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NUR242 / NUR 242 Exam 3
Medical-Surgical Nursing Concepts
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Consist of 50 Questions with Answers
- The nurse recognizes that a patient with sleep apnea may benefit from which intervention(s)? (Select all that apply.)
A. Weight loss B. Nasal mask to deliver BiPAP C. A change in sleeping position D. Medication to increase daytime sleepiness E. Position-fixing device that prevents tongue subluxation: : ANSWER A, B, C, E
All interventions listed are viable interventions that can be of benefit to patients who have sleep apnea. Patients should work with their providers of care to determine the severity of their sleep apnea and which specific interventions would be of most importance to them. Encouraging daytime sleepiness is the opposite of the effect needed for this patient.
- Based on the patient's diagnosis, which clinical manifestations would the nurse expect to see when assessing this patient? (Select all that apply.)
A. Bradycardia B. Shortness of breath C. Use of accessory muscles D. Sitting in a forward posture E. Barrel chest appearance: : ANSWER B, C, D, E
The patient with COPD often has a barrel chest appearance, is short of breath, and may use accessory muscles when breathing. These patients tend to move slowly and are slightly stooped. Usually they sit with a forward-bending posture. With severe dyspnea, they exhibit activity intolerance and activities such as bathing and grooming are avoided.
- When the patient arrives to the unit, she is assessed and is in acute respira- tory distress. Her respirations are labored and her respiratory rate is 34. She states that she had a peak flow meter measurement of "Red Zone" on the way and is severely short of air. Her oxygen saturation is 82% on O2 at 2 L via nasal cannula.
Based on these findings, what should the nurse do next?: : ANSWER The Rapid Response Team should be notified immediately. All of these
ØTemperature: 99.4° F (axillary) ØO2 saturation: 91% on 40% O2 via trach collar
Which of these findings are cause for concern?: : ANSWER **The BP is within normal range and only slightly elevated. **The temperature is only slightly elevated. **Her heart rate is elevated; the nurse should check the patient's medications to see if she is on a bronchodilator or other medication that could cause her heart rate to increase. The priority concern is the RESTLESSNESS with increased respiratory rate and the decreased oxygen saturation despite the 40% oxygen setting.
- A patient with a history of chronic obstructive pulmonary disease is admit- ted with shortness of breath. Which nursing intervention is most appropriate?
A. Do not administer oxygen. B. Administer oxygen via Venturi mask. C. Use nasal cannula to administer high flow oxygen. D. Administer oxygen at 6L per simple face mask.: : ANSWER B
Oxygen therapy is prescribed at the lowest liter flow needed to manage hypoxemia. A system that delivers more precise oxygen levels (e.g., a Venturi mask) is preferred. Monitor the patient's response to therapy closely to ensure adequate gas exchange and correction of hypoxemia.
- While suctioning a patient, vagal stimulation occurs. What is the appropriate
nursing action?
A. Instruct the patient to cough. B. Place the patient in a high Fowler's position. C. Oxygenate the patient with 100% oxygen. D. Instruct the patient to breathe slowly and deeply.: : ANSWER C
Vagal stimulation may occur during suctioning and result in severe bradycardia, hypotension, heart block, ventricular tachycardia, asystole, or other dysrhythmias. If vagal stimulation occurs, stop suctioning immediately and oxygenate the patient manually with 100% oxygen. Repositioning the patient, slow deep breathing, and coughing will not address the cardiovascular effects of vagal stimulation.
- The patient is in the ICU for 3 days and then transferred back to the pulmonary stepdown unit. She is still slightly short of breath with exertion. Her O2 saturation is 99% on oxygen at 2 L per nasal cannula. She denies any shortness of breath when resting during the assessment. The provider plans to discharge the patient on home oxygen in the morning.
What should the nurse include in this patient's discharge teaching?: : ANSWER Make sure that the patient understands any new medication regimen. She should be instructed to call 911 for any severe respiratory distress. Because she is being discharged with home oxygen, home health services should be arranged.
