Adult Medical Surgical Nursing Quiz

1. A client receiving Lopressor 50mg IV should most importantly have which vital signs checked prior to administration?

Temperature

Respirations

Blood pressure, and heart rate

Pain

Prior to administration of Lopressor 50mg IV, it is most important to check the client's blood pressure and heart rate. Lopressor is a medication used to treat high blood pressure and certain heart conditions. Monitoring the client's blood pressure and heart rate prior to administration is crucial in order to assess their baseline cardiovascular status and determine the appropriate dosage of the medication. This helps ensure the medication is administered safely and effectively.

Explanation

Prior to administration of Lopressor 50mg IV, it is most important to check the client's blood pressure and heart rate. Lopressor is a medication used to treat high blood pressure and certain heart conditions. Monitoring the client's blood pressure and heart rate prior to administration is crucial in order to assess their baseline cardiovascular status and determine the appropriate dosage of the medication. This helps ensure the medication is administered safely and effectively.

2. Which of the following foods should a patient receiving Coumadin therapy be instructed to eat in moderation?

Spinach and other green leafy vegetables

Corn

Brown Rice

Lean Chicken Breast

Patients receiving Coumadin therapy should be instructed to eat spinach and other green leafy vegetables in moderation. This is because these vegetables are high in vitamin K, which can interfere with the effectiveness of Coumadin, a medication used to prevent blood clots. Consuming large amounts of vitamin K-rich foods can reduce the medication's ability to thin the blood and increase the risk of clotting. Therefore, it is important for patients on Coumadin to maintain a consistent intake of vitamin K and be cautious about consuming excessive amounts of green leafy vegetables.

Explanation

Patients receiving Coumadin therapy should be instructed to eat spinach and other green leafy vegetables in moderation. This is because these vegetables are high in vitamin K, which can interfere with the effectiveness of Coumadin, a medication used to prevent blood clots. Consuming large amounts of vitamin K-rich foods can reduce the medication's ability to thin the blood and increase the risk of clotting. Therefore, it is important for patients on Coumadin to maintain a consistent intake of vitamin K and be cautious about consuming excessive amounts of green leafy vegetables.

3. Which of the following laboratory values is considered critical?

Potassium 4.2 mEq/L

Potassium 2.8 mEq/L

Potassium 3.7 mEq/L

Potassium 4.9 mEq/L

A potassium level of 2.8 mEq/L is considered critical because it is below the normal range (3.5-5.0 mEq/L). Low potassium levels can lead to serious complications such as muscle weakness, irregular heart rhythms, and even cardiac arrest. Therefore, immediate medical intervention is required to address the critical potassium level and prevent further complications.

Explanation

A potassium level of 2.8 mEq/L is considered critical because it is below the normal range (3.5-5.0 mEq/L). Low potassium levels can lead to serious complications such as muscle weakness, irregular heart rhythms, and even cardiac arrest. Therefore, immediate medical intervention is required to address the critical potassium level and prevent further complications.

4. You are caring for a patient who is newly diagnosed with Congestive Heart Failure CHF. Which statement by the patient would indicate that your patient teaching has been a success?

I will just smoke one half pack of cigarettes per day, as this is healthier than one pack

The statement indicates that the patient understands the importance of monitoring their weight and reporting any significant weight gain to their doctor. This is crucial in managing congestive heart failure as weight gain can be a sign of fluid retention and worsening of the condition. By conducting daily weight checks and keeping a log, the patient is actively participating in their own care and taking necessary steps to prevent complications.

Explanation

The statement indicates that the patient understands the importance of monitoring their weight and reporting any significant weight gain to their doctor. This is crucial in managing congestive heart failure as weight gain can be a sign of fluid retention and worsening of the condition. By conducting daily weight checks and keeping a log, the patient is actively participating in their own care and taking necessary steps to prevent complications.

5. You are the RN charge nurse on the medical surgical unit, and you are in charge of delegating assignments for the shift. Which of the following would be the most appropriate to delegate to the LPN/LVN?

A 72 year old patient who requires Lasix 20mg IV push

A 50 year old patient who is 3 days post op and requires a simple dressing change

A 45 year old patient who is a newly diagnosed diabetic and requires discharge teaching

The most appropriate task to delegate to the LPN/LVN would be the simple dressing change for the 50-year-old patient who is 3 days post-op. This task is within the scope of practice for an LPN/LVN and does not require specialized knowledge or skills. The other tasks, such as administering IV antibiotics, giving IV push medications, and providing discharge teaching to a newly diagnosed diabetic, require a higher level of expertise and should be performed by the RN.

Explanation

The most appropriate task to delegate to the LPN/LVN would be the simple dressing change for the 50-year-old patient who is 3 days post-op. This task is within the scope of practice for an LPN/LVN and does not require specialized knowledge or skills. The other tasks, such as administering IV antibiotics, giving IV push medications, and providing discharge teaching to a newly diagnosed diabetic, require a higher level of expertise and should be performed by the RN.

6. Which statement by the client receiving anticoagulation therapy with Coumadin would indicate a need for further teaching?

The statement "If I get a severe headache, worse than any other headache I have ever had in my life, I will take two aspirin, and take a nap, as that should help" indicates a need for further teaching because taking aspirin can increase the risk of bleeding in clients receiving anticoagulation therapy with Coumadin. It is important for the client to understand that they should consult their healthcare provider before taking any medication, especially if they are already on anticoagulation therapy.

Explanation

The statement "If I get a severe headache, worse than any other headache I have ever had in my life, I will take two aspirin, and take a nap, as that should help" indicates a need for further teaching because taking aspirin can increase the risk of bleeding in clients receiving anticoagulation therapy with Coumadin. It is important for the client to understand that they should consult their healthcare provider before taking any medication, especially if they are already on anticoagulation therapy.

7. Which of the following orders is complete, not requiring nurse clarification?

Tylenol 650mg PO q4hours PRN for mild pain

Ativan 1mg PO PRN

Ibuprofen 400mg q6hours PRN for moderate pain

Haldol 2mg IM q6hours PRN

The order for Tylenol 650mg PO q4hours PRN for mild pain is complete and does not require nurse clarification because it includes the medication name (Tylenol), the dose (650mg), the route of administration (PO - by mouth), the frequency (q4hours - every 4 hours), and the indication (PRN for mild pain). This order provides all the necessary information for the nurse to administer the medication safely and effectively without needing further clarification.

Explanation

The order for Tylenol 650mg PO q4hours PRN for mild pain is complete and does not require nurse clarification because it includes the medication name (Tylenol), the dose (650mg), the route of administration (PO - by mouth), the frequency (q4hours - every 4 hours), and the indication (PRN for mild pain). This order provides all the necessary information for the nurse to administer the medication safely and effectively without needing further clarification.