RN MEDSURG RETAKE 2 PROCTORED EXAM-LATEST GUIDE

1. A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of

the following findings indicates that the client is experiencing increased ICP?SATA.

a. Flat jugular veins

b. GCS score of 15

c. Sleepiness exhibited by the client

d. Widening pulse pressure

e. Decerebrate posturing

f. Flat jugular veins is incorrect. With increased ICP, the jugular veins are typically distended.

A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of 15

indicates neurological functioning within the expected reference range for eye opening, motor,

and verbal response.

Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from

sleep is an indication of increased ICP.

Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with

concurrent decrease in diastolic blood pressure) is an indication of increased ICP.

Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate

increased ICP.

2. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the

following prescribed medications should the nurse instruct the clients to withhold for 48hr prior to

cardioversion?

a. Enoxaparin

b. Metformin

c. Diazepam

d. Digoxin

e. Anticoagulants can be beneficial during cardioversion due to their ability to prevent

blood clots that can be released into the client's circulatory system after

cardioversion. This medication should not be withheld.

f. Metformin

g. Metformin might be withheld for a client scheduled for cardiac catheterization or

other procedures involving contrast dye in order to prevent damage to the kidneys.

However, metformin should not be withheld prior to cardioversion.

h. Diazepam

i. Sedatives are generally administered to clients prior to cardioversion to reduce

anxiety and minimize the discomfort associated with the procedure. This medication

should not be withheld.

j. Digoxin: ANSWER

k. Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These

medications can increase ventricular irritability and put the client at risk for

ventricular fibrillation after the synchronized countershock of cardioversion.

3. A nurse is assessing a client who has acute cholecystitis. which of the following findings is the nurse’s priority?

a. Anorexia

b. Abdominal pain radiating to the rightshoulder

c. Tachycardia

d. Rebound abdominal tenderness

i.

Anorexia

ii. Anorexia is nonurgent because it is an expected finding for a client who has

acute cholecystitis. Therefore, there is another finding that is the nurse's

priority.

iii. Abdominal pain radiating to the right shoulder

iv. MY ANSWER

v. Abdominal pain radiating to the right shoulder is nonurgent because it is an

expected finding for a client who has acute cholecystitis. Therefore, there is

another finding that is the nurse's priority.

vi. Tachycardia

vii. When using the urgent vs. nonurgent approach to client care, the nurse

should determine that the priority finding is tachycardia. Tachycardia is a

manifestation of biliary colic, which can lead to shock. The nurse should

position the head of the client's bed flat and report this finding immediately

to the provider.

viii. Rebound abdominal tenderness

ix. Rebound abdominal tenderness is nonurgent because it is an expected

finding for a client who has acute cholecystitis. Therefore, there is another

finding that is the nurse's priority.

4. A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following

items at the client’s bedside?

a. Suction machine

b. Wire cutters

c. Padded clamp

d. Communication board

e. Suction machine: ANSWER The nurse should ensure that a suction machine is at the

bedside of a client who has dysphagia to clear the client's airway as needed and

reduce the risk for aspiration.

f. Wire cutters: The nurse should ensure wire cutters are at the bedside of a client

who has an inner maxillary fixation to cut the wires in case the client vomits. This

enables the client to clear their airway and reduce the risk for aspiration.

g. Padded clamp: The nurse should ensure a padded clamp is at the bedside of a

client who has a chest tube to clamp the tube and prevent air from entering the

client's chest if there is an interruption in the sealed drainage system.

h. Communication board: The nurse should ensure a communication board is at the

bedside of a client who has aphasia to assist the client with communicating.

5. A nurse is caring for a client who is having a seizure. Which of the following intervention is the nurse’s priority?

a. Loosen the clothing around the client’s neck

b. Check the client’s pupillary response

c. Turn the client to the side.

d. Move furniture away from the client

i. Loosen the clothing around the client's neck: The nurse should loosen any

restrictive clothing the client is wearing to prevent injury to the client.

However, another action is the priority.

ii. Check the client's pupillary response: The nurse should perform neurologic

checks after the seizure to monitor the client's recovery. However, another

action is the priority.

iii. Turn the client to the side.: The greatest risk to this client is hypoxia from an

impaired airway. Therefore, the priority intervention the nurse should take is

to place the client in a side-lying position to prevent aspiration.

iv. Move furniture away from the client.: AThe nurse should move furniture away

from the client to prevent self-injury. However, another action is the priority.

6. A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse

shouldinstruct the client that which of the following supplements can interfere with the effectiveness of the

medication?

a. Ginkgo biloba

b. Glucosamine

c. Calcium

d. Vitamin C

i.

Ginkgo biloba

ii. Ginkgo biloba reduces the pain associated with peripheral vascular disease

by promoting vasodilation. It can interact with medications that have

anticoagulant properties, but it is not known to interfere with the absorption

of levothyroxine.

iii. Glucosamine: Glucosamine treats osteoarthritis by decreasing inflammation

and stimulating the body's production of synovial fluid and cartilage. It can

interact with medications that have antiplatelet or anticoagulant properties,

but it is not known to interfere with the absorption of levothyroxine.

iv. Calcium:NSWER

v. Calcium limits the development of osteoporosis in clients who are

postmenopausal and works as an antacid. Calcium supplements can interfere

with the metabolism of a number of medications, including levothyroxine. The

nurse should instruct the client to avoid taking calcium within 4 hr of

levothyroxine administration.

vi. Vitamin C: Vitamin C promotes wound healing. It can cause a false negative

in fecal occult blood tests, but it is not known to interfere with the absorption

of levothyroxine.

7. A nurse is planning to irrigate and dress a clean, granulation wound for a client who has a pressure injury. Which

of the following actions should the nurse take?

a. Apply a wet-to-dry gauze dressing

b. Irrigate with hydrogen peroxide solution

c. Use a 30-ml syringe

d. Attach a 24-gauge angiocatheter to the syringe.

a. Apply a wet-to-dry gauze dressing.: The nurse should not apply wet-to-dry dressings

to clean, granulating wounds as they interrupt viable, healing tissues when they are

removed. Appropriate dressings for a wound that is developing granulation tissue

include a hydrocolloid dressing and a transparent film dressing.

b. Irrigate with hydrogen peroxide solution: the nurse should use hydrogen peroxide to

clean contaminated surfaces. Hydrogen peroxide should not be used on a pressure

injury wound because it destroys newly granulated tissue. Instead, the nurse should

use solutions specifically designed as wound cleansers or 0.9% sodium chloride

irrigation to irrigate the wound.

c. Use a 30-mL syringe: NSWERThe nurse should use a 30-mL to 60-mL syringe with

an 18- or 19-gauge catheter to deliver the ideal pressure of 8 pounds per square

inch (psi) when irrigating a wound. To maintain healthy granulation tissue, the

wound irrigation should be delivered at between 4 and 15 psi.

d. Attach a 24-gauge angiocatheter to the syringe:the nurse should use an 18- or 19-

gauge catheter that will apply the appropriate irrigation pressure. A 24-gauge

angiocatheter delivers solutions at a higher pressure than necessary for irrigation

and a can potentially damage the developing granulation tissues.