200 Nursezone Medical-surgical Nursing Final Coaching Part 1 (51 To 75)
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SITUATION: As nurses, we should be prepared to care for patients with different cardiovascular problems A 45 year old man is recovering from surgical repair of dissecting aortic aneurysm. The nurse should evaluate the client for signs of bleeding or recurrent dissection. These signs include:
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Hypotension and tachycardia, decreased urine output
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Hematuria and decreased urine output
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Increased urine output and bradycardia
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Hypotension and bradycardia
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This quiz assesses nursing care for cardiovascular conditions, focusing on heart failure, myocardial infarction, and diabetic ketoacidosis. It tests practical knowledge needed for effective patient management and preparation for the NCLEX exam.
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- 2.
SITUATION: A nurse is participating in a health screening clinic and is preparing teaching materials about colorectal cancer The client had a new colostomy created two days earlier. The client is beginning to pass malodorous flatus from the stoma. The nurse interprets that:
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This indicates inadequate preoperative bowel preparation
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This is a normal expected event
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The client is experiencing early signs of ischemic bowel
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The client should not have the nasogastric tube removed
Correct Answer
A. This is a normal expected eventExplanation
The nurse interprets that the client passing malodorous flatus from the stoma is a normal expected event. This is because after a colostomy surgery, it takes some time for the digestive system to adjust and for the body to expel gas through the stoma. The malodorous flatus is a result of the normal digestive process and is not a cause for concern.Rate this question:
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- 3.
SITUATION: Mrs. Thomas is admitted to a hospital with a diagnosis of Diabetic Ketoacidosis (DKA). The initial blood glucose level was 950 mg/dl. A continuous intravenous infusion of regular insulin is initiated along with intravenous rehydration with normal saline. The serum glucose level is now 240 mg/dl Nurse Gina provides instruction to a client newly diagnosed with type 1 DM. She recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client states:
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“I will stop taking insulin if I’m too sick to eat”
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“I will decrease my insulin dose during times of illness”
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“I will notify my physician if my blood glucose level is greater than 250 mg/dl”
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“I will adjust my insulin dose according to the level of glucose in my urine”
Correct Answer
A. “I will notify my physician if my blood glucose level is greater than 250 mg/dl”Explanation
The correct answer is "I will notify my physician if my blood glucose level is greater than 250 mg/dl." This answer demonstrates an accurate understanding of measures to prevent diabetic ketoacidosis. Monitoring blood glucose levels is crucial in managing diabetes, and notifying a physician if the levels exceed a certain threshold is important for timely intervention and adjustment of treatment. This shows that the client is aware of the potential risks and is taking proactive steps to prevent complications.Rate this question:
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- 4.
SITUATION: The goals of treatment for hepatitis include resting the inflamed liver to reduce metabolic demand and increasing the blood supply, thus promoting cellular regeneration and preventing complication Doctor Gano has determined that the client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis?
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Hepatitis A
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Hepatitis B
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Hepatitis C
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Hepatitis D
Correct Answer
A. Hepatitis AExplanation
The client is most likely experiencing Hepatitis A because it is commonly transmitted through contaminated food or water.Rate this question:
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- 5.
SITUATION: Mrs. Thomas is admitted to a hospital with a diagnosis of Diabetic Ketoacidosis (DKA). The initial blood glucose level was 950 mg/dl. A continuous intravenous infusion of regular insulin is initiated along with intravenous rehydration with normal saline. The serum glucose level is now 240 mg/dl Which finding would a nurse expect to note as confirming this diagnosis?
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Elevated blood glucose level and a low potassium level and a low plasma bicarbonate
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Decreased urine output
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Increased respirations and an increase in pH
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Comatose state
Correct Answer
A. Elevated blood glucose level and a low potassium level and a low plasma bicarbonateExplanation
The nurse would expect to note an elevated blood glucose level, a low potassium level, and a low plasma bicarbonate in a patient with Diabetic Ketoacidosis (DKA). DKA is a life-threatening complication of diabetes characterized by high blood glucose levels, electrolyte imbalances (such as low potassium), and metabolic acidosis (indicated by low plasma bicarbonate levels). These findings are consistent with the diagnosis of DKA and would confirm it.Rate this question:
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- 6.
SITUATION: A nurse is participating in a health screening clinic and is preparing teaching materials about colorectal cancer The nurse plans to include which of the following in a list of risk factors for colorectal cancer?
