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Exam 4
MedSurg Exam 4
| Question | Answer |
|---|---|
| Which portion of the internal nose traps particles and kills bacteria? | Mucous membrane |
| Which of the following functions of the tonsils and adenoids in small children is correct? | Protect against bacterial infections of the throat |
| A patient comes into the clinic complaining of a runny nose and facial pain. Which information should the nurse’s initial assessment include? | Assessment for nasal drainage and sinus tenderness |
| A 68-year-old patient tells the nurse that her sense of smell is not as acute as before, her nose is drier, and she occasionally gets a nosebleed. Which situation should the nurse suspect? | Normal age-related changes |
| Which symptom does age-related relaxation of the esophageal sphincter in a 70-year-old patient cause? | Burning in the throat when lying down |
| A patient with sleep apnea says, “I’m not wearing that silly mask. I look like something out of Star Wars.” Which information should the nurse remind the patient about regarding the function of the mask? | Uses positive pressure to keep the airway open |
| Which information should patient education for a patient being given nose drops for the first time include? | Tipping the head back and holding the dropper over the nostril and then telling the patient to keep her head back for a few minutes |
| A patient comes into the clinic complaining of waking up with a dry mouth and nose and asks if the dryness has caused the colds she has had in the past few months. Which suggestion is most appropriate the nurse to suggest? | Use a humidifier at home. |
| Which assessment should indicate the necessity for a nurse to suction a patient with a tracheostomy? | Becomes restless and has increases in vital signs |
| Which position is the most appropriate for a patient returning from surgery with a nasal pack and mustache dressing? | High Fowler position and apply a cold dressing to reduce swelling |
| Which intervention should a nurse implement when providing tracheostomy care? | Use a sterile solution of normal saline or other solution to wash the inner cannula and then rinse with sterile water. |
| A nurse assesses wheezes in a patient with asthma. Which process should the nurse know is the cause of wheezes? | Movement of air through narrowed airways |
| The patient has had anterior nasal packing placed for severe epistaxis. The nurse notes that he is swallowing frequently. Which assessment should a nurse suspect? | The patient is bleeding. |
| Which sequence indicates how air goes from the nose to the lung? | Pharynx, trachea, bronchi, alveoli |
| A nurse charts that a patient has had periods of tachypnea during the night. Which assessment is true in regard to the respiration rate? | Above 20 breaths/min |
| A 90-year-old patient complains to the nurse of shortness of breath after walking up a flight of stairs. Which age-related change should the nurse explain results in this problem? | Enlarged bronchioles |
| Which personal data should the nurse exclude when documenting the findings in the functional assessment portion of the nursing assessment for a patient with a respiratory disorder? | Previous respiratory disorders |
| Which intercostal space is used to auscultate breath sounds in the right middle lobe from the anterior aspect? | Fifth |
| Which assessment should the nurse suspect regarding the bronchus when auscultating coarse crackles in the lower right lobe? | Partially filled with fluid |
| Which advantage of a fluoroscopy would the nurse explain when a worried patient enquires about their ordered procedure? | Shows respiratory function in motion |
| Which nursing intervention is inappropriate in the immediate post-procedure care of a patient who has had a fiberoptic bronchoscopy? | Offer fluids to assess swallowing ability. |
| Which rationale explains the importance of the nurse closely monitoring bilateral breath sounds and chest movement after a thoracentesis? | The lung may have been punctured during the procedure. |
| Which nursing assessment indicates a positive reading of a tuberculin (TB) skin test? | 2 days after injection with a 5-mm area of redness and swelling and swelling |
| A nurse performs an Allen test before performing the arterial stick for an arterial blood gas. Which information explains what this test assesses? | Perfusion of the hand |
| A patient who is severely dyspneic and cyanotic enters the emergency department. At which rate should a nurse administer oxygen to the patient? | 2 L to preserve the hypoxic drive |
| Which assessment indicates to the nurse that the chest tube in a water seal drainage device is working correctly? | Fluctuation of the column of water in the water seal |
