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NURSING 250 PROCTORED 1 MEDSURG% verified exam with answers
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NURSING 250 PROCTORED 1 MEDSURG% verified exam with answers
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1. A hhnurse hhis hhassessing hha hhclient hhwho hhhas hhleft-sided hhheart hhfailure. hhWhich hhof hhthe hhfollowing hhfindings hhshould hhthe hhnurse hhexpect?a. Bradycardia- hhmore hhtachycardia hhcuz hhof hha hhfailing hhventricle hh, hhSNS hhis hhactivated hhto hhcompensate hh.
b. Flushed hhskin- hhduskly hhit hhwIll hhlook hhlike
c. Frothy hhsputum-Left hhsided- hhcan hhbe hhblood hhtinged
d. Jugular hhvein hhdistention→
hhRight h h Rationale: hhATI hhMS: hhpg. hh198 hhch
hh32 hhpdf
Left hhside: hhdyspnea, hhorthopnea, hhfatigue, hhpulmonary hhcongestion, hhfrothy hhsputum, hhorgan hhfailure hhsuch hhas hholiguria.
Right hhSide: hhJugular hhvein hhdistention, hhascending hhdependent hhedema, hhabdominal hhdistention, hhpolyuria hhar hhrest, hhliver hhenlargement,
2. A hhnurse hhis hhassessing hha hhclient hhwho hhis hhexperiencing hhrenal hhcolic hhfrom hha hhcalculus hhin hhleft hhrenal hhpelvis. hhIdentify hhthe
hharea hhwhere hhthe h h nurse hhshould hhexpect hhthe hhclient hhto hhhave hhreferred hhpain. hh( hhFind hh“hot hhspots” hhin hhthe hhartwork)
hhPain hhtravels hhdownward hhto hhthe hhinguinal h h area hhand hhlower hhback
Renal hhcolic hhoccurs hhin hhthe hhkidney hharea. hhReferred hhpain hhis hhsomewhere hhthat hhhappens hhin hhanother hhplace hhother hhthan hhwhere
hhthe hhpain hhshould h h be hhfelt.
2. A hhnurse hhis hhcaring hhfor hha hhclient hhwho hhis hhreceiving hhperitoneal hhdialysis hhand hhnotes hha hhdecrease hhin hhthe hhdialysate hhflow
hhrate. hhWhich hhof hhthe h h following hhactions hhshould hhthe hhnurse hhtake? hh(Select hhall hhthe hhapply?). hhCheck hhanswer hhi hhread hhpg
hh644-647 hhmed hhsurg hhit’s hhnot hhso hhspecific h h p. h h 370 hhch hh57 hhpdf
a. monitor hhthe hhaccess hhsite hhfor hhdrainage.- hhto hhcheck hhfor hhsxs hhof hhinfection.
b. Strip hhthe hhcatheter hhtubing
c. Measure hhthe hhamount hhof hhthe hhdialysate hhoutflow
d. Raise hhthe hhclient hhto hhhigh hhfowlers hhposition- hhthey hhmust hhlie hhsupine
e. Position hhthe hhclient hhto hhher hhother hhside.
3. A hhnurse hhis hhplanning hhto hhinsert hhan hhindwelling hhcatheter hhfor hha hhfemale hhclient. hhWhich hhof hhthe hhfollowing hhactions hhshould
hhthe hhnurse hhplan hhto h h take? hhAti hhvideo hhtutorials hhfoley
a. Collect hhurine hhspecimen hhfrom hhthe hhdrainage hhbag hh1 hhhr hhafter hhinsertion
b. Raise hhthe hhhead hhof hhthe hhbed hhto hh45 hhdegrees hhprior hhto hhinsertion
c. Secure hhthe hhcatheter hhto hhthe hhclient's hhinner hhthigh
d. Attach hhthe hhbag hhto hhthe hhrail hhof hhthe hhbed. hh–under hhnon hhmovable hharea
6. A hhnurse hhis hhproviding hhteaching hhfor hha hhclient hhwho hhhas hhage-related hhmacular hhdegeneration hhwhich hhof h h the hhfollowing
hhinformation hhshould hhthe h h nurse hhinclude hhin hhthe hhteaching
a. A hhpossible hhcause hhof hhthis hhproblem hhis hhlong-term hhlack hhof hhdietary hhprotein
b. You hhprobably hhhave hha hhDetachment hhof hhyour hhretina hh-vision hhis hhlike hhhaving hhcurtains hhover hheyes
c. You hhprobably hhhave hhnoticed hha hhdecline hhin hhyour hhcentral hhvision
d. The hhdoctor hhcan hhperform hhsurgery hhto hhcorrect hhthe hhstart hhpaying hhthe hhfolds hhin hhyour hhretina
Rationale: hhATI hhMS: hhPG. hh63 h h Macular hhdegeneration, hhoften hhcalled hhage-related hhmacular hhdegeneration hh(AMD), hhis hhthe
hhcentral hhloss hhof h h vision hhthat hhaffects hhthe hhmacula hhof hhthe hheye. hhNO hhcure hh, hhhappens hhalot hhin hhold hhpeople. hhSxs:
hhdistorted hhvision, hhblurred hhvision, hhcaused hhby h h smoking, hhfemale, hhHTN, hhdiet hhlacking hhcarotene.