D. Bubbling present in the water seal chamber when the patient coughs.: : ANSWER A
After lung surgery, two tubes, anterior and posterior, are used. Dressings around the wound should not be loose. The wounds should be covered with airtight dressings.
- A home health patient with a history of asthma is having shortness of breath. The nurse discovers that the peak flowmeter indicates a peak expi- ratory flow (PEF) reading that is in the red zone. What is the priority nursing action?
A. Call 911 immediately. B. Take the patient's vital signs. C. Notify the patient's prescriber. D. Repeat the PEF reading to verify the results.: : ANSWER A A PEF reading in the red zone indicates a range that is 50% below the patient's personal best PEF reading and indicates serious respiratory obstruction requiring 911 or rapid response. Offer medications and stay with the patient. Repeating the PEF reading and taking vital signs are also important, but doing so first delays the administration of the rescue drugs and physician notification.
- The patient is assessed and a blood glucose level and vital signs are obtained upon arrival on the unit. Results are as follows: BG — 239 mg/dL BP — 138/88 mm Hg HR — 128 RR — 36 breaths/min
O2 saturation — 88% (room air) Temperature — 101.6º F
Which vital sign or test result requires the nurse's immediate attention? A. Blood pressure B. Respiratory rate C. Temperature
to enhance pulmonary toileting, and the laboratory should be notified to draw the needed blood cultures. UAP can obtain the specimen for urinalysis. The blood cultures and the UA should be obtained before the IVP Ancef is administered.
- The nurse understands that which of the following is the most common symptom of pneumonia in the older adult patient?
A. Fever B. Cough C. Confusion D. Weakness: : ANSWER C
The older adult with pneumonia often has weakness, fatigue, lethargy, confusion, and poor appetite. Fever and cough may be absent, but hypoxemia is usually present. The most common manifestation of pneumonia in the older adult patient is confusion from hypoxia rather than fever or cough.
- Which assessment finding for an older adult patient does the nurse ascribe to the natural aging process?
A. Tightening of the vocal cords B. A decrease in residual volume C. A decrease in the anteroposterior diameter D. A decrease in respiratory muscle strength: : ANSWER D
As a person ages, vocal cords become slack, changing the quality and strength of the voice; the anteroposterior diameter increases; respiratory muscle strength decreases; and the residual volume increases.
- The nurse knows that under normal physiologic conditions of tissue perfusion, a patient will have what percent of oxygen dissociate from the hemoglobin molecule?
A. 25% B. 50% C. 75% D. 100%: : ANSWER B
Oxygen dissociates with the hemoglobin molecule based on the need for oxygen to perfuse tissues. Under normal conditions, 50% of hemoglobin molecules completely dissociate their oxygen molecules when blood perfuses tissues that have an oxygen
condition. Chest pain can occur with other health problems, as well as with lung problems.
- A patient in the ED has been experiencing upper abdominal pain after meals for the past 2 months. She also notices that when she takes a nap or sleeps at night, she has pain. Eating seems to decrease pain. She has been taking OTC antacids with some relief.
Which assessment factor puts the patient at risk for peptic ulcer disease? A. Weight loss of 35 pounds B. Use of NSAIDs to control arthritis pain C. GERD 4 years ago D. Use of prednisone (Deltasone) for inflammation: : ANSWER B
Peptic ulcer development is associated primarily with NSAID use and bacterial infections with H. pylori.
- Which diagnostic results support the diagnosis of peptic ulcer disease? (Select all that apply.) A. Low hemoglobin B. Low WBC level C. Low hematocrit D. Positive for H. Pylori bacteria E. Low potassium of 3.4 mEq/L.: : ANSWER A, C, D
Low HCT and Hgb often occur related to bleeding. The presence of infection with H.
pylori is the second most common factor associated with the development of PUD. The patient would have a high, not low, WBC count. The potassium level is not a diagnostic factor for PUD.
- An EGD confirms that the patient has PUD. Three hours later, the patient is admitted to the medical unit for workup and further testing. On admission the patient reports midline epigastric tenderness and indigestion (dyspepsia). The patient is prescribed triple therapy.
