurs when the patient is walking?
Intermittent claudication
Which of the following medication classifications lyses and dissolves thrombi
Fibrinolytic
A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client?
Stop smoking.
The nurse is monitoring a patient who is on heparin anticoagulant therapy. What should the nurse determine the therapeutic range of the international normalized ratio (INR) should be?
2.0-3.0
You are assessing a client recently admitted to your unit for hypotension. While assessing this client, you find a pulsatile mass near the umbilicus. What would you suspect?
Aortic aneurysm
A community health nurse teaches a group of seniors about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which of the following statements?
"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet."
According to the classification of hypertension diagnosed in older adults, hypertension that can be attributed to an underlying cause is termed
secondary.
Which term is refers to hypertension in which blood pressure that is controlled with therapy becomes uncontrolled (abnormally high) when the therapy is discontinued?
Rebound
Officially, hypertension is diagnosed when the client demonstrates a systolic blood pressure greater than ______ mm Hg and a diastolic blood pressure greater than _____ mm Hg over a sustained period.
140, 90
A systolic blood pressure of 135 mm Hg would be classified as
prehypertension.
A diastolic blood pressure of 90 mm Hg is classified as
stage 1 hypertension.
A 77-year-old client has newly diagnosed stage 2 hypertension. The physician has prescribed a thiazide and an angio-converting enzyme inhibitor. About what is the nurse most concerned?
Postural hypotension and resulting injury
A nurse is educating a client about monitoring blood pressure readings at home. Which of the following will the nurse be sure to emphasize?
"Sit quietly for 5 minutes prior to taking blood pressure."
Which of the following diagnostic tests may reveal an enlarged left ventricle?
Echocardiography
A female client, aged 82, visits the clinic for a blood pressure (BP) check. Her hypertension is not well controlled, and a new blood pressure medicine is prescribed. What is important for the nurse to teach this client about her blood pressure medicine?
A possible adverse effect of blood pressure medicine is dizziness when you stand.
The nurse is caring for a client with hypertension who is experiencing complications. What diagnostic test evaluates the efficiency or inefficiency of the heart to pump blood?
Multiple gated acquisition (MUGA) scan
A client, newly admitted to the nursing unit, has a primary diagnosis of renal failure. When assessing the client, the nurse notes a blood pressure (BP) of 180/100. The nurse knows that this is what kind of hypertension?
Secondary
A client is being seen at the clinic for a routine physical when the nurse notes the client's blood pressure is 150/97. The client is considered to be a healthy, well-nourished young adult. What type of hypertension does this client have?
Essential (primary)
You are the triage nurse in a walk-in clinic when a diabetic client visits the clinic and asks you to take her blood pressure (BP). The measurements are 150/90 mm Hg. Which of the following would the nurse expect as the treatment to normalize the client's BP?
Drug therapy
The nurse is administering the morning mediations to a patient on the cardiac telemetry unit. Atenolol has been prescribed for this patient. Prior to administration, the nurse would tell the patient that the medication is which type of antihypertensive?
Beta blocker
Which of the following would be inconsistent as a component of metabolic syndrome?
Hypotension
When measuring the blood pressure in each arm of a healthy adult client, the nurse recognizes that which statement is true?
Pressures should not differ more than 5 mm Hg between Pressures should not differ more than 5 mm Hg between arms.
A client is admitted to the intensive care unit (ICU) with a diagnosis of hypertension emergency/crisis. The client's blood pressure (BP) is 200/130 mm Hg. The nurse is preparing to administer IV nitroprusside. Upon assessment, which finding requires immediate intervention by the nurse?
Numbness and weakness in the left arm
A patient with long-standing hypertension is admitted to the hospital with hypertensive urgency. The physician orders a chest x-ray, which reveals an enlarged heart. What diagnostic test does the nurse anticipate preparing the patient for to determine left ventricular enlargement?
Echocardiography
A client experiences orthostatic hypotension while receiving furosemide (Lasix) to treat hypertension. How should the nurse intervene?
Instruct the client to sit for several minutes before standing.
Which diuretic medication conserves potassium?
Spironolactone
Following a voiding cystogram, the client has a nursing diagnosis of risk for infection related to the introduction of bacterial following manipulation of the urinary tract. An appropriate nursing intervention for the client is to
Encourage high fluid intake
An appropriate nursing intervention for the client following a nuclear scan of the kidney is to
Encourage high fluid intake
Which of the following diagnostic tests would the nurse expect to be ordered to determine the details of the arterial supply to the kidneys?
Angiography
A client reports urinary frequency, urgency, and dysuria. Which of the following would the nurse most likely suspect?
Infection
A client is scheduled for a renal ultrasound. Which of the following would the nurse include when explaining this procedure to the client?
"You don't need to do any fasting before this noninvasive test."
A patient has undergone a renal biopsy. After the test, while the patient is resting, the patient complains of severe pain in the back, arms, and shoulders. Which of the following appropriate nursing interventions should be offered by the nurse?
Asses the patient's back and shoulder areas for signs of internal bleeding.
The most frequent reason for admission to skilled care facilities includes which of the following?
Urinary incontinence
Urine specific gravity is a measurement of the kidney's ability to concentrate and excrete urine. The specific gravity measures urine concentration by measuring the density of urine and comparing it with the density of distilled water. Which is an example of how urine concentration is affected?
On a hot day, a person who is perspiring profusely and taking little fluid has low urine output with a high specific gravity.
A client is having a blood urea nitrogen (BUN) test. BUN level is
increased in renal disease and urinary obstruction.
A client is scheduled for a renal angiography. Which of the following would be appropriate before the test?
Monitor the client for an allergy to iodine contrast material.
A group of students is reviewing for a test on the urinary and renal system. The students demonstrate understanding of the information when they identify which of the following as part of the upper urinary tract?
Ureters
The nurse reviews a client's history and notes that the client has a history of hyperparathyroidism. The nurse would identify that this client most likely would be at risk for which of the following?
Kidney stones
The nurse is providing care to a client who has had a renal biopsy. The nurse would need to be alert for signs and symptoms of which of the following?
Bleeding
The nurse is completing a full exam of the renal system. Which assessment finding best documents the need to offer the use of the bathroom?
A dull sound when percussing over the bladder
The nurse is caring for a client after a cystoscopic examination. Following the procedure, the nurse informs the client that which effect may occur?
Blood-tinged urine
The nurse is caring for a client who is brought to the emergency department after being found unconscious outside in hot weather. Dehydration is suspected. Baseline lab work including a urine specific gravity is ordered. Which relation between the client's symptoms and urine specific gravity is anticipated?
The specific gravity will be high.
A 24-hour urine collection is scheduled to begin at 8
00 am. When should the nurse initiate the procedure?:
After discarding the 8:00 am specimen
A 24-year-old patient was admitted to the emergency room after a water skiing accident. The X-rays revealed two fractured vertebrae, T-12 and L1. Based on this information, the nurse would know to perform which of the following actions?
Check the patient's urine for hematuria.
A client is scheduled for a renal arteriogram. When the nurse checks the chart for allergies to shellfish or iodine, she finds no allergies recorded. The client is unable to provide the information. During the procedure, the nurse should be alert for which finding that may indicate an allergic reaction to the dye used during the arteriogram?
Pruritis
Which value does the nurse recognize as the best clinical measure of renal function?
Creatinine clearance
Which of the following is a term used to describe excessive nitrogenous waster in the blood, as seen in acute glomerulonephritis?
Azotemia