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Age over 30 years
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High fiber, low fat diet
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Distant relative with colorectal cancer
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Personal history of ulcerative colitis or gastrointestinal polyps
Correct Answer
A. Personal history of ulcerative colitis or gastrointestinal polypsExplanation
Personal history of ulcerative colitis or gastrointestinal polyps is included in the list of risk factors for colorectal cancer because individuals with these conditions have a higher risk of developing colorectal cancer compared to those without these conditions. Age over 30 years, high fiber, low fat diet, and distant relative with colorectal cancer are not mentioned as risk factors in this context.Rate this question:
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- 7.
SITUATION: Mrs. Thomas is admitted to a hospital with a diagnosis of Diabetic Ketoacidosis (DKA). The initial blood glucose level was 950 mg/dl. A continuous intravenous infusion of regular insulin is initiated along with intravenous rehydration with normal saline. The serum glucose level is now 240 mg/dl Nurse Gilda gives an inaccurate dose of a medication to the client. Following assessment of the client, she completes an incident report. She notifies the Nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication dose understands that the:
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Error will result in suspension
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Incident report is a method of promoting quality care and risk management
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Incident will be reported to the board of nursing
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Incident will be documented in the personnel file
Correct Answer
A. Incident report is a method of promoting quality care and risk managementExplanation
The nurse who administered the inaccurate medication dose understands that the incident report is a method of promoting quality care and risk management. Incident reports are used to document any unexpected or adverse events that occur in healthcare settings, such as medication errors. By reporting and documenting these incidents, healthcare organizations can identify patterns, implement corrective actions, and improve patient safety and quality of care. The incident report is not intended to result in suspension, be reported to the board of nursing, or be documented in the personnel file of the nurse.Rate this question:
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- 8.
SITUATION: Nurse Ferdinand, a nurse in the emergency department receives a telephone call from emergency medical services and is told that several victims who survived a plane crash and are suffering from cold exposure will be transported to the hospital The nurse is evaluating the status of the client who had craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits:
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A positive Brudzinki’s sign
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A negative Kernig’s sign
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Absence of nuchal rigidity
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A Glasgow Coma Scale score of 15
Correct Answer
A. A positive Brudzinki’s signExplanation
A positive Brudzinki's sign is a symptom of meningitis, which is an inflammation of the membranes surrounding the brain and spinal cord. This sign is characterized by the involuntary flexion of the hips and knees when the client's neck is flexed. Therefore, if the client exhibits a positive Brudzinki's sign, it suggests that they may be developing meningitis as a complication of the craniotomy surgery.Rate this question:
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- 9.
SITUATION: The goals of treatment for hepatitis include resting the inflamed liver to reduce metabolic demand and increasing the blood supply, thus promoting cellular regeneration and preventing complication The client diagnosed with hepatitis B is admitted to the hospital. All of the following are standard precautions to be initiated, except:
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Needle precautions
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Strict hand washing
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Screening blood donors
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Wearing a mask in the clients room
Correct Answer
A. Wearing a mask in the clients roomExplanation
Wearing a mask in the client's room is not a standard precaution for hepatitis B. Standard precautions for hepatitis B include needle precautions to prevent transmission of bloodborne pathogens, strict hand washing to prevent the spread of infection, and screening blood donors to ensure the safety of blood transfusions. Wearing a mask is typically not necessary unless there is a specific respiratory infection present.Rate this question:
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- 10.
SITUATION: The goals of treatment for hepatitis include resting the inflamed liver to reduce metabolic demand and increasing the blood supply, thus promoting cellular regeneration and preventing complication The client admitted to the hospital with viral Hepatitis is complaining of “no appetite” and “losing his taste for food.” To provide adequate nutrition, the nurse would instruct the client to:
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Eat a good supper when anorexia is not as severe
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Eat less often preferably only 3 large meals daily
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Increase intake of fluids including juices
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Select foods high in fat
Correct Answer
A. Increase intake of fluids including juicesExplanation
The correct answer is to increase intake of fluids including juices. This is because the client is experiencing a loss of appetite and a decrease in taste for food, which can lead to inadequate nutrition. Increasing intake of fluids, including juices, can help provide hydration and some nutrients, even if the client is not eating solid foods. This can help prevent dehydration and provide some energy and nutrients to support the liver's healing and regeneration process.Rate this question:
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- 11.
