Detailed Answer Key
Med Surg Final Retake
1. A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? .
2. A nurse is c...
a nurse is caring for a client who has heart failure and has been taking digoxin 025 mg daily the client refuses breakfast and reports nausea which of the following actions should the nurse take
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Northampton County Area Community College
NURSING 105-02 (NURSING10502)
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Detailed Answer Key
Med Surg Final Retake
1. A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses
breakfast and reports nausea. Which of the following actions should the nurse take first? .
A. Suggest that the client rests before eating the meal.
Rationale: The nurse should encourage frequent rest periods for the client who has heart failure, as
dyspnea and fluid overload increases the workload to consume adequate nutrition; however,
another action is the priority.
B. Request a dietary consult.
Rationale: The nurse should consider obtaining a dietary consult for the client who has heart failure to
provide nutritional evaluation and counseling; however, another action is the priority.
(ft- C. Check the client's vital signs.
Rationale: When using the airway, breathing, circulation approach to client care, the nurse should place the
priority on obtaining vital signs. Nausea is a manifestation ofdigoxin toxicity, along with other
manifestations such as muscle weakness, confusion, abdominal cramping, and changes in
vision. .
D. Request an order for an antiemetic.
Rationale: The nurse should request antiemetics for the client who is experiencing nausea in order to
maintain client comfort and nutritional intake; however, another action is the priority.
2. A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction.
The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the
following effects?
A. To provide analgesia
Rationale: Although aspirin is used to provide analgesia for mild to moderate pain, the nurse should
recognize that it is prescribed to this client for a different therapeutic effect.
B. To reduce inflammation
Rationale: Although aspirin is used to reduce inflammation for illnesses such as osteoarthritis, the nurse
should recognize that it is prescribed to this client for a different therapeutic effect.
• c. To prevent blood clotting
Rationale: Aspirin is used to prevent clot formation by reducing platelet aggregation. Therefore, the nurse
should instruct the client the aspirin is prescribed for clients who have coronary artery disease to
prevent myocardial infarction caused by clots in the coronary arteries.
D. To prevent fever
Rationale: Although aspirin is used as an antipyretic agent for adult clients, the nurse should recogriize that
it is prescribed to this client for a different therapeutic effect. Aspirin should not be used to treat
fever for client suspected to have meningitis.
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3. A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which
of the following manifestations?
.'@- A. Hypotension
Rationale: The client who has diabetes insipidus produces excessive urine resulting in hypovolemia and
hypotension. The nurse should monitor the client for hypotension and dehydration.
B. Polyphagia
Rationale: Polyphagia, or excessive hunger, is a manifestation of diabetes mellitus.
C. Hyperglycemia
Rationale: Hyperglycemia, or elevated blood glucose, is a manifestation of diabetes mellitus.
D. Bradycardia
Rationale: Tachycardia is a manifestation of diabetes insipidus.
4. A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that
which of the following statements by the client indicates a need for further teaching?
A. "I will avoid crossing my legs at the knees."
Rationale: The nurse should reinforce with the client to avoid crossing her legs at the knees because this
can impair circulation.
B. "I will use a thermometer to checkthe temperature of my bath water."
Rationale: The nurse should reinforce with the client to use a thermometer to check the temperature of bath
water to reduce the risk of burns. PVD can impair the client's ability to sense water temperature.
C. "I will not go barefoot."
Rationale: The nurse should reinforce with the client to wear shoes at all times to protect her feet from
injury.
@- D. "I will wear stockings with elastic tops."
Rationale: The nurse should reinforce with the client to avoid constrictive clothing that can impair
circulation.
5. A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis (DVT) of the left leg.
Which of the following interventions should the nurse include in the plan?
A. Apply ice to the extremity
Rationale: The nurse should include the application of warm, moist heat.. rather than ice to decrease
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Detailed Answer Key V
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Med SIng Final Retake
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inflammation and edema, relieve muscle spasms, and promote comfort.
i! ~
\ t r- B. Monitor platelet levels
Rationale: The nurse should monitor platelet levels along with other laboratory results related to blood
coaqulability and the medication therapy for the treatment of a deep vein thrombosis. Initially,
medications such as heparin or enoxaparin are administered; laboratory test would include PTI.
Later, warfarin therapy may be initiated for which PT/INR would be monitored. Platelets are
monitored 'because the Client is at risk for heparin inducted thrombocytopenia, placing the client
at risk for bleeding.
C. Restrict oral fluids
Rationale: The nurse should encourage fluids to reduce blood viscosity.
D. Administer vasodilating medications
Rationale: The nurse should recognize thatantlcoaqulant medications, such as heparin and warfarin, are
used to prevent further clot formation. Administration of vasodilators, which may be used as
antihypertensives, have no beneficial effect for thrombophlebitis. .
6. A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of Raynaud's phenomenon.
Which of the following statements should the nurse identify as an indication that the client needs further teaching?
:6
I.~~ A. "I will keep my house at a cool temperature."
Rationale: Raynaud's phenomenon occurs during exposure to extreme temperatures or from stress,
resulting in painful vasoconstriction of peripheral blood vessels, typically in the hands and feet.
Keeping the house comfortably warm can help prevent the manifestations of Raynaud's
phenomenon.
B. "I will try to anticipate and avoid stressful situations."
Rationale: Avoiding stressful situations is an action the client should take to manage stress and prevent the
onset of the manifestations of Raynaud's phenomenon.
C. "I will complete the smoking cessation program I started."
Rationale: Smoking cessation is an action the client should take to prevent the onset of the manifestations
of Raynaud's phenomenon. The client should also limit caffeine intake.
D. "I will wear gloves when removing food from the freezer."
Rationale: Wearing gloves when removing food from the freezer or reaching inside hot ovens is an action
the client should take to prevent the onset of the manifestations of Raynaud's phenomenon.
7. A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse
expect? .
A. Frothy sputum
, Rationale:
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