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MEDSURG Final Practice

Which nursing action should the nurse take first to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes?

Collect a detailed diet history.

Provide a list of low-sodium foods.

Help the patient make an appointment with a dietitian.

Teach the patient about foods that are high in potassium.

A patient has just been diagnosed with hypertension and has been started on captopril. Which information is most important to include when teaching the patient about this drug?

Include high-potassium foods such as bananas in the diet.

Increase fluid intake if dryness of the mouth is a problem.

Change position slowly to help prevent dizziness and falls.

Check blood pressure (BP) in both arms before taking the drug.

Which information is most important for the nurse to include when teaching a patient with newly diagnosed hypertension?

Most people are able to control BP through dietary changes.

Annual BP checks are needed to monitor treatment effectiveness.

Hypertension is usually asymptomatic until target organ damage occurs.

Increasing physical activity alone controls blood pressure (BP) for most people.

Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a 48-yr-old patient with newly diagnosed hypertension?

98/56 mm Hg

128/76 mm Hg

128/92 mm Hg

142/78 mm Hg

After reviewing information shown in the accompanying figure from the medical records of a 43-yr-old patient, which risk factor modification for coronary artery disease should the nurse include in patient teaching?

Importance of daily physical activity

Effect of weight loss on blood pressure

Dietary changes to improve lipid levels

Cardiac risk associated with previous tobacco use

A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is appropriate when scheduling this medication?

Administer the medication at the patient’s usual bedtime.

Have the patient take the colesevelam 1 hour before breakfast.

Give the patient’s other medications 2 hours after colesevelam.

Have the patient take the dose at the same time as the prescribed aspirin.

Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain?

Inverted P wave

Sinus tachycardia

ST-segment elevation

First-degree atrioventricular block

Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor for

Decreased blood pressure and heart rate.

Fewer complaints of having cold hands and feet.

Improvement in the strength of the distal pulses.

Participation in daily activities without chest pain.

A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of daily medications to the nurse. Which medication has the most immediate implications for the patient’s care?

Captopril

Sildenafil (Viagra)

Furosemide (Lasix)

Warfarin (Coumadin)

After an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse evaluates the patient’s response to the activity, which data would indicate that the exercise level should be decreased?

O2 saturation drops from 99% to 95%.

Heart rate increases from 66 to 98 beats/min.

Respiratory rate goes from 14 to 20 breaths/min.

Blood pressure (BP) changes from 118/60 to 126/68 mm Hg.

The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider?

The troponin level is elevated.

The patient denies having a heart attack.

Bilateral crackles in the mid-lower lobes.

Occasional premature atrial contractions (PACs).

The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain is caused by an acute myocardial infarction (AMI)?

The pain increases with deep breathing.

The pain has lasted longer than 30 minutes.

The pain is relieved after the patient takes nitroglycerin.

The pain is reproducible when the patient raises the arms.

A patient admitted with acute dyspnea is newly diagnosed with dilated cardiomyopathy. Which information will the nurse plan to teach the patient about managing this disorder?

A heart transplant should be scheduled as soon as possible.

Elevating the legs above the heart will help relieve dyspnea.

Careful compliance with diet and medications will prevent heart failure.

Notify the health care provider about symptoms such as shortness of breath.

Which assessment finding in a patient who is admitted with infective endocarditis (IE) is most important to communicate to the health care provider?

Generalized muscle aching

Sudden onset right flank pain

Janeway’s lesions on the palms

Temperature 100.7°F (38.1°C)

The nurse is admitting a patient with possible rheumatic fever. Which question on the admission health history focuses on a pertinent risk factor for rheumatic fever?

�Do you use any illegal IV drugs?”

�Have you had a recent sore throat?”

�Have you injured your chest in the last few weeks?”

�Do you have a family history of congenital heart disease?”

The nurse obtains a health history from an older patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most focused on identifying a risk factor for IE?

�Do you have a history of a heart attack?”

�Is there a family history of endocarditis?”

�Have you had any recent immunizations?”

�Have you had dental work done recently?”

During discharge teaching with an older patient who had a mitral valve replacement with a mechanical valve, the nurse must instruct the patient on the

Use of daily aspirin for anticoagulation.