SITUATION: As nurses, we should be prepared to care for patients with different cardiovascular problems A client is admitted to the hospital with right-sided heart failure. When assessing him for jugular vein distention, the nurse should position him:
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Flat on his back
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Sitting upright
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Lying on his side with the head of bed flat
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Lying on his back with the head of the bed elevated at 30 to 45 degrees
Correct Answer
A. Lying on his back with the head of the bed elevated at 30 to 45 degreesExplanation
Lying on his back with the head of the bed elevated at 30 to 45 degrees is the correct position to assess for jugular vein distention in a client with right-sided heart failure. This position helps to decrease venous congestion and allows for easier visualization of the jugular veins. Lying flat on the back or on the side with the head of the bed flat would not provide optimal visualization of the jugular veins. Sitting upright may increase venous congestion and is not recommended for this assessment.Rate this question:
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- 12.
SITUATION: As nurses, we should be prepared to care for patients with different cardiovascular problems A client is suspected of having myocardial infarction. When providing care for the client, the nurse avoids which route when taking a temperature?
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Rectal
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Anally
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Axillary
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Tympanic
Correct Answer
A. RectalExplanation
When a client is suspected of having a myocardial infarction, the nurse should avoid taking the client's temperature rectally. This is because rectal temperature measurement can cause the client to strain or bear down, which can increase the workload on the heart and potentially worsen their condition. Therefore, it is important for the nurse to choose a different route, such as axillary or tympanic, to take the client's temperature.Rate this question:
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- 13.
SITUATION: A nurse is participating in a health screening clinic and is preparing teaching materials about colorectal cancer The client diagnosed with cancer is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, “I have read a lot about complimentary therapies. Do you think that I should try it?” The nurse responds by making which most appropriate statement?
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“No, because it will interact with the chemotherapy”
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“You need to ask your physician about it”
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“I would try anything that I could if I had cancer”
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“There are many different forms of complementary therapies. Let’s talk about these therapies”
Correct Answer
A. “There are many different forms of complementary therapies. Let’s talk about these therapies”Explanation
The nurse's response of "There are many different forms of complementary therapies. Let's talk about these therapies" is the most appropriate statement because it acknowledges the client's interest in complementary therapies and opens up a discussion about the different options available. This response shows that the nurse is supportive and willing to explore alternative treatments with the client, while also recognizing the importance of discussing these options further before making any decisions.Rate this question:
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- 14.
SITUATION: Mrs. Thomas is admitted to a hospital with a diagnosis of Diabetic Ketoacidosis (DKA). The initial blood glucose level was 950 mg/dl. A continuous intravenous infusion of regular insulin is initiated along with intravenous rehydration with normal saline. The serum glucose level is now 240 mg/dl Diabetic ketoacidosis is a life-threatening complication of which type of diabetes?
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Gestational diabetes
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Type 1 diabetes mellitus
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Type 2 diabetes mellitus
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Diabetes insipidus
Correct Answer
A. Type 1 diabetes mellitusExplanation
Diabetic ketoacidosis (DKA) is a life-threatening complication that primarily occurs in individuals with Type 1 diabetes mellitus. It is caused by a severe lack of insulin in the body, leading to high blood glucose levels and the breakdown of fat for energy. This breakdown of fat produces ketones, which can lead to acidosis. In Type 2 diabetes mellitus, the body still produces insulin but is unable to use it effectively, and gestational diabetes occurs during pregnancy. Diabetes insipidus is a condition that affects water balance in the body and is unrelated to DKA.Rate this question:
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- 15.
SITUATION: Nurse Ferdinand, a nurse in the emergency department receives a telephone call from emergency medical services and is told that several victims who survived a plane crash and are suffering from cold exposure will be transported to the hospital Nurse Adrian is assessing the motor function of an unconscious client brought to the emergency room. The nurse would plan to use which of the following to test the client’s peripheral response to pain?
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Sternal rub
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Pressure on the orbital rim
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Squeezing of the sternocleidomastoid muscle
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Nail bed pressure
Correct Answer
A. Nail bed pressureExplanation
Nail bed pressure is used to test the client's peripheral response to pain. This test involves applying pressure to the nail bed and observing the client's response. This can help determine if the client has intact sensory and motor function in their peripheral nerves. The other options, such as sternal rub, pressure on the orbital rim, and squeezing of the sternocleidomastoid muscle, are not specific tests for peripheral response to pain.Rate this question:
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- 16.
SITUATION: The goals of treatment for hepatitis include resting the inflamed liver to reduce metabolic demand and increasing the blood supply, thus promoting cellular regeneration and preventing complication Nurse Tina is caring for a dark skinned client who has a diagnosis of acute viral hepatitis. The nurse assess for jaundice by checking which specific area?