| Which assessment by the nurse at the bedside of a patient with a chest tube attached to a water seal drainage device should require intervention? | Dependent loops in the chest tube |
| A home health nurse who is caring for an 88-year-old patient with severe hypertension in addition to a respiratory problem notices several drugs on the bedside table. Which medication should the nurse suggest the patient avoid? | Decongestant |
| In which position should a nurse place a patient who had a left pneumonectomy in an effort to enhance gas exchange? | In a semi-Fowler position |
| Which position should the nurse assist a patient to maintain during a thoracentesis? | Sitting on the side of the bed bent over bedside table |
| Which purpose describes how the ventilator function of positive end-expiratory pressure assists the patient? | Keeps pressure in the lungs after expiration |
| The patient has had anterior nasal packing placed for severe epistaxis. The nurse notes that he is swallowing frequently. Which assessment should a nurse suspect? | The patient is bleeding. |
| Which actions should be included in the postoperative care of a patient who has had nasal surgery? (Select all that apply.) | Placing the patient in a semi-Fowler position without a pillow Giving frequent oral hygiene Providing humidification for dry mucous membranes Assessing the back of the throat for bleeding |
| Which information correctly explains that the breathing pattern has been altered when a patient complains of tachypnea? (Select all that apply.) | Decreased oxygen level signals the phrenic nerve to alter the respiration rate. Muscles of respiration respond to the stimulus. |
| Which assessment findings would indicate respiratory dysfunction when examining a patient with respiratory difficulty? (Select all that apply.) | Cyanotic nail beds Abdominal distention |
| Which instructions should a nurse provide to a patient just before a scheduled spirometry test? (Select all that apply.) | Avoid smoking 4 to 6 hours before test. Do not use bronchodilator medications for at least 4 hours. |
| A patient complains of morning headaches, a feeling of fullness in her head, and a pain similar to that of a toothache under her eye. Which diagnosis t should the nurse recognize that these symptoms indicate? | Sinusitis |
| Which response is the best when a patient complains that they want an antibiotic medication for their cold? | “Antibiotics are not effective with viral infections.” |
| Which initial action of a nurse should be implemented when providing first aid to a person with spontaneous epistaxis? | Have the person sit down and lean forward. |
| Which statement is true regarding bacterial pharyngitis that is untrue for viral pharyngitis? | Has an abrupt onset |
| Which patient is the best candidate for a tonsillectomy? | A 23-year-old patient with a peritonsillar abscess |
| Which item is best for a nurse to offer when encouraging a new patient after a tonsillectomy to increase fluids? | Flavored popsicles to suck |
| Which are the most common causes of laryngitis? | Respiratory infections and voice strain |
| Which is the most significant topic for a nurse to include in a teaching plan for a patient with frequent episodes of laryngitis? | Observing voice rest |
| A patient who has cancer of the larynx has been told that he needs a total laryngectomy. Which action should this nurse consider to help the patient cope with the loss of his voice? | Offer to have a volunteer from a local laryngectomy organization visit the patient. |
| Which nursing concern takes priority in the care of a patient after a laryngectomy? | Establishing a communication system |
| A patient who had a laryngectomy 3 months earlier returns to the physician’s office with the complaint of increasing dyspnea. Which common post-laryngectomy complication should the nurse recognize this complaint as indicating? | Tracheal stenosis |
| Which is one major postoperative difficulty for a patient having a supraglottic laryngectomy? | Teaching the patient to swallow without aspiration |
| Which actions should the nurse include in a care plan to effectively assist the patient with a total laryngectomy to maintain airway clearance? (Select all that apply.) | Turning, coughing, and deep breathing Placing the patient in a semi-Fowler position Maintaining hydration Attaching a tracheostomy collar |
| A nurse is caring for a patient with asthma and assesses signs and symptoms of inadequate oxygenation. Which intervention is the most appropriate? | Increase fluid intake. |
| What is a characteristic of chronic obstructive pulmonary disease that places a patient at risk for poor nutrition? | Excessive respiratory effort |