The primary presenting features of acute glomerulonephritis are hematuria, edema, azotemia (excessive nitrogenous wastes in the blood), and proteinuria (>3 to 5 g/day). Bacteremia is excessive bacteria in the blood.
A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client?
Risk for infection

The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, Toileting self-care deficit, and Activity intolerance may be pertinent but are secondary to the risk of infection.
The nurse is reviewing the results of a urinalysis on a client with acute pyelonephritis. Which of the following would the nurse most likely expect to find?
Pyuria

The chief abnormality noted with the urinalysis is pyuria (combination of bacteria and leukocytes). Specific gravity would be low, pH would be slightly alkaline, and proteinuria would be minimal to mild.
When assessing the impact of medications on the etiology of ARF, the nurse recognizes which of the following as the drug that is not nephrotoxic?
Penicillin

The three nephrotoxic drugs are aminoglycerides.
For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important?
Limiting fluid intake

During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and I.V. fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn't take precedence over fluid limitation. Controlling pain isn't important because ARF rarely causes pain.
The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for?
Hypovolemic shock caused by hemorrhage

If bleeding goes undetected or is not detected promptly, the patient may lose significant amounts of blood and may experience hypoxemia. In addition to hypovolemic shock due to hemorrhage, this type of blood loss may precipitate a myocardial infarction or transient ischemic attack.
Which of the following is as integumentary manifestation of chronic renal failure?
Gray-brown skin color

Integumentary manifestations of chronic renal failure include a gray-bronze skin color and ecchymosis. Asterixis, tremors, and seizures are neurological manifestations of chronic renal failure.
A patient admitted with electrolyte imbalance has carpopedal spasm, ECG changes, and a positive Chvostek's sign. What deficit does the nurse suspect the patient has?
Calcium

Calcium deficit is associated with abdominal and muscle cramps, stridor, carpopedal spasm, hyperactive reflexes, tetany, positive Chvostek's or Trousseau's sign, tingling of fingers and around mouth, and ECG changes.
Sevelamer hydrochloride (Renagel) has been prescribed for a client with chronic renal failure. The physician has prescribed Renagel 800 mg orally three times per day with meals to treat the client's hyperphosphatemia. The medication is available in 400 mg tablets. How many tablets per day will the nurse administer to the client?
6

The nurse will administer 2 tablets per dose (800 mg/400 mg per tablet). The client receives a total of 3 doses per day or 6 tablets (2 tablets per dose x 3 doses).
When preparing a client for hemodialysis, which of the following would be most important for the nurse to do?
Check for thrill or bruit over the access site.

