Targeted Med-Surg Practice Assessment 2021/22 (ALL ANSWERS ARE 100% CORRECT)
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MED
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MED
A nurse is caring for a client who has acute respiratory failure. What lab findings should the nurse expect? - PaO2 58mmHg
Rat.: nurse should expect to find a low partial pressures of oxygen for a patient who has acute resp. failure
A nurse is assessing a client who has emphysema. Which of th...
targeted med surg practice assessment 202122 all answers are 100 correct
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Targeted Med-Surg Practice Assessment
2021/22
A nurse is caring for a client who has acute respiratory failure. What lab findings should the nurse
expect? - PaO2 58mmHg
Rat.: nurse should expect to find a low partial pressures of oxygen for a patient who has acute resp.
failure
A nurse is assessing a client who has emphysema. Which of the following findings should the nurse
report to the provider? - Elevated temp.
Rat.: clients who have emphysema are at risk for the development of pneumonia and other resp.
infections. A nurse should report this as it indicates a possible resp. infection.
A nurse is caring for a client who is postop and has a respiratory rate of 9/min secondary to general
anesthesia effects and incisional pain. What ABG values support the nurses suspicion of respiratory
acidosis? - pH 7.30, PO2 80mmHg, PaCO2 55mmHg, HCO3 22mEq/L
Rat.: The pH is less than 7.35 and PaCO2 is greater than 45mmHg, which indicates resp. acidosis.
A nurse is positioning a client who has emphysema to promote effective breathing. The nurse should
place the client in what position? - High fowlers position with arms supported on the overbed table.
Rat.: The nurse should place the client in a position that allows for greater expansion of the chest.
A nurse is providing discharge teaching to a client who has pulmonary TB and a new prescription for
rifampin. Which of the following instructions should the nurse include? - "Expect your urine and other
secretions to be orange while taking this medication."
, A nurse working in th ER is caring for a client following an acute chest trauma. Which of the following
findings indicates tot he nurse the client is possibly experiencing a tension pneumothorax? - Tracheal
deviation to the unaffected side.
Rat.: a tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse
and forcing the trachea to deviate to the unaffected side
A nurse is caring for a client who has COPD. What findings should the nurse report to the provider? -
Productive cough with green sputum
Rat.: A nurse should report this as it indicates an infection
A nurse is assisting with a thoracentesis. What actions is appropriate for the nurse to take when
assisting with this procedure? - -Wear goggles and mask during the procedure: should wear this to
reduce the risk of exposure to pleural fluid.
-Cleanse the area with an antiseptic solution: this decreases the risk of infection, which is increased due
to the invasive procedure.
-Apply pressure to the site after the needle is withdrawn: this decreases the risk of bleeding at the
needle insertion site
A nurse is caring for a client who has pulmonary embolism. Which of the following interventions is the
priority? - Administer heparin via continuous IV infusion.
Rat.: using the airway, breathing, circulation approach to client care, the nurse should place priority on
stabilizing circulation to the lungs by admin. heparin to prevent further clot formation. Therefore, this is
the priority intervention.
A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items
should the nurse keep easily accessible for the client? - container of sterile water.
Rat.: the nurse should plan to place the open end of the tubing if it becomes disconnected into the
sterile water to prevent a pneumothroax. The tubing and sterile water are then placed below the clients
chest.
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