,7. A hhnurse hhis hhassessing hha hhclient hhwho hhhas hhcirrhosis. hhWhich hhof hhthe hhfollowing hhfindings hhis hhthe hhpriority hhfor hhthe hhnurse hhto
hhreport? hhP hh. hh357 h h ch hh55 h h pdf hhMed hhsurg
a. Platelets hh70,000/mm3- hhrisk hhof hhbleed hhnormal hhrange hhis hh150,000 hh- hh300,00- h h ABCS hhis hhcompromised hhautomatically hh.
b. Distended hhabdomen- hhexpected
c. Alkaline hhphosphatase hh125 hhunits/L hh-norm h h normal hhis hh30 hh-120 h h D. Clay hhcolored hhstools- hhbile hhnot hhon hhyour hhshit
8. A hhnurse hhis hhpreparing hhto hhdiscontinue hhlong-term hhtotal hhparenteral hhnutrition hh(TPN) hhtherapy hhfor hha hhclient hhfor hha hhclient. hhThe
hhnurse hhshould hhplan hhto h h discontinue hhthe hhTPN hhgradually hhto hhreduce hhthe hhrisk hhof hhwhich hhof hhthe hhfollowing hhadverse hheffects?
hhOld hhmed hhsurge hhdocs hhwe hhused
a. Hyperglycemia
b. Diarrhea
c. Constipation
d. Hypoglycemia hh(Repeat) hhSince hhyour hhbody hhis hhproducing hhenough hhinsulin hhto hhtake hhon hhhigher hhloads, hhyou
hhmust hhtaper hhit h h down hhto hhavoid hhhypoglycemia hhwith hhlower hhconcentrations hhof
TPN
Abruptly hhdiscontinuing hhTPN hhwill hhcause hhrebound hhhypoglycemia
9. A hhnurse hhis hhpreparing hhto hhadminister hha hhunit hhof hhpacked hhRBCs hhto hha hhclient. hhWhich hhof hhthe hhfollowing hhactions hhshould hhthe hhnurse hhplan hhto
hhtake? hhP
. hh250 hhchapter hh40 hhpdf h h p hh. hh678 hhlewis
a. Administer hhthe hhunit hhof hhpacked hhRBC’s hhover hh1 hhhr- hh2- hh4 hhhr hhits hhmust hhbe hhgiven hhfor hh2 hh-4 hhhours. h h older hhadults
b. Obtain hhthe hhclient’s hhfirst hhset hhof hhvital hhsigns hh1 hhhr hhafter hhinitiating hhthe hhtransfusion- hhyou hhget hhvital hhsigns hhat hhthe
hhinitial hhfirst hh15 hhto hh30 h h minutes hhof hhthe hhtransfusion.
c. Initiate hhvenous hhaccess hhwith hha hh21-gauge hhneedle hh- hhno hhmore hhthan hh19, hhfor hha hhregular hhadult hhit hhis hh18 hhor hh20 hh.
d. Use hhY hhtubing hhwith hh0.9% hhsodium hhchloride hhwhen hhadministering hhthe hhtransfusion. hhPg hh249
10. TOXIC hhSHOCK hhSYNDROME- hhsame
11. A hhnurse hhis hhproviding hhdischarge hhteaching hhto hhan hholder hhadult hhclient hhwho hhhad hhan hhexacerbation hhof hhCOPD. hhThe
hhclient hhis hhto hhstart h h fluticasone hhby hhmetered-dose hhinhaler. hhWHich hhof hhthe hhfollowing hhinstructions hhshould hhthe
hhnurse hhinclude? hh( hhC) hhp hh. hh132 hhch hh22
a. Use hhfluticasone hhas hhneeded hhfor hhshortness hhof hhbreath.- hhfluticasone hhused hhto hhtreat hhinflammation.
