3/5/2023 MED SURG III EXAM #3
Question 1
The nurse is preparing for suctioning an unconscious client who has a tracheostomy. The nurse would perform which actions for this procedure? Select all that apply.
Keeping a supply of suction catheters at the bedside
Auscultating breath sounds to determine the need for suctioning
Hyperoxygenating the client before, during, and after suctioning
Intermittently suctioning during insertion of the suction catheter
Placing suction on the catheter for at least 30 seconds to ensure that all secretions are removed
Question 2
The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication?
Excessive secretions
Kinks in the ventilator tubing
The presence of a mucous plug
Disconnection of the ventilator tube
Question 3
The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply.
Water or a kink in the tubing
Biting on the endotracheal tube
Increased secretions in the airway
Disconnection or leak in the system
The client ceasing spontaneous breathing
Question 4
The client diagnosed with cancer of the bladder is scheduled to have a cutaneous urinary diversion procedure. Which preoperative teaching intervention specific to the procedure should be included?
Demonstrate turn, cough, and deep breathing.
Explain a bag will drain the urine from now on.
Instruct the client on the use of a PCA pump.
Take the client to the ICU to become familiar with it.
Question 5
A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which problem?
Rupture of the bladder
The development of a vesicovaginal fistula
Extreme stress because of the diagnosis of cancer
Altered perineal sensation as a side effect of radiation therapy
Question 6
A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit. Preoperatively, the nurse reinforces the client’s understanding of the surgical procedure by explaining that an ileal conduit:
Is a temporary procedure that can be reversed later.
Diverts urine into the sigmoid colon, where it is expelled through the rectum.
Conveys urine from the ureters to a stoma opening in the abdomen.
Creates an opening in the bladder that allows urine to drain into an external pouch.
Question 7
You are receiving shift report on a patient with cirrhosis. The nurse tells you the patient’s bilirubin levels are very high. Based on this, what assessment findings may you expect to find during your head-to-toe assessment? Select all that apply:
Frothy light-colored urine
Dark brown urine
Yellowing of the sclera
Dark brown stool
Jaundice of the skin
Bluish mucous membranes
Question 8
A client is to undergo a TURP for BPH. Which statement is accurate with regard to a TURP?
There is no danger of retrograde ejaculation.
Urethral strictures are more frequent for TURP than for nontransurethral procedures.
A TURP causes erectile dysfunction.
It is done on an outpatient basis.
Question 9
Which information regarding the care of a cutaneous ileal conduit should the nurse discuss with the client?
Teach the client to instill a few drops of vinegar into the pouch.
Tell the client the stoma should be slightly dusky colored.
Inform the client large clumps of mucus are expected.
Vinegar will act as a deodorizing agent in the pouch and help prevent a strong urine smell.
Question 10
A patient with severe chronic liver dysfunction comes to the clinic with bleeding of the gums and blood in the stool. What vitamin deficiency does the nurse suspect the patient may be experiencing?
Riboflavin deficiency
Folic acid deficiency
Vitamin A deficiency
Vitamin K deficiency
Question 11
patient is scheduled for a diagnostic paracentesis, but when coagulation studies are reviewed, the nurse observes results outside of normal parameters. How does the nurse anticipate the healthcare provider will proceed with the paracentesis?
An ultrasound-guided paracentesis will be performed
The procedure will be canceled until the laboratory results are within normal parameters
The paracentesis will be performed at the bedside
The nurse will administer packed red blood cells (RBCs) prior to the paracentesis
Question 12
he physician prescribes the patient a potassium-sparing diuretic. Which statement below best describes how this medication works to cause diuresis?
These medications work to inhibit the sodium-chloride cotransporter in the early part of the distal convoluted tubule.
These medications work to inhibit the sodium-potassium-chloride cotransporter in the thick ascending limb of the loop of Henle.
These medications work to inhibit the sodium and potassium exchange within the sodium channels in the distal tubule and collecting duct.
These medications work to inhibit the sodium channels within the proximal convoluted tubule by decreasing sodium reabsorption.
