Review Medical surgical Nursing exam (Viterbo university)

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Medical surgical Nursing exam (Viterbo university)

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Total Questions : 89

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Question 1:

The nurse is caring for a patient with diabetic ketoacidosis. Which assessment finding indicates to the nurse that the patient is experiencing fluid volume deficit?

A. Hypotension B. Bradycardia C. Polyphagia D. Rapid, deep respiration

Answer and Explanation

Choice A:

Hypotension, or low blood pressure, is a common indicator of fluid volume deficit. When a patient is dehydrated or has a significant loss of fluids, their blood volume decreases, leading to lower blood pressure. This condition requires immediate attention and management to prevent complications such as shock or organ failure. Monitoring and correcting fluid balance is crucial in managing patients with diabetic ketoacidosis, making hypotension a significant assessment finding.

Choice B:

Bradycardia, or slow heart rate, is not typically associated with fluid volume deficit. It is more often related to other conditions such as heart block, hypothyroidism, or use of certain medications. In the context of diabetic ketoacidosis, fluid volume deficit would not manifest primarily as bradycardia.

Choice C:

Polyphagia, or excessive hunger, is a symptom commonly associated with diabetes mellitus but does not indicate fluid volume deficit. Polyphagia results from the body's inability to use glucose properly, leading to increased hunger. It is not directly related to the patient's hydration status or fluid volume.

Choice D:

Rapid, deep respiration, also known as Kussmaul breathing, is a compensatory mechanism in response to metabolic acidosis, a hallmark of diabetic ketoacidosis. While it is an important clinical sign, it does not specifically indicate fluid volume deficit. Kussmaul respiration occurs due to the body's attempt to expel excess carbon dioxide and correct the acid-base imbalance.

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Question 2:

The nurse is caring for a patient with a new diagnosis of irritable bowel syndrome (IBS). The patient is upset and concerned about how they got IBS. What evidence-based information, related to the causes of IBS, will the nurse provide to this patient?

A. Your family history of common bile duct disorder is a trigger for this disease. B. The frequent occurrence of blood in your stool is the main cause of your IBS. C. People with a family history of psychiatric disorders and food allergies are more likely to get IBS. D. Environmental and psychosocial factors can be associated with the onset of this disease.

Answer and Explanation

Choice A:

Family history of common bile duct disorder is not a known trigger for irritable bowel syndrome (IBS). IBS is a functional gastrointestinal disorder with multifactorial causes, including but not limited to genetics, gut-brain axis, and environmental factors. Bile duct disorders and IBS have different pathophysiological mechanisms and are not directly linked.

Choice B:

The frequent occurrence of blood in the stool is not a cause of IBS. Blood in the stool is more indicative of other gastrointestinal conditions such as inflammatory bowel disease (IBD), colorectal cancer, or haemorrhoids. IBS is characterized by abdominal pain, bloating, and changes in bowel habits without organic pathology such as bleeding.

Choice C:

While there is some evidence suggesting that individuals with a family history of psychiatric disorders and food allergies may have a higher prevalence of IBS, it is not the main cause. These factors may contribute to the onset and exacerbation of symptoms but are part of a broader spectrum of triggers, including genetics, stress, and gut microbiota.

Choice D:

Environmental and psychosocial factors are indeed associated with the onset of IBS. Factors such as stress, anxiety, depression, and traumatic life events can play a significant role in the development and exacerbation of IBS symptoms. Additionally, environmental factors like diet, infections, and changes in gut microbiota are known to influence IBS. This choice aligns with current evidence-based understanding of the condition.

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Question 3:

The nurse is caring for a patient with heart failure who is receiving lisinopril twice a day. What intervention will the nurse implement when administering this medication?

A. Hold medication if B-type natriuretic peptide (BNP) results are high. B. Check serum potassium and creatinine levels. C. Encourage the patient to add salt substitute with all meals. D. Document extent of vision changes every shift.

Answer and Explanation

Choice A:

Holding medication if B-type natriuretic peptide (BNP) results are high is not a standard intervention when administering lisinopril. BNP levels are used to assess the severity of heart failure, but they do not directly influence the administration of lisinopril. Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that helps manage heart failure by reducing blood pressure and decreasing the workload on the heart.

Choice B:

Checking serum potassium and creatinine levels is crucial when administering lisinopril. Lisinopril can affect kidney function and electrolyte balance. It may cause hyperkalaemia (elevated potassium levels) and increase serum creatinine levels, indicating impaired kidney function. Regular monitoring of these parameters helps ensure the patient's safety and the effectiveness of the medication.

Choice C:

Encouraging the patient to add salt substitute with all meals is not recommended for patients taking lisinopril. Many salt substitutes contain potassium chloride, which can further increase the risk of hyperkalaemia in patients on ACE inhibitors like lisinopril. This intervention could lead to dangerous electrolyte imbalances.

Choice D:

Documenting the extent of vision changes every shift is not related to the administration of lisinopril. Vision changes are not a common side effect of this medication. This intervention may be more relevant for patients on medications known to affect vision, but it is not specific to lisinopril.