| Which nursing intervention enhances the nutritional status of a patient with COPD? | Offer small, frequent meals. |
| Which walking program would be the most effective for the nurse to recommend as part of a progressive walking program for an obese patient with COPD? | 10 to 15 minutes a day |
| What is the result of status asthmaticus that is not corrected? | Pneumothorax, severe hypoxemia, and respiratory arrest |
| What should a nurse focus on when assessing for major sources of infection in a patient with COPD? | Stasis of respiratory secretions |
| A young patient with acquired immunodeficiency syndrome (AIDS) reports debilitating night sweats. Why should the home health nurse suggest that the patient visit the clinic? | Tuberculosis (TB) screening |
| A nurse is caring for an 80-year-old patient with COPD and suspects right-sided heart failure after assessing and recording the data. What should decrease with right-sided heart failure? | Urine output |
| A patient with TB asks the nurse how long he will have to take his TB medications. What is the nurse’s best response? | “Depending on the drug, it may be as long as 2 years .” |
| A patient with TB asks how to protect family members from the disease. Which discharge instruction given by the nurse is most informative? | “You should always cover your mouth and nose if coughing or sneezing.” |
| A nurse is providing education to a patient taking rifampin as a result of an exposure to TB. What side effect of this drug should the nurse include? | Body fluids to become red-orange |
| A patient with asthma asks the purpose of learning how to use a peak expiratory flow rate (PEFR) device. What is the nurse’s best response regarding PEFR? | Measures expired air to evaluate ventilation |
| A nurse is assigned to care for a patient with the diagnosis of centriacinar (centrilobar) emphysema. What is a characteristic of this type of emphysema? | Enlarged and broken down bronchioles with intact alveoli |
| A 25-year-old patient with cystic fibrosis (CF) tells the home health nurse that he wants to take a nice vacation. What is the best suggestion for the nurse to make? | New York in November |
| Which assessment made by a nurse indicates that respiratory arrest is imminent in a patient with asthma? | Absence of wheezing |
| A patient with COPD is observed to have extreme shortness of breath when ambulating. Which nursing intervention is most inappropriate? | Bunch all nursing activities and treatments close together. |
| A nurse recognizes that a patient diagnosed with COPD has a rising level of partial pressure of carbon dioxide (CO2) in arterial blood (PaCO2). How should the nurse interpret this assessment? | Respiratory acidosis has begun. |
| Which early characteristic in a patient with emphysema gives rise to the term pink puffer? | Normal arterial blood gases (ABGs) |
| A patient with COPD asks a nurse if nicotine patches are very effective for smoking cessation. What is the best response by the nurse? | “No. Only about 25% are successful.” |
| A patient with cystic fibrosis (CF) furiously refuses any more manual chest physiotherapeutic treatment. Which alternative is appropriate for the nurse to suggest? | Flutter mucus device |
| What should a nurse expect when assessing the CBC results of a patient with chronic bronchitis? | Increased red blood cells (RBCs) |
| A patient with COPD delightedly tells the nurse that he has quit smoking and is using chewing tobacco. What is the most appropriate nursing intervention? | Warn him of the dangers of oral cancer. |
| A newly diagnosed patient with non–small cell lung carcinoma (NSCLC) is anxious about upcoming surgery. Which intervention by the nurse would be most helpful? | Support the patient in preparation for surgery. |
| A nurse documents and reports the presence of foul, bulky stool in a patient with cystic fibrosis (CF). What does this finding indicate about the patient? | Is not adequately digesting food |
| What should a patient who had the BCG (Bacillus Calmette-Guérin) vaccine 2 years ago anticipate? | False-positive result from TB skin tests |
| What nursing action should be implemented to help combat anorexia in a patient with COPD? | Perform oral hygiene before meals. |
| A nurse explains to a family how the asthma attack progresses by using a progressive list of pathologic events. (Place the options in the correct sequence. Do not separate answers with a space or punctuation. Example: ABCD.) | Triggering of inflammatory process, bronchoconstriction, production of mucous plugs, ventilation-perfusion mismatch, hypoxemia with compensatory hyperventilation |