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Flexor surfaces of the extremities
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Hard palate of the mouth
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Nail beds
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Skin
Correct Answer
A. Hard palate of the mouthExplanation
The nurse assesses for jaundice by checking the hard palate of the mouth. Jaundice is a yellowing of the skin and eyes that occurs when there is a buildup of bilirubin in the body. Bilirubin is a yellow pigment that is produced when red blood cells are broken down. The hard palate of the mouth is an area where jaundice can be easily observed, as it often appears yellow in individuals with liver dysfunction. Checking the flexor surfaces of the extremities, nail beds, and skin may also provide information about jaundice, but the hard palate is a specific area where it can be easily assessed.Rate this question:
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- 17.
SITUATION: Nurse Ferdinand, a nurse in the emergency department receives a telephone call from emergency medical services and is told that several victims who survived a plane crash and are suffering from cold exposure will be transported to the hospital The client underwent a supratentoral craniotomy due to his head injury. Which of the following actions done by the post anesthesia care unit nurse is contraindicated?
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Maintain mechanical ventilation and slight hyperventilation for the first 24 to 48 hours as prescribed to prevent increase in ICP
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Monitor vital signs and neurological status every 30 minutes to 1 hour
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Monitor the head dressing frequently for signs of drainage
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Position the patient flat in bed without head elevation
Correct Answer
A. Position the patient flat in bed without head elevationExplanation
Positioning the patient flat in bed without head elevation after a supratentorial craniotomy is contraindicated because it can increase intracranial pressure (ICP). Elevating the head of the bed helps to promote venous drainage and reduce the risk of cerebral edema.Rate this question:
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- 18.
SITUATION: Mrs. Thomas is admitted to a hospital with a diagnosis of Diabetic Ketoacidosis (DKA). The initial blood glucose level was 950 mg/dl. A continuous intravenous infusion of regular insulin is initiated along with intravenous rehydration with normal saline. The serum glucose level is now 240 mg/dl Nurse Gilda would next prepare to administer which of the following?
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Intravenous fluids containing 5% dextrose
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NPH insulin subcutaneously
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An ampule of 50% dextrose
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Phenytoin (Dilantin) for the prevention of seizures
Correct Answer
A. Intravenous fluids containing 5% dextroseExplanation
After the initial administration of regular insulin and intravenous rehydration with normal saline, the serum glucose level has decreased to 240 mg/dl. This indicates that the patient's blood glucose is now within the target range. In order to prevent hypoglycemia, the nurse would next prepare to administer intravenous fluids containing 5% dextrose. This will provide a small amount of glucose to maintain the patient's blood sugar level and prevent it from dropping too low.Rate this question:
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- 19.
SITUATION: Nurse Ferdinand, a nurse in the emergency department receives a telephone call from emergency medical services and is told that several victims who survived a plane crash and are suffering from cold exposure will be transported to the hospital One of the victims was brought to the emergency room due to severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which of the following is the best action?
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Ask the EMS team to sign the informed consent
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Call the police to identify the client and locate the family
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Transport the victim to the operating room for surgery
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Obtain a court order for the surgical procedure
Correct Answer
A. Transport the victim to the operating room for surgery -
- 20.
SITUATION: As nurses, we should be prepared to care for patients with different cardiovascular problems Mr. Rimorin who suffered an acute myocardial infarction is anxious because he is going to be transferred from the intensive care unit to the coronary ward. The patient asks the charge nurse if he can have the same nurse care for him every day. how should the nurse respond?
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“It’s very important for you to receive care from a variety of nurses so you can evaluate your care”
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“We’ll try to assign you the same nurse as often as possible”
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“It’s our policy to rotate client care assignments to ensure quality car for everyone”
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“Different nurses will be assigned to you each day to avoid your becoming dependent on one nurse”
Correct Answer
A. “We’ll try to assign you the same nurse as often as possible”Explanation
The nurse should respond by saying "We'll try to assign you the same nurse as often as possible." This response acknowledges the patient's request for consistency in care while also recognizing the need for flexibility due to staffing and scheduling constraints. It shows that the nurse values the patient's preferences and will make an effort to accommodate them, while also ensuring that the patient receives care from a variety of nurses to maintain quality and prevent dependence on one nurse.Rate this question:
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- 21.
