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Exam (elaborations)

med surg final Questions & 100% Correct Answers

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  • Course
  • Med surg
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  • Med Surg

A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm...

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  • September 9, 2024
  • 34
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • Med surg
  • Med surg
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1 | P a g e | © copyright 2024/2025 | Grade A+




med surg final Questions & 100%
Correct Answers
A nurse is caring for a female client in the emergency department who reports

shortness of breath and pain in the lung area. She states that she started taking

birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min,

respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood

gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2

86%. Which of the following is the priority nursing intervention?

✓ :~~ Administer oxygen via face mask.




Rational: The pH reflects alkalosis, and the low PaCO2 indicates that the lungs are

involved, so the client has respiratory alkalosis. The client's oxygen saturation is

low, so one priority is to administer oxygen via mask attempting to achieve an

oxygen saturation of at least 95%. The greatest risk to this client is hypoxia, thus

the priority is to restore oxygenation.




A nurse is caring for a client who has a chest tube connected to a closed drainage

system and needs to be transported to the x-ray department. Which of the

following actions should the nurse take?




Master01 | September, 2024/2025 | Latest update

, 2 | P a g e | © copyright 2024/2025 | Grade A+


✓ :~~ Keep the drainage system below the level of the client's chest at all

times.




During transport, the drainage system should be kept below the level of the client's

chest to prevent air and drainage fluid from re-entering the thoracic cavity.




A nurse in the intensive care unit is providing teaching for a client prior to removal

of an endotracheal tube. Which of the following instructions should the nurse

include in the teaching?

✓ :~~ Avoid speaking for long periods."




The client should avoid speaking for long periods to promote gas exchange.




A nurse is monitoring a client following a thoracentesis. The nurse should identify

which of the following manifestations as a complication and contact the provider

immediately?

✓ :~~ Increased heart rate




Master01 | September, 2024/2025 | Latest update

, 3 | P a g e | © copyright 2024/2025 | Grade A+


Clients are at risk for developing pulmonary edema or cardiovascular distress due

mediastinal content shift after the aspiration of a large amount of fluid from the

client's pleural space.

Therefore, the client may experience an increase in heart and respiratory rate,

along with coughing with blood-tinged frothy sputum, and tightness in the chest.

These findings require notification of the provider immediately.




A nurse is caring for a client who develops a pulmonary embolism. Which of the

following interventions should the nurse implement first?

✓ :~~ Administer oxygen therapy.




The greatest risk to the safety of a client who has a pulmonary embolism is

hypoxemia with respiratory distress and cyanosis. Oxygen therapy should be

applied by the nurse using a nasal cannula or mask. Pulse oximetry should be

initiated to monitor oxygen saturation.




A nurse in an emergency department is caring for a client who has a sucking chest

wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg,

a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the

following actions should the nurse take?




Master01 | September, 2024/2025 | Latest update

, 4 | P a g e | © copyright 2024/2025 | Grade A+


✓ :~~ Administer oxygen via nasal cannula.




The client has an increased respiratory rate and heart rate, indicating that she is

having respiratory difficulty. The sucking chest wound indicates the client has a

pneumothorax and/or a hemothorax. Administering oxygen will increase the

oxygen exchange in the lungs and the oxygen available to the tissues.




A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and

a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing

which of the following acidbase imbalances?

✓ :~~ Respiratory alkalosis




With uncompensated respiratory acidosis, the pH is less than 7.35 and the PaCO2 is

greater than 45 mm Hg.




A client admitted to the hospital for evaluation of chest pain has no abnormal

serum cardiac markers 4 hours after the onset of pain. What noninvasive diagnostic

test can be used to differentiate angina from other types of chest pain?

✓ :~~ Exercise stress test




Master01 | September, 2024/2025 | Latest update

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