VATI Med Surge assessment. Questions and answers. Graded A+

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A nurse is caring for a client who has atopic dermatitis and a prescription for triamcinolone ointment. The nurse should assess the client to monitor for which of the following adverse effects? - ✔�... ��Thinning of the skin. Only apply the ointment to dry patches of the skin to avoid atrophy. Topical Glucocorticoids Side effects - ✔✔Tiamcinolone - Hypopigmentation - Excessive hair growth (hypertrichosis) - Thinning of the skin A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse identify as a manifestation of left-sided heart failure? - ✔✔Frothy sputum Pink-tinged frothy sputum can be an early indication of pulmonary edema and can be life-threatening. Therefore, the nurse should notify the provider immediately. Left Sided Heart Failure - ✔✔- Frothy sputum - Dyspnea - Wheezing Treatment: Fluid restriction & diuretics to decrease preload & pulmonary congestion Right heart sided failure - ✔✔- Dependent edma - Jugular distention - Weight gain A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of the lips and fingers. The client's ABGs are: pH 7.48, PCO2 30 mm Hg, HCO3- 24 mEq/L, PaO2 85 mm Hg. Which of the following acid-base imbalances should the nurse identify that the client is experiencing? - ✔✔Respiratory alkalosis - The pH is alkaline (increased) - PCO2 is decreased representing alveolar hyperventilation & resultant respiratory alkalosis A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the nurse expect? - ✔✔Osteoporosis Bone become thinner as a result of mineral loss & nitrogen depletion. A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of the following lesion characteristics on the client's skin? - ✔✔A pearly, waxy nodule. - Basal cell carcinoma has a nodular lesion with well defined borders & pearly or waxy appearance resulting from overexposure to the sun. especially on the face, head, and neck. -A client who has melanoma has a lesion with irregular borders and variegated colors of red, white, and blue, most often on the upper back or lower legs. -A client who has squamous cell carcinoma has a firm, nodular, and crusty lesion with a ulcerated center, resulting from sun exposure, chronic irritation, burns, or irradiation to the skin. Melanoma - ✔✔Irregular border and varigated colored lesions of red, white, blue. - Most often on the upper back or lower legs Squamous cell carcinoma - ✔✔Firm, nodular, and crusty lesion with an ulcerated center from sun exposure, chronic irritation, burns, or irradiation to the skin. weeping vescile - ✔✔Herpes Zoster - Weeping, blister type lesions. A nurse in an emergency department is assessing a client who is overusing prescribed diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings should the nurse expect? - ✔✔LOW URINE SPECFIC GRAVITY. -A client who has hyponatremia as a result of diuretic overuse has a low urine specific gravity. The increased excretion of water alters the ratio of particulate matter, which affects the specific gravity. Hyponatremia - ✔✔- Low specific gravity - Elevated hemoglobin A home health nurse is assisting a client with planning care for a family member who has Alzheimer's disease. Which of the following instructions should the nurse include? - ✔✔Remove clutter from rooms and hallways - This allows the client is able to walk without the risk of falling or tripping over objects. Later in the disease, the client can experience seizures, so cluttered areas could be a risk to the client Alzheimer's interventions - ✔✔- Single date calender - Redirect the client by starting another activity - Use short, simple senteces when explaining an activity - Explanation should be done immediately before an activity A nurse is caring for a client who has developed acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse identify as a manifestation of this syndrome? - ✔✔REFRACTORY HYPOXEMIA - A client who has ARDS has refractory hypoxemia, which is hypoxemia that does not improve with oxygen therapy. Extensive pulmonary edema evident on a chest x-ray is a manifestation of ARDS. Pulmonary embolism - ✔✔- Pleural friction rub - Tachypnea - Tachycardia - Dyspnea - Sudden, sharp chest pain Tension pneumothorax - ✔✔- Trachial deviation - Dyspnea - Tachycardia - Tachypnea - Decreased or absent breath sounds over area Lung cancer - ✔✔Hemoptysis Bloody expectorant when coughing An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the following findings should indicate to the nurse that the client is experiencing status asthmaticus? - ✔✔USE OF ASSCESSORY MUSCLES. - A client who has status asthmaticus uses accessory muscles to help facilitate breathing, which is a manifestation of a severe airflow obstruction. The situation is life-threatening and the nurse should intervene immediately with strong systemic bronchodilators, epinephrine, corticosteroids, and oxygen. status asthmaticus - ✔✔- Labored breathing & wheezing - Distended neck veins - Use of accessory muscle - Bronchodilators - Epinephrine - Corticosteroids - Oxygen A nurse is teaching a client who has a new prescription for PHENYTOIN to treat a seizure disorder. Which of the following adverse effects should the nurse instruct the client to report IMMEDIATELY to the provider? - ✔✔SKIN RASH. - the nurse should determine that the priority finding is a rash, which can have a measles-like appearance and progress to exfoliative dermatitis or Stevens-Johnson syndrome. The client should report this finding to the provider immediately. Phenytoin side effects - ✔✔- Skin Rash - Bleeding gums - Increased facial hair - Constipation A nurse is monitoring a client following a LUMBAR LAMINECTOMY. