Medsurge 2 Exam 2

1. A nurse is caring for a client who has burns to approximately 50% of their body. Which of the following physiological changes related to the burns should the nurse anticipate? (Select all that apply.)

   1. Loss of protein

   2. Diuresis

   3. Hypermagnesemia

   4. Decreased plasma volume

   5. Capillary leak

Loss of protein, decreased plasma volume, capillary leak

1. What is the best assessment of fluid resuscitation for an adult burn patient?

   1. Urine output of 0.5 mL/kg/hr

   2. Normalization of blood pressure (BP)

   3. Normalization of heart rate (HR)

   4. Measuring a normal central venous pressure

   5. Providing 4 mL/kg/% body burned over 24 hours with crystalloid fluid

Urine output of 0.5mL/kg/hr

1. A nurse is providing education to a community group about burn prevention. Which of the following is an example of a first-degree burn?

   1. Excessive scarring

   2. Blistering from flames

   3. Blackened dead skin

   4. A sunburn

A sunburn

1. A nurse is caring for a client during fluid rescuscitaiton for burns. Which of the following are used to evaluate the success of fluid resuscitation? (Select all that apply)

   1. Blood pressure

   2. Bowel sounds

   3. Level of consciousness

   4. Urine output

   5. Platelet count

Blood pressure, level of consciousness, urine output

1. Which of the following actions should the nurse take when caring for a client with severe burns? Select all that apply.

   1. Cool the burn with ice water

   2. Administer opioid analgesics

   3. Administer systemic antibiotics

   4. Administer benzodiazepines for anxiety management

   5. Lay the head of the bed flat

Administer opioid analgesics, administer benzodiazepines for anxiety management

1. A nurse is assessing a client who reports trauma to the arm from falling off a bicycle. The skin has a large abrasion that is warm, darker than the surrounding skin, and edematous. Which of the following stages of healing is the wound in?

   1. Tissue remodeling

   2. Proliferation

   3. Hemostasis and inflammation

   4. Calcification

Hemostasis and inflammation

1. The nurse is caring for a client with a skin injury. Which of the following pairings represents the correct skin layer and function?

   1. Epidermis - contains adipose lobules

   2. Dermis - contains hair follicles

   3. Epidermis - contains sweat glands

   4. Hypodermis -contains a moisture barrier

Dermis - contains hair follicles

1. A nurse is caring for a client with a wound. Which of the following pairings reflect the correct wound infection stage with description?

   1. Colonization - replicating microorganisms: not yet infected

   2. Systemic infection - wound is darker than the surrounding skin with notes drainage present

   3. Contaminated: infection beyond the wound

   4. Local infection - sepsis

Colonization - replication microorganisms: not yet infected

1. A nurse is caring for a client with a chronic wound and is discussing smoking cessation. The client does not understand how smoking may impact wound healing. Which of the following would be the best nurse response?

   1. Smoking causes you to cough frequently and the wound might get infected by sputum

   2. Nicotine causes vasoconstriction so your wound might not get enough blood flow to heal

   3. Nicotine causes tar to build up in the wound and it will impair healing

   4. Smoking is bad and you should stop right away

Nicotine causes vasoconstriction so your wound might not get enough blood flow to heal

1. A nurse is discussing moisture-related skin conditions with a nursing student. Which of the following clients is most likely to have a moisture-related skin condition?

   1. A client who is post-op day one for an appendectomy

   2. A client who has recently delivered a baby

   3. A client in the intensive care unit in a coma

   4. A client in the emergency department for asthma

A client in the intensive care unit in a coma

1. A nurse is caring for a 70-year-old client who has a pressure injury in the coccyx area. The nurse identifies which of the following factors associated with aging may impact the ability for the ulcer to heal?

   1. Elevated hemoglobin

   2. Low bone density

   3. Increased muscle mass

   4. Decreased protein level

Decreased protein level

1. A nurse is caring for a client who has psoriasis presenting as reddish/purple and flaky patches on their arms and legs. The nurse should be alert to which of the following potential complications of this condition?

   1. Decreased breath sounds

   2. Urinary tract infection

   3. Hiatal hernia

   4. Psychological distress

Psychological distress

1. A nurse is caring for several medical surgical clients. Which of the following should the nurse see first?

   1. A client with a new scalp laceration

   2. A client with cellulitis of the hand

   3. A client with chronic psoriasis

   4. A client with a vaginal yeast infection

A client with a new scalp laceration

1. A nurse is caring for a client with a chronic wound. Which of the following is a systemic cause of chronic wounds?

   1. Infection

   2. Malnutrition

   3. Continuous pressure

   4. Venous insufficiency

Malnutrition

1. A patient is experiencing pain and blisters along the right side of the torso.Which health problem should the nurse suspect this patient is experiencing?

