Med SURG Practice EXAM
Questions
The nurse is assessing a client's laboratory values
following administration of chemotherapy. Which lab value
... [Show More]
leads the nurse to suspect that the client is experiencing
tumor lysis syndrome (TLS)?
A Serum PTT of 10 seconds.
B Serum calcium of 5 mg/dl. Correct
C Oxygen saturation of 90%.
D Hemoglobin of 10 g/dl.
TLS results in hyperkalemia, hypocalcemia,
hyperuricemia, and hyperphosphatemia. A serum calcium
level of 5 (B), which is low, is an indicator of possible tumor
lysis syndrome. (A, C, and D) are not particularly related to
TLS. Awarded 0.0 points out of 1.0 possible points.
2.ID: 6974889585A client is admitted to the hospital with
a diagnosis of severe acute diverticulitis. Which assessment
finding should the nurse expect this client to exhibit?
A Lower left quadrant pain and a low-grade fever. Correct
B Severe pain at McBurney's point and nausea.
C Abdominal pain and intermittent tenesmus.
D Exacerbations of severe diarrhea.
Left lower quadrant pain occurs with diverticulitis
because the sigmoid colon is the most common area for
diverticula, and the inflammation of diverticula causes a lowgrade fever (A). (B) would be indicative of appendicitis. (C
and D) are symptoms exhibited with ulcerative colitis.
Awarded 0.0 points out of 1.0 possible points.
3.ID: 6974891763During CPR, when attempting to
ventilate a client's lungs, the nurse notes that the chest is
not moving. What action should the nurse take first?
A Use a laryngoscope to check for a foreign body lodged in the
esophagus.
B Reposition the head to validate that the head is in the proper
position to open the airway. Correct
C Turn the client to the side and administer three back blows.
D Perform a finger sweep of the mouth to remove any vomitus.
The most frequent cause of inadequate aeration of the
client's lungs during CPR is improper positioning of the head
resulting in occlusion of the airway (B). A foreign body can
occlude the airway, but this is not common unless choking
preceded the cardiac emergency, and (A, C and D) should
not be the nurse's first action. Awarded 0.0 points out of 1.0
possible points.
4.ID: 6974891794A client is admitted to the hospital with
a medical diagnosis of pneumococcal pneumonia. The nurse
knows that the prognosis for gram-negative pneumonias
(such as E. coli, Klebsiella, Pseudomonas, and Proteus) is
very poor because
A they occur in the lower lobe alveoli which are more sensitive
to infection.
B gram-negative organisms are more resistant to antibiotic
therapy. Correct
C they occur in healthy young adults who have recently been
debilitated by an upper respiratory infection.
D gram-negative pneumonias usually affect infants and small
children.
The gram-negative organisms are resistant to drug
therapy (B) which makes recovery very difficult. Gramnegative pneumonias affect all lobes of the lung (A). The
mean age for contracting this type of pneumonia is 50 years
(C and D), and it usually strikes debilitated persons such as
alcoholics, diabetics, and those with chronic lung diseases.
Awarded 0.0 points out of 1.0 possible points.
5.ID: 6974891705A client is placed on a mechanical
ventilator following a cerebral hemorrhage, and vecuronium
bromide (Norcuron) 0.04 mg/kg q12 hours IV is prescribed.
What is the priority nursing diagnosis for this client?
A Impaired communication related to paralysis of skeletal
muscles. Correct
B High risk for infection related to increased intracranial
pressure.
C Potential for injury related to impaired lung expansion.
D Social isolation related to inability to communicate.
To increase the client's tolerance of endotracheal
intubation and/or mechanical ventilation, a skeletal-muscle
relaxant, such as vecuronium, is usually prescribed. Impaired [Show Less]