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Ati Nur 212 Med Surg Proctored Exam
Total Questions : 57
Showing 10 questions, Sign in for moreA nurse is teaching a client diagnosed with Crohn's disease about a low-fiber diet. Which of the following statements indicates the client understands the teaching?
Mr. Smith had a TURP earlier today and is receiving continuous bladder irrigation (CBI). The new CBI irrigation bag (3 L volume) was hung at 1800 h. At 2100 h, the bag still has 1.8 L remaining. The nurse empties the urine collection bag and measures 1,500 mL of pink-tinged fluid with a few small clots. The nurse is calculating the amount of urine output. What volume should the nurse document as urine output in ml?
Explanation
Step 1: Identify the formula
Urine output = Total drainage − Irrigation solution infused
Step 2: Calculate the irrigation infused
Starting irrigation volume = 3 L = 3,000 mL
Remaining irrigation volume = 1.8 L = 1,800 mL
Irrigation infused = 3,000 mL − 1,800 mL = 1,200 mL
Step 3: Identify the total drainage
Total drainage in urine collection bag = 1,500 mL
Step 4: Calculate the actual urine output
= 1,500 mL − 1,200 mL
= 300 mL
Final Answer: 300 mL
The nurse is taking care of a patient after a thyroidectomy. Which assessment finding is the priority?
1100:
35-year-old client received from the PACU following a total thyroidectomy. Drowsy but responds appropriately. Skin warm and dry. Respirations unlabored. Lung sounds are clear to auscultation. Heart sounds moderate and regular. Abdomen soft, nondistended with active bowel sounds x4. No peripheral edema noted. Client reports pain at the incision site and rates pain as 4 on a scale of 0 to 10. Incisional dressing on neck intact; scant sanguineous drainage noted.
1500:
Client is restless, with tremors noted in extremities. Client reports nausea, vomiting, and abdominal pain. Rates pain as 5 on a scale of 0 to 10. Denies discomfort at the incision site. Heart sounds moderate and regular. Lung sounds diminished bibasilar.
Calcium level 10.1 mg/dL (9.0-10.5 mg/dL)
A nurse is caring for a 35-year-old client on a medical-surgical floor.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Explanation
Rationale for Correct Choices
- Thyroid storm: The client develops restlessness, tremors, nausea, vomiting, abdominal pain, and increasing systemic symptoms several hours after a total thyroidectomy. These findings are consistent with thyroid storm, a rare but life-threatening complication caused by a sudden release of thyroid hormones. Although fever and marked tachycardia are common, early manifestations include agitation, tremors, and gastrointestinal symptoms. The normal calcium level (10.1 mg/dL) makes hypocalcemia an unlikely cause of the symptoms.
- Maintain an oral airway: Thyroid storm can rapidly progress to respiratory compromise due to severe metabolic demand, altered mental status, and possible airway edema following neck surgery. Maintaining a patent airway is a priority intervention.
- Apply a cardiac monitor: Excess thyroid hormone increases myocardial oxygen demand and cardiac excitability, placing the client at high risk for tachyarrhythmias and other dysrhythmias. Continuous ECG monitoring allows for prompt detection and treatment.
- Dysrhythmias: Cardiac complications are a major cause of morbidity and mortality in thyroid storm. Continuous monitoring helps identify tachycardia, atrial fibrillation, or other life-threatening arrhythmias.
- Calcium level: Although the current calcium level is normal, clients following thyroidectomy remain at risk for hypocalcemia due to accidental injury or removal of the parathyroid glands. Continued monitoring helps detect postoperative electrolyte disturbances.
Rationale for Incorrect Choices
- Hypercalcemia: The client's calcium level is within the normal range. Hypercalcemia typically presents with weakness, constipation, polyuria, and confusion rather than tremors and acute postoperative symptoms.
- Hemorrhage: Post-thyroidectomy hemorrhage usually presents with neck swelling, excessive drainage, respiratory distress, dysphagia, or tracheal deviation. The dressing shows only scant drainage and there are no signs of neck hematoma.
- Paralytic ileus: Paralytic ileus presents with abdominal distention, absent bowel sounds, nausea, and vomiting. This client has abdominal pain and gastrointestinal symptoms but no evidence of abdominal distention or absent bowel sounds, and the neurologic findings are more consistent with thyroid storm.
- Insert nasogastric tube: This intervention is appropriate for bowel obstruction or paralytic ileus, not thyroid storm.
- Obtain a hemoglobin level: There is no evidence of significant blood loss or hemorrhage that would warrant immediate hemoglobin assessment.
- Obtain a prescription for furosemide: Furosemide may be used in hypercalcemia or fluid overload but is not indicated for thyroid storm.
- Incisional dressing: Routine postoperative assessment is appropriate, but the dressing is intact with only scant drainage and is not the primary indicator of the client's deteriorating condition.
- Bowel sounds: Monitoring bowel sounds is more relevant for suspected paralytic ileus than for thyroid storm.
- Patency of urinary catheter: There is no indication that the client has a urinary catheter or urinary complications requiring priority monitoring.
The nurse is caring for a patient with a history of epilepsy who is taking phenytoin. The patient's morning labs are back, and the phenytoin level is 7 mcg/mL (10-20 mcg/mL). Based on this finding, what is the nurse's priority action?
A nurse is preparing to administer amoxicillin 30 mg/kg/day divided equally every 12 hr to a toddler who weighs 33 lbs. Available is amoxicillin 200 mg/5 mL suspension. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Step 1: Identify the formula
mL per dose = [(Weight in kg × Prescribed dose per kg per day) ÷ Number of doses per day] ÷ Concentration (mg/mL)
Step 2: Convert weight and determine doses per day
33 lb ÷ 2.2 = 15 kg
Medication is given every 12 hr = 2 doses/day
Step 3: Calculate the daily dose
= 30 mg/kg/day × 15 kg
= 450 mg/day
Step 4: Calculate the dose per administration
Dose per dose = 450 mg ÷ 2
= 225 mg
Available concentration = 200 mg/5 mL
mL per dose = (225 mg ÷ 200 mg) × 5 mL
= 1.125 × 5
= 5.625 mL
Step 5: Round to the nearest tenth
= 5.6 mL
Final Answer: 5.6 mL
You are the nurse case manager discussing discharge options with a patient who has prostate cancer. The patient asks, "What is the difference between palliative and hospice care?" Which of the following is your best response?
A 7-year-old patient is being evaluated for seizures. While in the child's room talking with the parents, you notice the child appears to be daydreaming. You time this event to be 10 seconds. After 10 seconds, the child appropriately responds and does not recall the event. The nurse hypothesizes that the client is experiencing which type of seizure?
A nurse is caring for a client who is unable to express their own wishes, and does not have any advanced directives. The family is in a state of disagreement over the care of their family member. The nurse should report the situation to which of the following facility personnel?
You are caring for a patient who has arrived in the Emergency Department and reports she has just been raped. You have determined that there are no life- threatening injuries, and you are waiting for the arrival of the Sexual Assault Nurse Examiner. Which of the following actions should you perform to preserve the existence of any evidence? (Select 3 options that apply.)
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