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a COMPLICATION of the surgery? - ✔✔CLEAR DRAINAGE OF DRESSINGS - This is an indication of a cerebral spinal leak lumbar laminectomy postoperative - ✔✔- Slight elevation in temperature - No more than 125 mL of drainage in 4 hours - Decreased bowel sounds due to anesthesia - Monitor for paralytic ileus A nurse is assessing a client who has RIGHT-SIDED HEART FAILURE. Which of the following findings should the nurse identify as a manifestation of RIGHT- SIDED HEART FAILURE? - ✔✔INCREASED ABDOMINAL GIRTH A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates ACCEPTANCE of the role change? - ✔✔" I changed the floor plan of our homes to accommodate my father's wheelchair. " A nurse is caring for a client who is receiving VANCOMYCIN intermittent IV bolus therapy for METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS. Which of the following findings is an indication to the nurse that the client is experiencing an ADVERSE EFFECT of the medication? - ✔✔THE CLIENT IS BECOMING FLUSHED. - Flushing is a manifestation of an infusion reaction to vancomycin that also causes a rash on the face and upper body, called red man syndrome. Red man syndrome results from infusing vancomycin to rapidly. The nurse should infuse the medication over at least 60 mins. Red man sydrome - ✔✔Results from infusing vancomycin too rapidly. The nurse should infuse the medication over at least 60 min. - Hypotension - Tachycardia - Ototoxcity - Renal failure - Flushing A nurse is caring for a male client who has a new prescription for CYCLOSPORINE following a kidney transplant. Which of the following findings should the nurse identify as an adverse effect of this therapy? - ✔✔BUN 24 mg/dL. - A BUN of 24 mg/dL is above the expected reference range of 10 to 20 mg/dL, indicating renal impairment. An adverse effect of cyclosporine is nephrotoxicity WBC normal range - ✔✔5,000-10,000 RBC count normal range - ✔✔4.7-6.1 million Potassium normal range - ✔✔3.5-5.0 A nurse is caring for a client who has DUMPING SYNDROME following a gastric resection. The nurse should monitor the client for which of the following complications of DUMPING SYNDROME? - ✔✔IRON DEFICIENCY ANEMIA. - The nurse should monitor the client for manifestations of anemia, such as pallor, tachycardia, and fatigue. Rapid emptying of the stomach contents into the intestine can lead to reduced absorption of iron in the duodenum, causing iron-deficiency anemia. A nurse is assessing a client who takes SALMETEROL to treat moderate asthma. Which of the following findings should indicate to the nurse that the medication has been effective? - ✔✔The client's daily peak expiratory flow (PEF) measures 85% above personal best. - A client who has asthma should use a peak flow meter twice daily to monitor asthma control. A PEF in the green zone, or 80% or above personal best, indicates the effectiveness of medication therapy. Dumping syndrome - ✔✔- Anorexia - Iron deficiency anemia - Hypocalcemia - Tachycardia - Rapid gastric emptying - Nausea & abdomnial cramping A nurse is providing teaching about health promotion activities for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? - ✔✔" I WILL CHECK MY BLOOD SUGAR LEVEL BEFORE EXCERCISING. " - Clients who have diabetes mellitus should not exercise if their blood glucose level is less than 80 mg/dL or greater than 250 mg/dL. A client who has type 1 diabetes mellitus and is hyperglycemic can experience even higher blood glucose levels. Hypoglycemia can also occur during exercise and up to 24 hr following exercise A nurse is providing teaching to a client who has a new prescription for WARFARIN. Which of the following medications should the nurse instruct the client to avoid? - ✔✔ASPIRIN & NAPROXEN. - Aspirin is an antiplatelet medication. It can increase the risk of bleeding when taken with warfarin. - . Naproxen is an NSAID that relieves mild to moderate pain. It can increase the risk of bleeding if taken with warfarin. A nurse is assisting with the care of a client who is scheduled for a THORACENTESIS. Which of the following interventions should the nurse plan to take? - ✔✔PLACE THE CLIENT LEANING FORWARD OVER THE BEDSIDE TABLE FOR THE PROCEDURE. - This allows the provider complete access to the client's chest and back. This position also expands the spaces between the ribs where the pleural fluid accumulates. paracentesis - ✔✔- Empty the bladder before the procedure - Weigh the client before and after procedure - Keep the client on bedrest after the procedure [Show More]

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