SITUATION: A nurse is participating in a health screening clinic and is preparing teaching materials about colorectal cancer The client who has undergone creation of a colostomy has a nursing diagnosis disturbed body image. The nurse would evaluate that the client is making the most significant progress toward identified goals if the client:
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Watches the nurse empty the ostomy bag
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Looks at the ostomy site
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Reads the ostomy product literature
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Practices cutting the ostomy appliance
Correct Answer
A. Practices cutting the ostomy applianceExplanation
Practicing cutting the ostomy appliance would indicate that the client is actively engaging in self-care and taking steps towards accepting and managing their colostomy. By practicing this task, the client is demonstrating a level of comfort and acceptance with their body image and the changes that have occurred. Watching the nurse empty the ostomy bag, looking at the ostomy site, and reading the ostomy product literature may also be important for education and understanding, but they do not directly address the client's body image concerns.Rate this question:
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- 22.
SITUATION: As nurses, we should be prepared to care for patients with different cardiovascular problems Arby, a new nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that planning care delivery will be based on which charact4eristic of this type of nursing model of practice?
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A task approach method is used to provide care to clients
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Managed care concepts and tools are used in providing client care
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An RN leads nursing personnel in providing care to a group of clients
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A single RN is responsible for providing nursing care to a group of clients
Correct Answer
A. An RN leads nursing personnel in providing care to a group of clientsExplanation
In a team nursing approach, an RN leads nursing personnel in providing care to a group of clients. This means that the RN will be responsible for overseeing and coordinating the care provided by other members of the nursing team. This characteristic of the nursing model ensures that there is effective teamwork and collaboration in delivering care to patients with different cardiovascular problems.Rate this question:
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- 23.
SITUATION: Nurse Ferdinand, a nurse in the emergency department receives a telephone call from emergency medical services and is told that several victims who survived a plane crash and are suffering from cold exposure will be transported to the hospital The initial nursing action of Nurse Ferdinand is which of the following?
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Supply the trauma rooms with bottles of sterile water and normal saline
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Call the laundry department and ask them to send as many warm blankets as possible to the emergency room
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Call the nursing supervisor to activate the agency disaster plan
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Call the intensive care unit to request that nurses be sent to the emergency room
Correct Answer
A. Call the nursing supervisor to activate the agency disaster planExplanation
Activating the agency disaster plan is the initial nursing action because it ensures that the necessary resources and personnel are mobilized to effectively respond to the situation. This plan includes protocols for managing emergencies, coordinating resources, and providing appropriate care to the victims. By calling the nursing supervisor to activate the plan, Nurse Ferdinand ensures a coordinated and organized response to the influx of patients.Rate this question:
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- 24.
SITUATION: The goals of treatment for hepatitis include resting the inflamed liver to reduce metabolic demand and increasing the blood supply, thus promoting cellular regeneration and preventing complication The nurse is caring for a client suspected with hepatitis A. Which statement when given by client indicates sign of Hepatitis A?
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“Lately I’ve been passing out dark stools”
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“I have noticed that I gained weight”
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“I feel so weak”
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“My stomach aches specifically at the left side”
Correct Answer
A. “I feel so weak”Explanation
The statement "I feel so weak" indicates a sign of Hepatitis A because weakness and fatigue are common symptoms of hepatitis. This is due to the inflammation and damage to the liver, which can lead to decreased energy levels and overall weakness in the body. It is important for the nurse to further assess the client's symptoms and provide appropriate care and support.Rate this question:
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- 25.
SITUATION: A nurse is participating in a health screening clinic and is preparing teaching materials about colorectal cancer The client with an intestinal tumor is scheduled for a bowel resection and creation of colostomy. The nurse caring for this client will provide which most appropriate nursing intervention?
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Instruct to eat high residue diet for 1 to 2 days before surgery
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Administer laxatives and enemas as prescribed
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Monitor stool characteristics
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Restrict dark colored foods
Correct Answer
A. Monitor stool characteristicsExplanation
The most appropriate nursing intervention for a client scheduled for a bowel resection and creation of colostomy would be to monitor stool characteristics. This is important because it allows the nurse to assess the client's bowel function and ensure that the colostomy is functioning properly. By monitoring the stool characteristics, the nurse can identify any changes or abnormalities that may indicate complications or issues with the colostomy. This intervention helps to ensure the client's safety and well-being post-surgery.Rate this question:
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Current Version
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Mar 20, 2023Quiz Edited by
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Jan 02, 2012Quiz Created by
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