b. Limit hhfluid hhintake hhto hh1 hhL hhper hhday. h h - hhdrink hhplenty hhto hhavoid hhdehydration. h h 2-3 hhliters.
c. Obtain hha hhyearly hhinfluenza hhimmunization. hh- hhreduce hhrisk hhof hhinfection.
d. Assist hhuse hhof hhpursed-lip hhbreathing.- hhthis hhis hhalso hhone hhof hhthe hhinterventions hhthe hhnurse hhdoes hhbut hhthe
hhquestion hhask hhabout h h fluticasone. hhIt hhis hha hhsteroid, hhand hhwe hhall hhknow hhsteroids hhdecresaes hhinflammation hhbut
hhalso hhdepress hhour hhimmunue hhsystem. hhSo h h getting hha hhflu hhshot hhis hhpriority.
12. A hhnurse hhis hhproviding hhdischarge hhteaching hhto hhan hholder hhadult hhclient hhfollowing hha hhleft hhtotal hhhip hharthroplasty.
hhWhich hhof hhthe hhfollowing h h instructions hhshould hhthe hhnurse hhinclude hhin hhthe hhteaching?
a. “You hhcan hhcross hhyour hhlegs hhat hhthe hhankles hhwhen hhsitting hhdown.” hh-avoid hhflexion hhcontraction
b. “Clean hhthe hhincision hhdaily hhwith hhhydrogen hhperoxide.”- hhsoap hhand hhwater
c. “Install hha hhraised hhtoilet hhseat hhin hhyour hhbathroom.” hhPg hh437 hhalso hhuse hhstraight hhchairs hhwith hharms, hhabduction
hhpillow hhbetween h h the hhlegs, hhavoid hhlow hhchairs, hhand hhflexion hhof hhhip hhgreater hhthan hh90 hhdegrees. hhNO hhcrossing
hhlegs hh, hhno hhturing hhon hhoperative hhside.
d. “You hhshould hhuse hhan hhincentive hhspirometer hhevery hh8 hhhrs.”- hhonce hhevery hhhour hhat hhleast
13. Missing
14. A hhnurse hhis hhcaring hhfor hha hhclient hhwho hhis hhpostoperative hhfollowing hha hhfemur hhfracture. hhWhich hhof hhthe hhfollowing hhfindings
hhshould hhthe hhnurse h h report hhto hhthe hhprovider hhimmediately?
a. The hhclient hhreports hhshortness hhof hhbreath hh- hhembolism hhABCS h h p hh. hh457 h h chapter hh71
b. The hhclient hhhas hha hhtemperature hhof hh38.1 hhC hh(100.5F)
c. The hhclients hhincision hhis hhred hhand hhwarm
d. The hhclient hhreports hhincision hhpain
,15. A hhnurse hhis hhplanning hhcare hhfor hha hhclient hhwho hhClostridium hhdifficile hhgastroenteritis. hhWhich hhof hhthe hhfollowing hhis hhan
hhappropriate hhnursing h h action? hhP hh . hh290 h h ch hh46 hhpdf
a. Place hhthe hhclient hhin hha hhprotective hhenvironment
b. Obtain hha hhstool hhspecimen hhwith hhgloves→ hhCONTACT hhISO
c. Clean hhsurfaces hhwith hhchlorhexidine-bleach hhD. Wash hhhands hhwith hhalcohol-based hhhand hhrub.
16. A hhnurse hhis hhsetting hhup hha hhsterile hhfield hhbefore hhperforming hha hhdressing hhchange hhon hhclient hhwho hhis hhpostoperative.
hhWhich hhof hhthe hhfollowing h h actions hhshould hhthe hhnurse hhplan hhto hhtake hhto hhmaintain hhthe hhsterile hhfield? hh(select hhall hhthe
hhapply)
a. Grasp hh2.5 hhcm hh(1 hhin hh) hhof hhthe hhouter hhedge hhto hhopen hhthe hhsurgical hhwrap- hh1 hhinch hhform hhbroder hhis hhalways
hhnon hhsterile hhso hhits hhok hhto h h touch hhit hh.
b. Select hha hhwork hhsurface hhat hhthe hhnurses hhwaist hhlevel- h h body hhmchiancis hh.
c. Apply hhsterile hhgloves hhbefore hhopening hhthe hhpack- hhsterile hhpackage hhmust hhbe hhopened hhfirst hhbefore hhdonning hhsterile hhgloves
d. Open hhthe hhfirst hhflap hhof hhthe hhsterile hhpackage hhtoward hhthe hhnurse's hhbody- hhmust hhbe hhAWAY hhfirst hh, hhthen hhsides hh,
hhthen hhTOWARDS h h the hhnurse hh.
e. Place hha hhsurgical hhpack hhwith hha hhsterile hhdrape hhon hhthe hhwork hhsurface.
