NURSING 250 Proctored Med Surg Exam 1 with Solutions and Rationale
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NURSING 250 Proctored Med Surg Exam 1 with Solutions
1. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?
a. Bradycardia- more tachycardia cuz of a failing ventricle , SNS is activated to compensate .
b. Flushed skin- dus...
NURSING 250 Proctored Med Surg Exam 1
with Solutions
1. A nurse is assessing a client who has left-sided heart failure. Which of the following findings
should the nurse expect?
a. Bradycardia- more tachycardia cuz of a failing ventricle , SNS is activated to compensate
.
b. Flushed skin- duskly it wIll look like
c. Frothy sputum-Left sided- can be blood tinged
d. Jugular vein
distention→ Right Rationale:
ATI MS: pg. 198 ch 32 pdf
Left side: dyspnea, orthopnea, fatigue, pulmonary congestion, frothy sputum, organ failure such
as oliguria.
Right Side: Jugular vein distention, ascending dependent edema, abdominal distention, polyuria
ar rest, liver enlargement,
2. A nurse is assessing a client who is experiencing renal colic from a calculus in left
renal pelvis. Identify the area where the nurse should expect the client to have
referred pain. ( Find “hot spots” in the artwork) Pain travels downward to the
inguinal area and lower back
Renal colic occurs in the kidney area. Referred pain is somewhere that happens in
another place other than where the pain should be felt.
2. A nurse is caring for a client who is receiving peritoneal dialysis and notes a
decrease in the dialysate flow rate. Which of the following actions should the nurse
take? (Select all the apply?). Check answer i read pg 644-647 med surg it’s not so
specific p. 370 ch 57 pdf
a. monitor the access site for drainage.- to check for sxs of infection.
b. Strip the catheter tubing
c. Measure the amount of the dialysate outflow
d. Raise the client to high fowlers position- they must lie supine
e. Position the client to her other side.
,3. A nurse is planning to insert an indwelling catheter for a female client. Which of the
following actions should the nurse plan to take? Ati video tutorials foley
a. Collect urine specimen from the drainage bag 1 hr after insertion
b. Raise the head of the bed to 45 degrees prior to insertion
c. Secure the catheter to the client's inner thigh
d. Attach the bag to the rail of the bed. –under non movable area
6. A nurse is providing teaching for a client who has age-related macular degeneration
which of the following information should the nurse include in the teaching
a. A possible cause of this problem is long-term lack of dietary protein
b. You probably have a Detachment of your retina -vision is like having curtains over
eyes
c. You probably have noticed a decline in your central vision
d. The doctor can perform surgery to correct the start paying the folds in your
retina
Rationale: ATI MS: PG. 63 Macular degeneration, often called age-related macular
degeneration (AMD), is the central loss of vision that affects the macula of the eye.
NO cure , happens alot in old people. Sxs: distorted vision, blurred vision, caused
by smoking, female, HTN, diet lacking carotene.
,7. A nurse is assessing a client who has cirrhosis. Which of the following findings is the
priority for the nurse to report? P . 357 ch 55 pdf Med surg
a. Platelets 70,000/mm3- risk of bleed normal range is 150,000 - 300,00- ABCS is
compromised automatically .
b. Distended abdomen- expected
c. Alkaline phosphatase 125 units/L -norm normal is 30 -120 D. Clay colored stools-
bile not on your shit
8. A nurse is preparing to discontinue long-term total parenteral nutrition (TPN) therapy
for a client for a client. The nurse should plan to discontinue the TPN gradually to reduce
the risk of which of the following adverse effects? Old med surge docs we used
a. Hyperglycemia
b. Diarrhea
c. Constipation
d. Hypoglycemia (Repeat) Since your body is producing enough insulin to
take on higher loads, you must taper it down to avoid hypoglycemia
with lower concentrations of
TPN
Abruptly discontinuing TPN will cause rebound hypoglycemia
9. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following
actions should the nurse plan to take? P
. 250 chapter 40 pdf p . 678 lewis
a. Administer the unit of packed RBC’s over 1 hr- 2- 4 hr its must be given for 2 -4 hours.
older adults
b. Obtain the client’s first set of vital signs 1 hr after initiating the transfusion-
you get vital signs at the initial first 15 to 30 minutes of the transfusion.
c. Initiate venous access with a 21-gauge needle - no more than 19, for a regular adult it is
18 or 20 .
d. Use Y tubing with 0.9% sodium chloride when administering the transfusion. Pg 249
10. TOXIC SHOCK SYNDROME- same
11.A nurse is providing discharge teaching to an older adult client who had an
exacerbation of COPD. The client is to start fluticasone by metered-dose
inhaler. WHich of the following instructions should the nurse include? ( C) p .
132 ch 22
a. Use fluticasone as needed for shortness of breath.- fluticasone used to treat
inflammation.
b. Limit fluid intake to 1 L per day. - drink plenty to avoid dehydration. 2-3 liters.
, c. Obtain a yearly influenza immunization. - reduce risk of infection.
d. Assist use of pursed-lip breathing.- this is also one of the interventions the
nurse does but the question ask about fluticasone. It is a steroid, and we all
know steroids decresaes inflammation but also depress our immunue system.
So getting a flu shot is priority.
12. A nurse is providing discharge teaching to an older adult client following a
left total hip arthroplasty. Which of the following instructions should the nurse
include in the teaching?
a. “You can cross your legs at the ankles when sitting down.” -avoid flexion contraction
b. “Clean the incision daily with hydrogen peroxide.”- soap and water
c. “Install a raised toilet seat in your bathroom.” Pg 437 also use straight
chairs with arms, abduction pillow between the legs, avoid low chairs, and
flexion of hip greater than 90 degrees. NO crossing legs , no turing on
operative side.
d. “You should use an incentive spirometer every 8 hrs.”- once every hour at least
13. Missing
14. A nurse is caring for a client who is postoperative following a femur fracture.
Which of the following findings should the nurse report to the provider
immediately?
a. The client reports shortness of breath - embolism ABCS p . 457 chapter 71
b. The client has a temperature of 38.1 C (100.5F)
c. The clients incision is red and warm
d. The client reports incision pain
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