   1. Psoriasis

   2. Shingles caused by the varicella zoster virus (VZV)

   3. Infection

   4. Allergic reaction

Shingles caused by the varicella zoster virus (VZV)

1. For each preoperative assessment finding, click to specify if the assessment finding places the client at risk for hypoxemia, bleeding, or a DVT in the intra-op or post-op phases.

   1. Platelet count (bleeding)

   2. Hemoglobin (hypoxemia)

   3. International normalized ration (bleeding)

   4. Atrial fibrillation (DVT)

   5. Red blood cell count (hypoxemia)

Bleeding:

platelet count, INR

Hypoxemia:

hemoglobin, red blood cell count

DVT:

atrial fibrillation

What is the priority intervention for a client with postoperative hemorrhage? (Kahoot)

Administer NaCl Bolus

1. A nurse is providing postoperative education to a client who had a procedure 2 days ago. Which of the following postoperative education topics should be included?

   1. Medication regimen, continuing medication, and new medications

   2. Resumption of preoperative lifestyle behaviors

   3. Inform the client that loss of appetite after surgery is normal and will go away in a week or two.

   4. Inform the client that their employer will let them know when they are to return to work.

Medication regimen, continuing medication, and new medications

1. A nurse is preparing a client to be transferred to the operating room. The nurse informs the client that there is a delay and they will not be transferred for another 15 min. Which of the following actions should the nurse take during this delay?

   1. Practice postoperative breathing exercises with the client.

   2. Administer all of the client's daily medications.

   3. Instruct the client to get up and void if they need to do so.

   4. Verify that the client has not eaten anything for the last 24 hr.

Practice postoperative breathing exercises with the client

1. The nurse is providing preoperative teaching to the following patients. To which patient should the nurse plan to teach coughing and deep breathing exercises?

   1. A 20-year-old man who is scheduled for a tonsillectomy

   2. A 40-year-old woman who is scheduled for an open cholecystectomy

   3. A 30-year-old woman who is scheduled for a transsphenoidal hypophysectomy

   4. A 50-year-old man who is scheduled for an evacuation of a subdural hematoma

A 40-year-old woman who is schedules for an open cholecystectomy

1. A nurse working in the perioperative area is reviewing the Quality and Safety Education in Nursing (QSEN) competencies. Which of the following competencies should the nurse identify as the priority when caring for a client during the perioperative period?

   1. Safety (quizlet said this one is correct)

   2. Evidence-based practice

   3. Informatics

   4. Quality improvement

Evidence-based practice

1. A nurse is transferring a client to the surgical unit postoperatively. During the handoff report, the nurse states that "Dr. Jones performed a bowel resection." Which section of the SBAR communication tool does this statement address?

   1. Assessment

   2. Situation

   3. Recommendation

   4. Background

Situation

1. A nurse is preparing a client for surgery. Which of the following is a priority when completing an assessment preoperatively?

   1. To identify possible surgical risks

   2. To determine understanding of the procedure

   3. To recognize resources needed postoperatively

   4. To establish the need for psychological support

To identify possible surgical risks

1. A client was admitted to the surgical unit following a repair of a right femur fracture. Which of the following assessments is a priority in the postoperative period?

   1. Presence of significant other

   2. Operative leg skin color

   3. Last bowel movement

   4. Dietary restrictions

Operative leg skin color

1. A nurse is reviewing surgical screening lab work with a client who has arrived for an elective procedure. During which of the following phases is this task performed?

   1. Preoperative

   2. Intraoperative

   3. Postoperative

   4. Perioperative

Preoperative

1. A postoperative client begins to experience cardiac arrhythmia and muscular rigidity. The nurse notes that the client is breathing rapidly and that their blood oxygen is low on the monitor. Which of the following complications should the nurse suspect?

   1. Malignant hyperthermia

   2. Venous thromboembolism

   3. Postoperative malnutrition

   4. Postoperative pain

Malignant hyperthermia

1. A nurse from the recovery area is caring for a client who is beginning to wake up from anesthesia following a foot amputation. Which of the following priority postoperative complications should the nurse expect the patient to experience first?

   1. Pain

   2. Delirium

   3. Frequent falls

   4. Hypothermia

Frequent falls

1. The nurse reviews data from a new client's kidney function test. Which of the following standards of transplant nursing practice is the nurse primarily performing?

   1. Assessment

   2. Diagnosis

   3. Outcomes identification

   4. Implementation

Assessment

1.  A transplant nurse attends a conference about nursing practices that can help reduce the risk of health care-acquired infections in clients receiving immunosuppressive therapies related to organ transplants. Which of the following standards of professional performance for transplant nursing is the nurse primarily demonstrating?

   1. Education

   2. Ethics

   3. Communication

   4. Leadership

Education

1. A transplant nurse reflects on their performance as a member of the care team and asks a nurse supervisor for feedback on how well they implemented their portions of the care plan. Which of the following standards of professional performance for transplant nursing is the nurse primarily demonstrating?