When preparing a client for hemodialysis, the nurse would need to check for a thrill or bruit over the vascular access site to ensure patency. Inspecting the catheter insertion site for infection, adding the prescribed drug to the dialysate, and warming the solution to body temperature would be necessary when preparing a client for peritoneal dialysis.
The nurse is educating a patient who is required to restrict potassium intake. What foods would the nurse suggest the patient eliminate that are rich in potassium?
Citrus fruits

Foods and fluids containing potassium or phosphorus (e.g., bananas, citrus fruits and juices, coffee) are restricted.
Which nursing intervention should the nurse caring for the client with pyelonephritis implement?
Teach client to increase fluid intake up to 3 liters per day.

The nurse teaches the client to increase fluid intake to promote renal blood flow and flush bacteria from the urinary tract.
A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment?
Start I.V. fluids with a normal saline solution bolus followed by a maintenance dose.

The client is in prerenal failure caused by hypovolemia. I.V. fluids should be given with a bolus of normal saline solution followed by maintenance I.V. therapy. This treatment should rehydrate the client, causing his blood pressure to rise, his urine output to increase, and the BUN and creatinine levels to normalize. The client wouldn't be able to tolerate oral fluids because of the nausea, vomiting, and diarrhea. The client isn't fluid-overloaded so his urine output won't increase with furosemide, which would actually worsen the client's condition. The client doesn't require dialysis because the oliguria and elevated BUN and creatinine levels are caused by dehydration.
After teaching a group of students about how to perform peritoneal dialysis, which statement would indicate to the instructor that the students need additional teaching?
"It is appropriate to warm the dialysate in a microwave."

The dialysate should be warmed in a commercial warmer and never in a microwave oven. Strict aseptic technique is essential. The infusion clamp is opened during the infusion and clamped after the infusion. When the dwell time is done, the drain clamp is opened and the fluid is allowed to drain by gravity into the drainage bag.
Which nursing assessment finding indicates that the client who has undergone renal transplant has not met expected outcomes?
Fever

Fever is an indicator of infection or transplant rejection.
A client who suffered hypovolemic shock during a cardiac incident has developed acute renal failure. Which is the best nursing rationale for this complication?
Decrease in the blood flow through the kidneys

Acute renal failure can be caused by poor perfusion and/or decrease in circulating volume results from hypovolemic shock. Obstruction of urine flow from the kidneys through blood clot formation and structural damage can result in postrenal disorders but not indicated in this client.
A patient comes to the clinic suspecting a possible UTI. What symptoms of a UTI would the nurse recognize from the assessment data gathered?
c. Cloudy urine
A patient has been diagnosed with a UTI and is prescribed an antibiotic. What first-line fluoroquinolone antibacterial agent for UTIs has been found to be significantly effective?
b. Cipro
3. A patient with a UTI is having burning and pain when urinating. What urinary analgesic is prescribed for relief of these symptoms?
Pyridium
The nurse is educating a patient with urolithiasis about preventative measures to avoid another occurrence. What should the patient be encouraged to do?
Increase fluid intake so that the patient can excrete 2,500 to 4,000 mL every day, which will help prevent additional stone formation.
The nurse is providing an education program for the nursing assistants in a long-term care facility in order to decrease the number of UTIs in the female population. What interventions should the nurse introduce in the
program? (Select all that apply.)
Perform hand hygiene prior to patient care.- Assist the patients with frequent toileting.- Provide careful perineal care.
The nurse is caring for a patient with dementia in the long-term care facility when the patient has a change in cognitive function. What should the nurse suspect this patient may be experiencing?
UTI
The nurse is educating a female patient with a UTI on the pharmacologic regimen for treatment. What is important for the nurse to instruct the patient to do?
Take the antibiotic for 3 days as prescribed.
A patient informs the nurse that every time she sneezes or coughs, she urinates in her pants. What type of incontinence does the nurse recognize the patient is experiencing?
c. Stress incontinence
A patient taking an alpha-adrenergic medication for the treatment of hypertension is having a problem with incontinence. What does the nurse tell the patient?
When the medication is discontinued or changed, the incontinence will resolve.
The patient has been diagnosed with urge incontinence. What classification of medication does the nurse expect the patient will be placed on to help alleviate the symptoms?
Anticholinergic agents
A patient has a suprapubic catheter inserted postoperatively. What would be the advantages of the suprapubic catheter versus a urethral catheter? (Select all that apply.)
The patient can void sooner than with a urethral catheter.-The suprapubic catheter allows for more mobility.- The suprapubic catheter permits measurement of residual urine without urethral instrumentation.
The nurse is educating a patient who will be performing self-catheterization at home. What information provided by the nurse will help reduce the incidence of infection?
Clean the catheter with antibacterial soap thoroughly rinse and dry before reinsertion.
The nurse is caring for a patient with severe pain related to ureteral colic. What medication can the nurse administer with a physician's order that will inhibit the synthesis of prostaglandin E, reducing swelling and facilitating passage of the stone?
Ketoralac (Toradol)
A patient who has been treated with uric acid for stones is being discharged from the hospital. What type of diet does the nurse discuss with the patient?
Low-purine diet
A patient has had surgery to create an ileal conduit for urinary diversion. What is a priority intervention by the nurse in the postoperative phase of care?
Monitor urine output hourly and report output greater than 30 mL/hr.
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