Correct method for taking the radial pulse.

Need for frequent laboratory blood testing.

Need to avoid any physical activity for 1 month.

While caring for a 23-yr-old patient with mitral valve prolapse (MVP) without valvular regurgitation, the nurse determines that discharge teaching has been effective when the patient states that it will be necessary to

Take antibiotics before any dental appointments.

Limit physical activity to avoid stressing the heart.

Avoid over-the-counter (OTC) drugs that contain stimulants.

Take an aspirin a day to prevent clots from forming on the valve.

A patient with newly diagnosed lung cancer tells the nurse, “I don’t think I’m going to live to see my next birthday.” Which is the best initial response by the nurse?

�Are you ready to talk with your family members about dying now?”

�Would you like to talk to the hospital chaplain about your feelings?”

�Can you tell me what it is that makes you think you will die so soon?”

�Do you think that taking an antidepressant medication would be helpful?”

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect?

Increased tactile fremitus

Dry, nonproductive cough

Hyperresonance to percussion

grating sound on auscultation

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions?

�I will call my health care provider if I still feel tired after a week.”

�I will continue to do deep breathing and coughing exercises at home.”

�I will schedule two appointments for the pneumonia and influenza vaccines.”

�I will cancel my follow-up chest x-ray appointment if I feel better next week.”

A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the priority?

Hyperthermia related to infectious illness

Impaired transfer ability related to weakness

Ineffective airway clearance related to thick secretions

Impaired gas exchange related to respiratory congestion

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective?

�I am going to buy a rib binder to wear during the day.”

�I can take shallow breaths to prevent my chest from hurting.”

�I should plan on taking the pain pills only at bedtime so I can sleep.”

�I will use the incentive spirometer every hour or two during the day.”

A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?

Paradoxical chest movement

Complaint of chest wall pain

Heart rate of 110 beats/minute

Large bruised area on the chest

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient’s illness?

Ask the patient about any visual changes in red-green color discrimination.

Question the patient about experiencing shortness of breath, hives, or itching.

Explain that orange discolored urine and tears are normal while taking this medication.

Advise the patient to stop the drug and report the symptoms to the health care provider.

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?

�I will take the bus instead of driving.”

�I will stay indoors whenever possible.”

�My spouse will sleep in another room.”

�I will keep the windows closed at home.”

Which assessment information will be most important for the nurse to report to the health care provider about a patient with acute cholecystitis?

The patient’s urine is bright yellow.

The patient’s stools are tan colored.

The patient has increased pain after eating.

The patient complains of chronic heartburn.

A patient had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to

Perform leg exercises hourly while awake.

Ambulate the evening of the operative day.

Turn, cough, and deep breathe every 2 hours.

Choose preferred low-fat foods from the menu.

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis?

Nausea and vomiting

Hypotonic bowel sounds

Muscle twitching and finger numbness

Upper abdominal tenderness and guarding

Which assessment finding is of most concern for a patient with acute pancreatitis?

Absent bowel sounds

Abdominal tenderness

Left upper quadrant pain

Palpable abdominal mass

A patient with acute pancreatitis is NPO and has a nasogastric (NG) tube to suction. Which information obtained by the nurse indicates that these therapies have been effective?

Bowel sounds are present.

Grey Turner sign resolves.

Electrolyte levels are normal.

Abdominal pain is decreased.

The nurse is caring for a patient with pancreatic cancer. Which nursing action is the highest priority?

Offer psychologic support for depression.

Offer high-calorie, high-protein dietary choices.

Administer prescribed opioids to relieve pain as needed.

Teach about the need to avoid scratching any pruritic areas.

A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take?

Withhold both drugs.

Administer both drugs

Administer the furosemide.

Administer the spironolactone.

For a patient with cirrhosis, which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)?

Assessing the patient for jaundice

Providing oral hygiene after a meal

Palpating the abdomen for distention

Teaching the patient the prescribed diet

The son of a dying patient tells the nurse, “Mother doesn’t really respond any more when I visit. I don’t think she knows that I am here.” Which response by the nurse is appropriate?

�Cut back your visits for now to avoid overtiring your mother.”

�Withdrawal can be a normal response in the process of dying.”