| A nurse uses a picture to demonstrate the bullae and blebs associated with emphysema. How do blebs differ from bullae? (Select all that apply.) | They are in the lung parenchyma. They can rupture, causing the lungs to collapse. |
| What signs and symptoms are characteristic of a patient with chronic blue bloater bronchitis? (Select all that apply.) | Productive cough Peripheral edema Exertional dyspnea Elevated red blood cell count |
| A nurse is preparing to give a tube feeding using a large syringe. Which action should the nurse implement before starting the infusion? | Check for a residual formula and return the residual to his or her stomach. |
| After receiving a tube feeding, a nurse assesses the patient to be sweaty with abdominal distention and diarrhea. Which situation is the most likely cause of this response? | Dumping syndrome |
| A nurse administers promethazine (Phenergan) for nausea. Which extra precautionary action should the nurse implement because of the common side effect of antiemetic medications? | Put up side rails to prevent falls. |
| A patient complains about the placement of the total parenteral nutrition (TPN) line and asks why it cannot be inserted in the arm. Which fact regarding the placement of this line should the nurse base a response on? | Subclavian artery allows for rapid dilution. |
| A patient inquires if this newer type of gastric analysis is going to require passage of a nasogastric tube. Which reply by the nurse is the most accurate? | “No. You take a dye orally, which will be excreted in the urine in approximately 2 hours.” |
| A nurse is caring for a patient receiving total parenteral nutrition (TPN). Which nursing action is most appropriate to implement? | Monitor the temperature for elevation. |
| Which patient assessment indicates hyperglycemia with TPN feeding? | Increase of urine output |
| The TPN feeding is running at 20 mL and is 1 hour behind schedule. Which is the most appropriate initial nursing intervention? | Document the event and inform the charge nurse. |
| Which endoscopic procedure for examining the small intestine is the most current? | Capsule camera |
| A nurse has collected several stool specimens for ova and parasites that are to be sent to the laboratory. Which action is most appropriate for the nurse to implement? | Immediately take the specimens to the laboratory to be tested for parasites and ova. |
| Stool softeners are prescribed to promote normal elimination of feces. Which is the most appropriate way to ensure the effectiveness of this type of drug? | Adequate fluid intake |
| Which set of findings best indicates that a patient with intestinal obstruction has achieved normal hydration? | Pulse and blood pressure are within the patient’s norms, mucous membranes are moist, and fluid intake and output are equal. |
| After abdominal surgery, a patient must cough and take deep breaths. Which action explains how the nurse can best achieve this with this patient? | Help the patient splint the incision with a pillow. |
| A patient is being seen for the first time at a physician’s office. When assisting with the assessment, a nurse notices abdominal striae. Which alternative term should the nurse use when the patient asks what it is all over her abdomen? | Stretch marks |
| Which information about when and where specific digestion of food takes place should be included in a patient teaching plan? (Select all that apply.) | Renin breaks down milk protein in the stomach. Lipase breaks down fats in the stomach. Pepsin begins to break down proteins in the stomach. Liver and pancreatic secretions break down fats in the small bowel. |
| A nurse is assessing a patient for risk factors that increase the chances of developing oral cancer. Which information from this patient’s history indicates a risk factor? | Alcohol consumption |
| A home health nurse observes a patient with esophageal cancer tilt his head back while eating. Which complication might this cause? | Increased risk of aspiration |
| A nurse is caring for a patient with esophageal surgery who has had stents placed in the esophagus and instructs the patient how best to avoid regurgitation. Which information should the nurse include in this instruction? | Eat only small meals. |
| A nurse is constructing a teaching plan for a patient with a hiatal hernia. Which information should be included in this plan to help reduce the complaints of heartburn, regurgitation, and eructation? | Eating nothing for several hours before bedtime |
| A 60-year-old patient who has just been diagnosed with cancer of the stomach says, “I feel blank and numb.” Which response by the nurse is the best? | “What do you mean when you say ‘blank and numb’?” |