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Question 4:

The nurse is caring for a patient with end-stage kidney disease (ESKD). Which arterial blood gas results (ABG) will the nurse correlate with the patient's condition?

A. pH 7.21, PaCO2 36, HCO3 14 B. pH 7.50, PaCO2 29, HCO3 22 C. pH 7.47, PaCO2 45, HCO3 33 D. pH 7.31, PaCO2 48, HCO3 24

Answer and Explanation

Choice A:

The ABG results of pH 7.21, PaCO2 36, HCO3 14 indicate metabolic acidosis, which is common in patients with end-stage kidney disease (ESKD). In ESKD, the kidneys lose their ability to excrete acid and maintain bicarbonate levels, leading to an accumulation of acid in the blood. This condition results in a low pH (acidic), normal PaCO2 (as the respiratory system attempts to compensate), and low HCO3 (bicarbonate).

Choice B:

The ABG results of pH 7.50, PaCO2 29, HCO3 22 indicate respiratory alkalosis, which is not typically associated with ESKD. Respiratory alkalosis occurs when there is excessive exhalation of carbon dioxide, leading to a higher pH (alkaline). This condition is more likely to be seen in situations such as hyperventilation, anxiety, or certain lung diseases.

Choice C:

The ABG results of pH 7.47, PaCO2 45, HCO3 33 indicate metabolic alkalosis, which is not typically associated with ESKD. Metabolic alkalosis occurs when there is an excess of bicarbonate or a loss of acid. This condition can result from factors such as vomiting, diuretic use, or excessive antacid consumption. It is not a common finding in patients with ESKD.

Choice D:

The ABG results of pH 7.31, PaCO2 48, HCO3 24 indicate respiratory acidosis, which is not typically associated with ESKD. Respiratory acidosis occurs when there is an accumulation of carbon dioxide due to impaired respiratory function. This condition is more likely to be seen in chronic obstructive pulmonary disease (COPD) or other respiratory disorders. It is not a common finding in patients with ESKD.

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Question 5:

The nurse is caring for a patient diagnosed with rheumatoid arthritis (R

A. Osteoarthritis B. Osteoporosis C. Hyperglycaemia D. Mucositis

Answer and Explanation

Choice A:

Osteoarthritis is a degenerative joint disease characterized by the breakdown of cartilage and underlying bone. It is not directly associated with corticosteroid treatment. Osteoarthritis develops due to wear and tear over time, and while corticosteroids are used to manage inflammation, they do not cause osteoarthritis.

Choice B:

Osteoporosis is a potential complication of long-term corticosteroid use. Corticosteroids can interfere with bone formation and increase the rate of bone resorption, leading to decreased bone density and an increased risk of fractures. Patients on long-term corticosteroid therapy should be monitored for signs of osteoporosis, and preventive measures such as calcium and vitamin D supplementation may be recommended.

Choice C:

Hyperglycaemia, or elevated blood glucose levels, is a common side effect of corticosteroid therapy. Corticosteroids can increase insulin resistance and promote glucose production in the liver, leading to higher blood sugar levels. Patients with diabetes or those at risk for diabetes should be closely monitored for changes in their blood glucose levels when on corticosteroid therapy.

Choice D:

Mucositis, or inflammation of the mucous membranes, is not a typical complication of corticosteroid therapy. Mucositis is more commonly associated with chemotherapy or radiation therapy used in cancer treatment. While corticosteroids can affect the immune system, they do not directly cause mucositis.

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Question 6:

The nurse is caring for a patient with chronic kidney disease (CKD) who is at risk for renal osteodystrophy. Which intervention will the nurse implement to manage this condition?

A. Administer phosphate binders with meals. B. Encourage the patient to increase potassium-rich foods. C. Monitor calcium levels for signs of hypocalcaemia. D. Increase fluid intake to 3 litters per day.

Answer and Explanation

Choice A:

Administering phosphate binders with meals is an essential intervention for managing renal osteodystrophy in patients with chronic kidney disease (CKD). Renal osteodystrophy results from an imbalance of calcium and phosphate in the body due to impaired kidney function. Phosphate binders help reduce the absorption of phosphate from the diet, thereby lowering serum phosphate levels and preventing complications such as secondary hyperparathyroidism and bone disorders. This intervention helps maintain the proper balance of minerals, improving bone health and reducing the risk of fractures and other skeletal complications in CKD patients.

Choice B:

Encouraging the patient to increase potassium-rich foods is not appropriate for managing renal osteodystrophy. Patients with CKD often need to limit their potassium intake because impaired kidney function can lead to hyperkalaemia (elevated potassium levels), which is potentially life-threatening. Instead of promoting potassium-rich foods, the focus should be on controlling phosphate and maintaining calcium levels.

Choice C:

Monitoring calcium levels for signs of hypocalcaemia is important in CKD management, but it is not the primary intervention for renal osteodystrophy. While hypocalcaemia can occur in CKD due to disrupted vitamin D metabolism, addressing phosphate levels through the use of phosphate binders is a more targeted approach to managing renal osteodystrophy and preventing secondary hyperparathyroidism.