�Most dying patients don’t know what is going on around them.”

�It is important to stimulate your mother so she can’t retreat from you.”

The nurse is caring for an adolescent patient who is dying. The patient’s parents are interested in organ donation and ask the nurse how the health care providers determine brain death. Which response by the nurse accurately describes brain death determination?

�If CPR does not restore a heartbeat, the brain cannot function.”

�Brain death has occurred if there is not any breathing or brainstem reflexes.”

�Brain death has occurred if a person has flaccid muscles and does not awaken.”

�If respiratory efforts cease and no apical pulse is audible, brain death is present.”

After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been most effective?

The patient avoids eating nuts or nut butters.

The patient restricts intake of chicken and fish.

The patient drinks low-fat milk with each meal.

The patient has two cups of coffee in the morning.

Which action should the nurse take when giving the initial dose of oral labetalol to a patient with hypertension?

Encourage the use of hard candy to prevent dry mouth.

Teach the patient that headaches often occur with this drug.

Instruct the patient to call for help if heart palpitations occur.

Ask the patient to request assistance before getting out of bed.

The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?

48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain

52-yr-old with a blood pressure of 198/90 mm Hg who has intermittent claudication

50-yr-old with a blood pressure of 190/104 mm Hg who has a creatinine of 1.7 mg/dL

43-yr-old with a blood pressure of 172/98 mm Hg whose urine shows microalbuminuria

A patient who has recently started taking pravastatin (Pravachol) and niacin reports several symptoms to the nurse. Which information is most important to communicate to the health care provider?

Generalized muscle aches and pains

Dizziness with rapid position changes

Nausea when taking the drugs before meals

Flushing and pruritus after taking the drugs

After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective?

�I can expect nausea as a side effect of nitroglycerin.”

�I should only take nitroglycerin when I have chest pain.”

�Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart.”

�I will call an ambulance if I still have pain after taking three nitroglycerin 5 minutes apart.”

The nurse is obtaining a health history from a 24-yr-old patient with hypertrophic cardiomyopathy (CMP). Which information obtained by the nurse is most important?

The patient has a history of a recent upper respiratory infection.

The patient has a family history of coronary artery disease (CAD).

The patient reports using cocaine a “couple of times” as a teenager.

The patient’s 29-yr-old brother died from a sudden cardiac arrest.

The nurse will plan discharge teaching about prophylactic antibiotics before dental procedures for which patient?

Patient admitted with a large acute myocardial infarction

Patient being discharged after an exacerbation of heart failure

Patient who had a mitral valve replacement with a mechanical valve

Patient being treated for rheumatic fever after a streptococcal infection

A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. The patient reports that discomfort in the joints prevents favorite activities such as taking a daily walk and working on sewing projects. Based on these findings, which nursing diagnosis statement would be appropriate?

Activity intolerance related to arthralgia

Anxiety related to permanent joint fixation

Altered body image related to polyarthritis

Social isolation related to pain and swelling

Which action by the nurse will determine if the therapies ordered for a patient with chronic constrictive pericarditis are most effective?

Assess for the presence of a paradoxical pulse.

Monitor for changes in the patient’s sedimentation rate.

Assess for the presence of jugular venous distention (JVD).

Check the electrocardiogram (ECG) for ST segment changes.

A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take?

Keep the head of the patient’s bed positioned flat.

Cover the wound tightly with an occlusive dressing.

Position the patient so that the left chest is dependent.

Tape a nonporous dressing on three sides over the wound.

The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse?

The patient is offered a tissue from the box at the bedside.

A surgical face mask is applied before visiting the patient.

A snack is brought to the patient from the unit refrigerator.

Hand washing is performed before entering the patient’s room.

The nurse recognizes that teaching a patient following a laparoscopic cholecystectomy has been effective when the patient makes which statement?

�I can expect yellow-green drainage from the incision for a few days.”

�I can remove the bandages on my incisions tomorrow and take a shower.”

�I should plan to limit my activities and not return to work for 4 to 6 weeks.”

�I will need to maintain a low-fat diet for life because I no longer have a gallbladder.”

Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a patient who has acute pancreatitis?

Calcium

Bilirubin

Amylase

Potassium

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