| A goal for a patient with gastritis who has experienced nausea, vomiting, and diarrhea is to have a return of normal elimination patterns. Which statement best reflects this goal in a measurable manner? | The patient’s bowel pattern will return to normal. |
| A nurse is caring for a patient hemorrhaging from a peptic ulcer when the patient complains of a sharp sudden pain and has a rapidly deteriorating condition. Which action is the best first action of the nurse? | Roll the patient flat and assess the vital signs. |
| A long-term care nurse is assisting a well-nourished, 80-year-old resident with the diagnosis of esophageal cancer on methods to deal with dysphagia. Which nursing intervention will best help to improve the resident’s condition? | Instruct the patient to tilt his or her head slightly forward. |
| A home health nurse is assigned to follow-up on a patient recently diagnosed with gastroesophageal reflux disease (GERD). Which primary symptom should the nurse take into consideration when updating the nursing interventions on this patient’s care plan? | Heartburn |
| A patient experiencing nausea reports to the nurse that she adds ginger root to her morning tea to calm her stomach. Which classification of medication in the patient history alerts the nurse to provide further education? | Anticoagulants |
| A patient is diagnosed with Vincent infection. What treatment should the nurse anticipate being prescribed for this patient? | Mouthwash rinse |
| When assessing the tongue of patient in the outpatient clinic, a nurse observes bluish-white lesions on the mucous membranes, the nurse notes long-term antibiotic therapy for chronic prostatitis. Which diagnosis should the nurse suspect? | Thrush |
| When assisting with the admission of a new resident to a long-term care facility, a nurse notes a current history of peptic ulcer disease. Which type of pain should the nurse expect the resident to describe? | Burning |
| A nurse is caring for a patient with achalasia. Which nursing actions should be implemented to help the patient reduce swallowing difficulty? (Select all that apply.) | Identify foods that cause the problem. Experiment with different eating positions. Elevate the head of the bed at night. |
| Which instruction given to a patient with irritable bowel syndrome (IBS) should lessen discomfort? | Take small bites and chew well. |
| A nurse is caring for a 34-year-old patient admitted with severe diarrhea that has been going on for 2 weeks. Which assessment should the nurse anticipate? | Hypotension and fatigue |
| A nurse describes a patient as morbidly obese because the patient has a weight of 387 lb and a height of 2 meters. Which number correctly indicates the patient’s body mass index (BMI)? | 43.9 |
| Which statement by a patient with an ileostomy as a remedy for ulcerative colitis indicates the need for further teaching? | “I will be glad when the surgeon closes this ileostomy.” |
| A nurse identifies a risk factor in an older man that places him at risk for developing diverticulosis. Which patient information indicates such a risk factor? | Eats a low-fiber diet |
| Which foods should an individual with diverticulosis avoid? | Peanuts and raspberries |
| Colonoscopy results indicate the diagnosis of irritable bowel disease (IBD) in a patient admitted to the hospital with diarrhea. Which information should the nurse include when preparing patient education regarding diet? | Low roughage should be followed. |
| A nurse is caring for a patient diagnosed with diverticulosis and assesses a temperature of 102.4 F and abdominal rigidity. Which problem should the nurse be aware is the most likely cause of these signs and symptoms? | Perforation |
| A patient is diagnosed with cancer of the large intestine. Which action is the most likely initial recommended medical intervention? | Surgery |
| A nurse is performing an assessment of a patient after an abdominoperineal resection. Which number correctly indicates how many incision sites will be present? | Three |
| A patient reports severe pain after an abdominoperineal resection. Which position should the nurse assist this patient into in order to promote comfort? | Side-lying |
| A nurse provides education to a patient after a hemorrhoidectomy. Which statement by the patient demonstrates the need for further instruction? | “Fluids are restricted.” |
| A nurse notes a diagnosis of pilonidal cyst on a patient’s admission assessment. Which anatomical location should the nurse expect to assess this cyst? | Sacrococcygeal area |
| A home health nurse is instructing an older adult patient regarding dietary changes to help prevent constipation. Which changes should the nurse indicate when providing this education? (Select all that apply.) | Addition of whole-grain cereal Cessation of laxative use Increase in liquid intake Eating fresh vegetables |