Which drugs will the nurse expect to be prescribed for the patient at this time? A. Proton pump inhibitor and two antibiotics B. Histamine antagonist, antacid, and proton pump inhibitor C. Antibiotic and two proton pump inhibitors D. Antacid, proton pump inhibitor, and prostaglandin analogue: : ANSWER A
For H. pylori infections, a common drug regimen is triple therapy, which includes a
Rationale: Long-term NSAID use creates a high risk for acute gastritis. Naproxen is an NSAID that may be used to treat arthritis. Other risk factors for acute gastritis include alcohol, caffeine, and corticosteroids. IV fluids may or may not be needed to replace any fluids or blood lost from the patient's gastritis. Stool guaiac is nonspecific but may be ordered to confirm blood in the stool, and a stool sample may be used to test for the presence of Helicobacter pylori infection. However, it is not as accurate as blood or breath tests.
- What is the nursing priority in the management of a patient with an active upper GI bleed?
A. Obtain vital signs. B. Apply oxygen by nasal cannula. C. Type and crossmatch the patient for blood products. D. Notify the physician.: Answer: A
Rationale: Vital signs are needed to evaluate the severity of the patient's bleed and hypovolemic status. Oxygen will assist with delivery of oxygen to the tissues and a type and crossmatch, although important, is not the immediate priority. Assessment data such as the patient's vital signs are needed before contacting the physician.
- A patient has recently been placed on corticosteroids as treatment for ulcerative colitis.The nurse should monitor the patient's laboratory results for evidence of which condition?
A. Hypernatremia B. Hypercalcemia C. Hyperglycemia D. Hyperkalemia: Answer: C
Rationale: Long-term adverse effects that commonly occur with steroid therapy include hyperglycemia, osteoporosis, peptic ulcer disease, and increased risk for infection
- The nurse is caring for a patient with a long history of osteoarthritis. Which risk factors will the nurse teach the patient that may contribute to development of gastroesophageal reflux disease (GERD)?
A. Weight of 130 lbs B. Walks 20 minutes once daily C. Frequently takes NSAIDs for pain D. Consumes foods with calcium supplementation: : ANSWER C
: ANSWER A
The most important role of the nurse in caring for a patient with a hiatal hernia is health teaching, specifically nutrition management to include weight loss. Education for prescribed medications is an important nursing function, as well as education for signs and symptoms of infection if the patient has a rolling hiatal hernia.
- A patient in the ED has been experiencing upper abdominal pain after meals for the past several months. She reports pain after napping or sleeping at night. She has been taking OTC antacids with some relief. The nurse un- derstands that which assessment finding places the patient at risk for peptic ulcer disease?
A. GERD 4 years ago B. Weight loss of 35 lbs C. Use of NSAIDs to control arthritis pain D. Recent discontinuation of prednisone (Deltasone): : ANSWER C
Peptic ulcer development is associated primarily with nonsteroidal anti-inflammatory drug (NSAID) use and bacterial infections with Helicobacter pylori.
- Which diagnostic results does the nurse recognize that support the diag- nosis of peptic ulcer disease (PUD)? (Select all that apply.)
A. Low hemoglobin (Hgb) B. Low white blood cell (WBC) level
C. Low hematocrit (Hct) D. Positive for H. pylori bacteria E. Low potassium of 3.4 mEq/L: : ANSWER A, C, D
Low Hct and Hgb often occur related to bleeding. Presence of infection with H. pylori is the second most common factor associated with development of PUD. The patient would have a high, not low, WBC count. Potassium level is not a diagnostic factor for PUD.
- An EGD, Esophagogastroduodenoscopy. confirms that the patient has PUD. Three hours later, the patient is admitted to the medical unit for workup and further testing. On admission the patient reports midline epigastric ten- derness and indigestion (dyspepsia). The patient is prescribed triple therapy. Which drugs does the nurse prepare to administer?
A. Proton pump inhibitor (PPI) and two antibiotics