17. A hhnurse hhis hhcaring hhfor hha hhclient hhwho hhhas hhacute hhappendicitis. hhWhich hhof hhthe hhfindings hhis hhthe hhpriority hhto hhthe
hhprovider? hhCh hh23 h h p hh. hh143 h h PEDIATRICS hhpdf h h also hhp hh944 hhlewis
a. Nausea- hhhas hhnot hhburst
b. Flank hhpain hh- hhnormal
c. Fever hh- hhhas hhnot hhburst
d. Rigid hhabdomen hh- hhmuscles hhcontract hhbecause hhit hhexploded- hhcan hhlead hhto hhrupture hhand hhinfection hhalso
hhHR hhELEVATED, h h shallow hhand hhrapid hhrespirations, hhpulse hhis hhweak. hh.
18. A hhnurse hhis hhcaring hhfor hha hhclient hhwho hhis hhreceiving hhradiation. hhThe hhclient hhreports hhnauseas hhsince hhthe hhtherapy hhwas
hhinitiated. hhWhich hhof hhthe h h following hhconsiderations hhshould hhthe hhnurse hhinclude hhwhen hhplanning hhthe hhclients hhmeals? hhP hh.
hh583 hhch hh91 hhalso hhch hh16 hhp hh269 hhof hhthe hhlewis hhbook
a. Offer hhfrequent, hhhigh-carbohydrate hhmeals- hhseveral hhsmall hhmeals hha hhday hhis hhpreffered.
b. Offer hhhighly hhseasoned hhfoods- hhyou hhwant hhCOLD hh, hhdry hh, hhfoods. hhCooking hhstimulates hhodors hhthat hhlead hhto hhnausea.
c. Offer hha hhsnack hhprior hhto hhradiation hhtherapy- hhseveral hhsmall hhmeals hha hhday hhis hhrecommended.
d. Offer hhhot hhbeverages hhwith hhmeals- hhhot hhfoods hhcan hhstimulate hhnausea. hhBeverage hhwith hhmeals hhleads hhto hhnausea.
19. A hhnurse hhis hhcaring hhfor hha hhclient hhwho hhis hhreceiving hhmechanical hhventilation. hhWhich hhof hhthe hhfollowing hhinterventions
hhshould hhthe hhnurse h h implement? hh(D) hhpage hh208-209 hhnot hhsure hhwhich hhanswer
Empty hhwater hhfrom hhthe hhventilator hhtubing hhdaily. hh( hh-INFECTION hhCONTROL: h h water hhthat hhcollects hhin hhthe hhventilator
hhtubing hhcan h h create hha hhbreeding hhground hhfor hhbacteria hhwhich hhmay hhlead h h to hhVAP.
Suction hhthe hhclient’s hhairway hhevery hh4 hhhr.(Suction hhevery hh2 hhhr hhand hhas hhneeded. hhp.157)
Maintain hhthe hhclient hhin hhsupine hhposition. hh(should hhreposition hhpt hhto hhhelp hhwith hhsecretions)
Perform hhoral hhcare hhevery hh2 hhhr.( hhyou hhdo hhoral hhcare hhbut hhnot hhevery hh2hrs hh)
20. A hhnurse hhin hhan hhemergency hhdepartment hhis hhassessing hha hhclient hhwho hhhas hhcirrhosis
of hhthe hhliver. h h Which hhof hhthe hhfollowing hhis hha hhpriority hhfinding? hh( hhC)
hh
a. Palmar hherythema
b. Spider hhangiomas
c. Mental hhconfusion hh(RM hh10 hhCh.55 hhp.359 hhpdf hh- hhtoo hhmuch hhbilirubin hhin hhthe hhblood hhwent hhto hhthe hhbrain
hhand hhnow hhcaused h h mental hhencephalopathy)
d. Yellow hhSclera
21. A hhnurse hhis hhpreparing hhto hhadminister hhbumetanide hhto hha hhclient hhwho hhhas hhheart hhfailure. hhWhich hhof hhthe
hhfollowing hhassessment h h findings hhshould hhindicate hheffectiveness hhof hhthe hhmedication
a. Bowel hhsounds hhpresent hhin hh4 hhquadrants hhon hhauscultation
b. Alert hhand hhoriented hhto hhtime hhplace hhand hhperson
, c. Lung hhsounds hhclear hh- hhit hhis hhBumex
d. Apical hhpulse hh80
h h Rationale: hhMS hhRM hh10 hhCh.32
hhp.198-9
23. A hhnurse hhis hhcaring hhfor hha hhclient hhwho hhhas hhhypertension hhand hhhas hha hhnew hhprescription hhfor hhlisinopril. hhThe hhnurse hhshould
hhconsult hhwith hhthe h h provider hhabout hhwhich hhof hhthe hhfollowing hhmedication hhin hhthe hhclient's hhmedication hhadministration
hhrecord?