   1. Professional practice evaluation

   2. Education

   3. Environmental health

   4. Evidence-based practice

Professional practice evaluation

What document should a newly licensed nurse review to understand the facility’s disaster response? (Kahoot)

Emergency operations plan

What is the recommended method for chemical decontamination after a refinery explosion?

Soap and water

1. While triaging the wounded from a disaster, you note that one of the wounded is not breathing, radial pulse is absent, capillary refill >2 seconds, and does not respond to your commands. What color tag is assigned?

   1. Green

   2. Red

   3. Yellow

   4. Black

Black

1. The wounded victim is unable to walk, respiratory rate is absent and when airway is repositioned breathing is still absent. The wounded victim is assigned what tag color?

   1. Green

   2. Red

   3. Yellow

   4. Black

Black

1. The wounded victim is unable to walk, has respiratory rate of 40, capillary refill is 6 seconds, and can't follow simple commands. The wounded victim is assigned what tag color?

   1. Green

   2. Red

   3. Yellow

   4. Black

Red

1. You're working as a triage nurse during a disaster situation. Based on the triage color code tags placed on each of the wounded, which tag color represents the wounded who have the highest priority of being treated first?

2. Green

3. Yellow

4. Red

5. Black

Red

1. A catastrophic disaster has occurred 5 miles from the hospital you are working in. The hospital's disaster plan is activated and the wounded are brought to the hospital. You're helping triage the survivors. One of the wounded is able to walk around and has minor lacerations on the arms, hands, chest, and legs. You would place what color tag on this survivor?

   1. Red

   2. Yellow

   3. Green

   4. Black

Green

What is the best action for a nurse when contacted by media during a disaster? (Kahoot)

Follow their agency policy regarding media

1. A client in the emergency department is in critical condition. The client's nurse recognizes that which of the following actions would be therapeutic for the family?

   1. Notifying the family once the client's care has been completed

   2. Asking the charge nurse to manage all communication with the client's family

   3. Asking the family to wait in the waiting room during the entirety of the care

   4. Providing open communication and updates on the client's condition

Providing open communication and updates on the client’s condition

1. A client in the emergency department is in critical condition. The client's nurse recognizes that which of the following actions would be therapeutic for the family?

   1. Notifying the family once the client's care has been completed

   2. Asking the charge nurse to manage all communication with the client's family

   3. Asking the family to wait in the waiting room during the entirety of the care

   4. Providing open communication and updates on the client's condition

Providing open communication and updates on the client’s condition

1. A nurse is preparing to discharge a client who was treated for sexual assault. Prior to discharge, which of the following actions should the nurse plan?

   1. Call the client's home for someone to pick up the client.

   2. Provide the client with grooming supplies and a private area to bathe.

   3. Send the client's clothes to the laundry before returning the items to the client.

   4. Retain the client's cell phone for evidence.

Provide the client with grooming supplies and a private area to bathe

What is the priority for a sexual assault client who wants to press charges? (Kahoot)

Obtain consent for forensic exams

1. An emergency department nurse who is leaving the shift is reporting off to the oncoming emergency department nurse. The off-going nurse reports that a client was admitted to the emergency department at 0800 today with head trauma from a fall in the client's bathroom where the client's head hit the edge of the bathtub. Which of the following parts of the SBAR report does this represent?

   1. Assessment

   2. Background

   3. Situation

   4. Recommendation

Background

1. On which of the following patients should a reassessment be performed?

   1. All patients, after lifesaving interventions

   2. A patient with chest pain

   3. A patient with a gunshot wound

   4. A patient having difficulty breathing

All patients, after lifesaving interventions

1. An emergency department nurse is providing handoff communication using SBAR (situation, background, assessment, recommendations) to the nurse accepting a client in the intensive care unit. The emergency department nurse reports that the client will require a suction set up for gastric tube drainage and will need an endoscopy performed. Which of the following parts of the SBAR report is the nurse communicating?

   1. R-Recommendations

   2. S-Situation

   3. B-Background

   4. A-Assessment

Recommendations

1. A nurse is performing a primary survey on a newly admitted client to the emergency room. Using the ABCDE assessment, which of the following areas are assessed under the "C" category?

   1. Heart and blood vessels

   2. Oxygen saturation and respiratory rate

   3. Mouth, larynx, and bronchi

   4. Response to voice and pain

Heart and blood vessels

1. A nurse is caring for a client in the emergency department who is actively dying from a catastrophic injury. Which of the following is the priority in planning care for this client?

   1. Creating a plan for pain relief, nutrition, and hydration

   2. Discussing organ donation with the family

   3. Contacting the family's spiritual advisor

   4. Communicating sensitively with the client and family

Communicating sensitively with the client and family

1. A nurse working with clients in the critical care unit has been feeling overwhelmed and losing focus while working. Which of the following is the most important strategy in minimizing stress and preventing burnout?