| Which complication should a nurse be careful to monitor for in a patient after a liver biopsy? | Bleeding |
| Which factor causes pruritus in the patient diagnosed with hepatitis? | Accumulation of bile salts under the skin |
| A young woman with severe jaundice has an altered body image. The patient says, “Will I always be this horrible color?” Which response by the nurse is best? | “No. The color will fade gradually as liver inflammation decreases.” |
| What action should a nurse implement to prevent complications in a patient with hepatitis who has been prescribed bed rest? | Encourage turning, coughing, and deep breathing every 2 hours. |
| Which sign indicates that the need for increased fluid intake would be contraindicated in a patient diagnosed with a hepatic disorder? | Signs of edema |
| Which intervention should a nurse implement when assessing a patient with jaundice who has been given the nursing diagnosis of disrupted skin integrity? | Apply mittens or socks to the hands. |
| Which vaccination does the Occupational Health and Safety Administration (OSHA) require all health care providers to receive? | Hepatitis B |
| Which statement defines the meaning of a dropping bilirubin level in a patient diagnosed with hepatitis? | Liver function is improving. |
| A goal of medical treatment for patients with cirrhosis is to prevent complications and limit cell damage. A major approach is to promote rest. Which rationale supports this approach? | Allows the liver to regenerate |
| Which nutritional component is necessary to restrict when the ammonia level of a patient diagnosed with cirrhosis continues to rise? | Protein |
| Which actions should a nurse implement to correctly assess the progress of ascites on a daily basis? | Daily weights and abdominal girth measurements |
| A patient with ascites is scheduled for a LeVeen peritoneal-venous shunt. The patient asks why this needs to be done instead of a paracentesis. Which nursing response is the best ? | “This procedure will prevent the loss of protein.” |
| A high ammonia level contributes to hepatic encephalopathy. Which nursing implementation needs to be added to the nursing care plan as this level continues to increase? | Increased frequency of neurologic checks |
| A nurse is educating a patient diagnosed with hepatitis A. Which item should the nurse instruct this patient to avoid sharing? | Food |
| Which dietary selection should lead the nurse to conclude that the dietary teaching is successful for a patient on a low-sodium diet? | Baked chicken, white rice, and apple juice |
| Which nursing measure takes priority in relation to the care of a patient with a gastroesophageal balloon tube? | Monitor respiratory status. |
| Which instruction should be given to a patient with portal hypertension to reduce the threat of hemorrhage? | Avoid straining to have a bowel movement. |
| Which precaution should a nurse initiate when caring for a patient with hepatitis B? | Standard Precautions |
| A patient was positive for hepatitis B virus, although she had the disease 4 years ago and now is symptom free. Which information is the nurse aware is true regarding this patient? | Is an infectious carrier and always will be |
| A nurse is providing information on the medication Pancrease (lipase, protease, amylase) to a patient diagnosed with pancreatitis .which important instruction should the nurse be sure to include? | Mixed with juice |
| A patient in acute pain is admitted with pancreatitis. A nurse reviews a laboratory report showing an elevation that is diagnostic for acute pancreatitis. Which laboratory report did the nurse most likely review? | Serum amylase |
| Which goal is the highest nursing priority outcome when planning the care for the patient with pancreatitis? | Patient claims satisfaction with pain control. |
| Which information should a nurse often find in the medical history of a patient diagnosed with pancreatic disease? | Alcohol abuse |
| Which observation by a nurse would indicate blocked flow of bile from the liver to the intestine? | Clay-colored stools |
| Which chronic condition is related to the presence of chronic pancreatitis? | Diabetes mellitus (DM) |
| Which risk is significantly increased in patients diagnosed with liver disease? | Drug toxicity |
| Which information should a nurse include in the discharge teaching for a patient after a laparoscopic procedure for cholelithiasis? | Follow a low-fat diet. |
| Which drugs and herbal remedies are considered harmful to the liver? (Select all that apply.) | Comfrey (herbal remedy) Acetaminophen (Tylenol) |
Created by:
DrFeelgood
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