a. Potassium hhchloride hh** hhfound hhon hhmedscape
b. evothyroxine
c. Acetaminophen
d. Metformin
Rationale: hhPharm hhRM hh7.0 hhCh.20 hhp.151; hhHyperkalemia hhis hha hhcomplication hhfor hhLisinopril; hhavoid hhany hhsalt hhsubstitutes hhcontaining hhK+.
24. A hhnurse hhis hhplanning hhcare hhfor hha hhclient hhwho hhis hh1 hhday hhpostoperative hhfollowing hhan hhopen hhcholecystectomy. hhWhich
hhof hhthe hhfollowing h h interventions hhshould hhthe hhnurse hhinclude hhin hhthe hhplan hhor hhcare?
a. Avoid hhuse hhof hhanticoagulants hh- hhuse hhit
b. Place hhpillow hhunder hhclient hhknees hh- hhstasis hhdanger
c. Discourage hhleg hhexercises hhwhile hhin hhbed hh- hhyou hhneed hhit
d. Apply hhcompression hhstocking hhin hhlower hhextremities
Rationale: hhIt’s hhcommon hhpost-op, hhalso, hhresume hhregular hhactivity hhafter hh4-6 hhwks.
25. What hhinterferes hhwith hhwarfarin hhtherapy
a. Potatoes
hh(Potassium)
h h Oranges hh(Vit hhC)
b. Bananas hh(Potassium)
c. Cauliflower hh- hhHuge hhVitamin hhK hhremember hhveggies
Rationale: hhAvoid hhany hhinteraction hhwith hhVitamin hhK hhwhen hhon hhanticoagulant hhtherapy, hhand hhdark, hhleafy hhveggies hh(or hhjust hhany
hhveggies) hhare hhTHE h h source hhfor hhit.
26. A hhnurse hhis hhadministering hhfurosemide hh80 hhto hha hhclient hhwith hhpulmonary hhedema. hhWhich hhof hhthe hhfollowing hhassessment
hhfindings hhindicates h h the hhnurse hhthat hhthe hhmedication hhis hheffective? hhP hh, hh144 hhch hh19 hhpharm hhpdf
a. Elevation hhin hhBP
b. Adventitious h h breath hh sounds
c. Weight hhloss hhof hh1.8 hhkg hh(4lb) hhin hhthe hhpast hh24 hhhr
d. Respiratory hhrate hhof hh24/min
27. A hhnurse hhis hhcaring hhfor hha hhclient hhwho hhhas hhCushing’s hhdisease. hhWhich hhof hhthe hhfollowing hhfindings hhshould hhthe hhnurse hhexpect? h h Ch hh80
hhpage hh518
a. Weight hhloss
b. Hyponatremia- h h increased
c. Hyperglycemia
d. Hypercalcemia- hhDECREASED
h h ERRYTHANG hhis hhUP hhexcept hhK+/Ca+, hhboth
hhHYPO
28. A hhnurse hhis hhmonitoring hha hhclient hhwho hhhas hhreceiving hh2 hhunits hhpacked hhRBCs. hhWhich hhof hhthe hhfollowing hhmanifestations
hhindicates hha hhhemolytic h h transfusion hhreaction? hh(MS hhRM hh10.0 hhCh.40
p.250: hhchills, hhfever, hhlow-back hhpain, hhtachycardia, hhflushing, hhhypotension, hhchest hhtightening hhor hhpain, hhtachypnea, hhnausea, hhanxiety,
h h hemoglobinuria, hhand hhan hhimpending hhsense hhof hhdoom)
a. Back hhpain
b. Bradycardia- hhshould hhbe hhtachycardia
c. Hypertension- hhhypotension hhit hhwill hhcause.
d. Chills
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