Question 13
A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this?
This is an expected finding.
The lung may have re-expanded or there is a kink in the system.
The system is broken and needs to be replaced.
There is an air leak in the tubing.
Question 14
The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate?
Keep the patient in a low Fowlers position.
Perform tracheostomy care at least once per day.
Maintain continuous bedrest.
Monitor cuff pressure every 8 hours.
Question 15
The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess?
Fluid intake for the last 24 hours
Baseline arterial blood gas (ABG) levels
Prior outcomes of weaning
Electrocardiogram (ECG) results
Question 16
The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning the patient from a ventilator, the nurse is aware that the weaning of the patient will progress in what order?
Removal from the ventilator, tube, and then oxygen
Removal from oxygen, ventilator, and then tube
Removal of the tube, oxygen, and then ventilator
Removal from oxygen, tube, and then ventilator
Question 17
The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify?
Stable vital signs and ABGs
Pulse oximetry above 80% and stable vital signs
Stable nutritional status and ABGs
Normal orientation and level of consciousness
Question 18
The nursing management of a patient with an artificial airway includes
maintaining the ET tube cuff pressure at 30 cm H20
routine suctioning of the tube at least every 2 hours
observing for cardiac dysrhythmias during suctioning
preventing tube dislodgment by limiting mouth care to lubrication of the lips
Question 19
Although his oxygen saturation is above 92%, an orally intubated, mechanically ventilated patient is restless and very anxious. What interventions will most likely decrease the risk of accidental extubation? Select all that apply
administer sedatives
have a caregiver stay with the patient
obtain an order and apply soft wrist restraints
remind the patient that he needs the tube inserted to breathe
move the patient to an area close to the nurse's station for closer observation
Question 20
Which patient's medical diagnoses should the nurse know are most likely to need mechanical ventilation? Select all that apply
sleep apnea
cystic fibrosis
acute kidney injury
type 2 DM
acute respiratory distress syndrome (ARDS)
Question 21
What characteristics describe positive pressure ventilators? Select all that apply
require an artificial airway
applied to outside of body
most similar to physiologic ventilation
most frequently used with critically ill patients
frequently used in the home for neuromuscular or nervous system disorders
Question 22
What is included in the description of positive pressure ventilation? Select all that apply
peak inspiratory pressure predetermined
consistent volume delivered with each breath
increased risk for hyperventilation and hypoventilation
preset volume of gas delivered with variable pressure based on compliance
volume delivered varies based on selected pressure and patient lung compliance
Question 23
What should the nurse recognize as a factor commonly responsible for sodium and fluid retention in the patient on mechanical ventilation?
increased release of ADH
increased release of atrial natriuretic factor
increased insensible water loss via the airway
decreased renal perfusion with release of renin
Question 24
The nurse is caring for a 65-yr-old man with acute respiratory distress syndrome (ARDS) who is on pressure support ventilation (PSV), fraction of inspired oxygen (FIO2) at 80%, and positive end-expiratory pressure (PEEP) at 15 cm H2O. The patient weighs 72 kg. What finding would indicate that treatment is effective?
PaO2 of 60 mm Hg
Tidal volume of 700 mL
Cardiac output of 2.7 L/min
Inspiration to expiration ratio of 1:2
Question 25
A patient who is receiving mechanical ventilation is anxious and is fighting the ventilator. Which action should the nurse take first?
Ventilate the patient with a manual resuscitation bag.
Verbally coach the patient to breathe with the ventilator.
Sedate the patient with the ordered PRN lorazepam (Ativan).
Increase the rate for the ordered propofol (Diprivan) infusion.
Question 26
The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action?
administer oxygen
check the client's vital signs
ventilate the client manually
start CPR
Question 27
The client with a new tracheostomy has a soiled dressing. What is the best nursing intervention?
Cut sterile 4 x 4 gauze to fit around the tracheostomy tube
Reinforce the dressing with sterile 4 x 4 gauze
Replace the dressing with clean, folded 4 x 4 gauze
Replace the dressing with sterile, folded 4 x 4 gauze