   1. Decreasing use of social media

   2. Ignoring fake news

   3. Incorporating diaphragmatic breathing

   4. Focusing on self-care

Focusing on self-care

1. A nurse is providing a presentation to colleagues on emphysema. Which of the following subtypes should the nurse identify as having a complication of pneumothorax? 

   1. Proximal acinar emphysema 

   2. Panacinar emphysema 

   3. Distal acinar emphysema 

   4. Centrilobular emphysema

Distal acinar emphysema

1. Which of the following is true regarding the physiology of an open pneumothorax? 

   1. Air moves in and out of a wound in the chest wall. 

   2. Air cannot pass freely into the thoracic cavity through a chest wound. 

   3. There are no audible sounds in an open pneumothorax. 

   4. The air is trapped when it enters the cavity.

Air moves in and out of a wound in the chest wall

1. Which of the following is the most common comorbidity of a secondary spontaneous pneumothorax (SSP)? 

   1. COPD 

   2. Cystic Fibrosis

   3. Sarcoidosis 

   4. Lung Cancer

COPD

1. Which of the following common characteristics of nonallergic asthma can the nurse expect to find when assessing an adult client? (Select all that apply.)

   1. Asthma flare-ups during exercise

   2. Nasal inflammation

   3. No hypersensitivity to allergens

   4. Asthma flare-ups with NSAID administration

   5. Persistence of manifestations

   6. Positive response to corticosteroids

No hypersensitivity to allergens, persistence of manifestations, positive response to corticosteroids

1. In which of the following types of pneumonia does consolidation involve the entire lobe of the lung?

   1. Bronchopneumonia

   2. Severe pneumonia

   3. Empyema

   4. Lobar pneumonia

Lobar pneumonia

1. Which of the following pathophysiological mechanisms lead to bronchospasm?

   1. Airway inflammation only

   2. Shortness of breath on exertion

   3. Excess mucus production followed by mucus plug

   4. Inflammation, edema, and excess mucus production

Inflammation, edema, and excess mucus production

1. Which of the following risk factors is associated with a client having a higher risk of experiencing status asthmaticus?

   1. Previous stroke

   2. Irritants and hypersensitivity to medications

   3. Previous intubation due to status asthmaticus episode

   4. Bronchial pneumonia

Previous intubation due to status asthmaticus episode

1. A nurse is caring for a client admitted with pneumonia caused by streptococcus pneumoniae. Which of the following types of pneumonia is streptococcus pneumoniae?

   1. Typical pneumonia

   2. Chemical pneumonitis

   3. Atypical pneumonia

   4. Aspiration pneumonia

Typical pneumonia

1. Which of the following is the most common risk factor for emphysema?

   1. Smoking tobacco

   2. Between 20 and 30 years of age

   3. Asthma

   4. Pollution

Smoking tobacco

1. A nurse is caring for a client who has COPD and observed weight loss, skeletal muscle dysfunction, and poor nutrition. The nurse should know that these factors represent what?

Systemic effects

Which are systemic effects of COPD?

1. Muscle dysfunction

2. Poor nutrition

3. Weight loss

1. Which of the following could the nurse expect to observe in an older adult client who has a pneumothorax?

   1. Higher oxygen saturation of 98% to 99%

   2. Lower oxygen saturations of 93% to 94%

   3. Lower energy expenditure

   4. Increased lung capacity

Lower oxygen saturations of 93% to 94%

1. Which of the following is an example of a complication that causes noncardiogenic pulmonary edema?

   1. Diastolic dysfunction, resulting from excess sodium and water retention

   2. Increase in fluid in the pulmonary interstitial spaces

   3. Kidney injury

   4. Myocardial ischemia

Kidney injury

1. A nurse is caring for a client with asthma. WHich of the following statements are true regarding physiological changes of the respiratory system in the aging adult client?

   1. Dyspnea is not commonly seen in other chronic conditions of the aging older adult

   2. Aging is associated with decreased sensitivity to medications

   3. Adverse effects to medications in the aging older adult are lower

   4. Physiological changes in the respiratory system can mimic the presence of airway obstruction

Physiological changes in the respiratory system can mimic the presence of airway obstruction

1. Which of the following are the most common manifestations of COPD? Select all that apply. (Don’t have all options)

1. Chronic cough

2. Sputum production

3. Dyspnea

1. Which of the following information should the nurse include when educating a client who has pulmonary edema as a result of a pre-existing cardiac condition?(Select all that Apply)

   1. Healthy lifestyle

   2. Smoking cessation

   3. Heart disease prevention

   4. Weight control if the client's BMI is greater than 35

   5. Glycemic control if the client is diabetic

All of them, although Delgado says only smoking cessation and heart disease prevention