RN VATI Medical Surgery 2019 - Questions, Answers and Rationales A nurse is caring for a client who is 24 hr postoperative following a total hip
... [Show More] arthroplasty. Which of the following actions should the nurse take? A. Place the affected leg in external rotation. B. Encourage the client to use the incentive spirometer every shift. C. Instruct the client to lean forward when rising from a chair. D. Maintain abduction of the affected extremity. The nurse should ensure that the affected extremity is in a position of abduction to prevent hip dislocation. The nurse should place an abductor pillow or several pillows between the client's legs to keep the affected extremity in abduction while the client is in bed A nurse is assessing a client who takes salmeterol to treat moderate asthma. Which of the following findings should indicate to the nurse that the medication has been effective? A. The client's daily peak expiratory flow (PEF) measures 85% above personal best. B. The client's ABGs shows a pH level of 7.32. C. The client's forced expiratory volume is decreased after treatment with medication. D. The client's wheezing is limited to expiratory. A client who has asthma should use a peak flow meter twice daily to monitor asthma control. A PEF in the green zone, or 80% or above personal best, indicates the effectiveness of medication therapy A nurse is caring for a client who has atopic dermatitis and a prescription for triamcinolone ointment. The nurse should assess the client to monitor for which of the following adverse effects? A. Increased pigmentation B. Localized hair loss C. Thinning of the hair D. Increased sensitivity to the sun Thinning of the skin and delayed healing are adverse effects of topical glucocorticoid preparations. The client should only apply the ointment to dry patches of the skin because topical steroids can cause atrophy of the dermis and epidermis, which can result in thinning of the skin A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse identify as a manifestation of left-sided heart failure? A. Dependent edema B. Jugular distention C. Weight Gain D. Frothy sputum The nurse should identify that frothy sputum, dyspnea, and wheezing are manifestations of left-sided heart failure. Treatment includes fluid restriction and diuretics to decrease preload and reduce pulmonary congestion. Pink-tinged frothy sputum can be an early indication of pulmonary edema and can be life-threatening. Therefore, the nurse should notify the provider immediately. A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of the lips and fingers. The client's ABGs are: pH 7.48, PCO2 30 mm Hg, HCO3 - 24 mEq/L, PaO2 85 mm Hg. Which of the following acid-base imbalances should the nurse identify that the client is experiencing? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis This pH is alkaline (increased) and the PCO2 is decreased, representing alveolar hyperventilation and resultant respiratory alkalosis. A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the nurse expect? A. Vitiligo B. Osteoporosis C. Myxedema D. Heat intolerance Osteoporosis is a common finding with Cushing's syndrome. Bones become thinner as a result of mineral loss and nitrogen depletion, and the risk for fractures increases A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of the following lesion characteristics on the client's skin? A. A pearly, waxy nodule B. An irregular border on a variegated-colored lesion C. A firm, nodular, crusty, or ulcerated lesion D. A weeping vesicle A client who has basal cell carcinoma has a nodular lesion with well-defined borders and a pearly or waxy appearance, resulting from overexposure to the sun, especially on the face, head, and neck A nurse is assessing a client who has hypocalcemia. In which of the following areas should the nurse tap on the client's face to detect the presence of Chvostek's sign? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) A is correct. The nurse should tap the client's cheek just in front of the ear and below the zygomatic arch. The client who has hypocalcemia will display a Chvostek's sign, which is a twitching of the facial muscle A nurse in an emergency department is assessing a client who is overusing prescribed diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings should the nurse expect? a. High lipase B. Low urine specific gravity C. Low Hemoglobin D. High creatine kinase-MB (CK-MB) A client who has hyponatremia as a result of diuretic overuse has a low urine specific gravity. The increased excretion of water alters the ratio of particulate matter, which affects the specific gravity A home health nurse is assisting a client with planning care for a family member who has Alzheimer's disease. Which of the following instructions should the nurse include? A. Remove clutter from room and hallways B. Place a monthly calendar in the client's room C. Use confrontation to manage the client's behavior D. Review the daily schedule with the client every morning The nurse should instruct the family member to use short, simple sentences when explaining an activity to the client. The explanation should be done immediately before the activity to aid the client's memory and ability to follow directions. A nurse is caring for a client who has developed acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse identify as a manifestation of this syndrome? A. An audile pleural friction rub B. Tracheal deviation from the midline
C. Refractory hypoxemia D. Bloody expectorant when coughing ARDS is a systemic inflammatory response to trauma, sepsis, burns, pancreatitis, and blood transfusions, when excess lung fluid dilutes surfactant activity in the lungs. A client who has ARDS has refractory hypoxemia, which is hypoxemia that does not improve with oxygen therapy. Extensive pulmonary edema evident on a chest x-ray is a manifestation of ARDS An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the following findings should indicate to the nurse that the client is experiencing status asthmaticus? A. Coughing B. Flat neck veins C. Use of accessory muscle D. Presence of coarse crackles A client who has status asthmaticus uses accessory muscles to help facilitate breathing, which is a manifestation of severe airflow obstruction. The situation is life-threatening and the nurse should intervene immediately with strong systemic bronchodilators, epinephrine, corticosteroids, and oxygen. A nurse is teaching a client who has a new prescription for phenytoin to treat a seizure disorder. Which of the following adverse effects should the nurse instruct the client to report immediately to the provider? A. Tender bleeding gums B. Increased facial hair C. Constipation D. Skin Rash When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a rash, which can have a measles-like appearance and progress to exfoliative dermatitis or Stevens-Johnson syndrome. The client should report this finding to the provider immediately. A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery? A. Oral temperature of 37.2 C (99 F) B. Clear drainage on the dressings C. Drain output 75 mL in 4 hours D. Decreased bowel sounds in all quadrants of the abdomen The nurse should identify clear drainage on or around the dressing as an indication of a cerebral spinal leak and should report this finding to the provider immediately. A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse identify as a manifestation of right-sided heart failure? A. S3 gallop B. Weak peripheral pulses C. Increased abdominal girth d. Wheezing Increased abdominal girth is an expected finding with right-sided heart failure due to systemic congestion and an enlarged liver and spleen. Systemic congestion can lead to fluid retention and increased pressure in the venous system, which can manifest with edema in the lower extremities. A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change? A. " I changed the floor plan of our home to accommodate my father's wheelchair." B. "I'm so stressed out that it makes it difficult for me to manage everything." C. "At times, I get so frustrated with how to care for my parents." D. "I am learning to take care of my parents as I go." The nurse should identify that the client has accepted the role change of caring for their aging parents by changing the floor plan of the home to accommodate their father's wheelchair. A nurse is caring for a client who is receiving vancomycin intermittent IV bolus therapy for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the medication? A. The client's BP is elevated B. the client is becoming flushed C. the client reports blurred vision D. The client is experiencing polyuria The client can have an adverse effect called red man syndrome, which causes hypotension and tachycardia, due to infusing the vancomycin too rapidly. The nurse should infuse the medication over at least 60 min. A nurse is caring for a male client who has a new prescription for cyclosporine following a kidney transplant. Which of the following findings should the nurse identify as an adverse effect of this therapy? [Show Less]