Choice D:

Increasing fluid intake to 3 litters per day is generally not recommended for CKD patients, especially those with reduced urine output or fluid retention issues. Excessive fluid intake can lead to fluid overload, hypertension, and heart failure in CKD patients. The intervention should focus on phosphate control rather than fluid intake adjustments.

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Question 7:

The nurse is caring for a patient receiving chemotherapy who is admitted with an absolute neutrophil count (ANC) of 459 cells/ulu. The healthcare provider orders G-CSF (filgrastim). Which action will the nurse take to promote safe and effective use of filgrastim for this patient?

A. Monitor the patient's ANC daily and stop medication when the ANC is greater than 20,000 cells/ulu. B. Teach the patient how to administer the medication via intramuscular. C. Ensure the patient understands the risk of bone pain and how to manage it. D. Administer filgrastim as needed for symptoms of infection.

Answer and Explanation

Choice A:

Monitoring the patient's absolute neutrophil count (ANC) daily and stopping medication when the ANC is greater than 20,000 cells/uL is an essential aspect of using filgrastim safely. However, this is typically managed by the healthcare provider and not the primary action for the nurse to take for patient education. The nurse's role focuses more on educating the patient about potential side effects and self-care.

Choice B:

Teaching the patient how to administer the medication via intramuscular is not relevant for filgrastim, as it is typically administered via subcutaneous injection. Proper administration technique is crucial for ensuring the medication's effectiveness, but this choice does not accurately reflect the standard administration method for filgrastim.

Choice C:

Ensuring the patient understands the risk of bone pain and how to manage it is crucial for promoting safe and effective use of filgrastim. Bone pain is a common side effect of filgrastim due to the stimulation of bone marrow to produce more neutrophils. Educating the patient about this potential side effect and providing strategies for managing the pain, such as using over-the-counter pain relievers, helps improve patient comfort and adherence to the medication.

Choice D:

Administering filgrastim as needed for symptoms of infection is not appropriate. Filgrastim is used to stimulate neutrophil production and prevent infection, rather than treating active infections. The medication should be administered according to the prescribed schedule, not based on the presence of infection symptoms.

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Question 8:

The nurse is caring for a patient with respiratory alkalosis. Which clinical manifestations will the nurse expect to find?

A. Lethargy and hypoxia B. Light-headedness and muscle spasms C. Hypotension and respiratory depression D. Muscle twitching and hyperkalaemia

Answer and Explanation

Choice A:

Lethargy and hypoxia are not typically associated with respiratory alkalosis. Respiratory alkalosis occurs when there is excessive exhalation of carbon dioxide, leading to a decrease in blood CO2 levels and an increase in pH. Lethargy and hypoxia are more often related to respiratory acidosis, where CO2 accumulates due to hypoventilation.

Choice B:

Light-headedness and muscle spasms are common clinical manifestations of respiratory alkalosis. The decrease in carbon dioxide (CO2) levels leads to cerebral vasoconstriction, resulting in light-headedness or dizziness. Additionally, respiratory alkalosis can cause a shift of calcium in the blood, leading to muscle spasms, tingling, and even tetany.

Choice C:

Hypotension and respiratory depression are not typical findings in respiratory alkalosis. Hypotension can be a symptom of various conditions but is not directly associated with respiratory alkalosis. Respiratory depression is related to hypoventilation and respiratory acidosis, not hyperventilation.

Choice D:

Muscle twitching and hyperkalaemia are not manifestations of respiratory alkalosis. Hyperkalaemia is more commonly seen in metabolic acidosis and not in respiratory alkalosis. Muscle twitching can occur in various conditions, but respiratory alkalosis typically causes muscle spasms and tetany due to calcium shifts.

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Question 9:

The nurse is caring for a patient 22 hours after undergoing kidney transplantation. The patient develops hyperacute rejection of the transplanted kidney. What intervention will the nurse anticipate for this patient at this time?

A. Removal of the transplanted kidney. B. An increase in the dose of cyclosporine therapy. C. A new kidney transplant from a living donor. D. Administration of methylprednisolone sodium succinate.

Answer and Explanation

Choice A:

Removal of the transplanted kidney is the definitive intervention for hyperacute rejection. Hyperacute rejection occurs within minutes to hours after transplantation due to pre-formed antibodies against the donor organ. This form of rejection is irreversible and requires immediate removal of the transplanted kidney to prevent further complications and damage to the recipient's health.

Choice B:

An increase in the dose of cyclosporine therapy is not effective in hyperacute rejection. Cyclosporine is an immunosuppressive medication used to prevent rejection, but in cases of hyperacute rejection, the rapid and severe immune response cannot be controlled by increasing the dose. The affected kidney must be removed.

Choice C:

A new kidney transplant from a living donor is not an immediate intervention for hyperacute rejection. Before considering another transplant, it is essential to identify and address the underlying cause of hyperacute rejection and ensure that the recipient's immune system is adequately managed to prevent recurrence.

Choice D:

Administration of methylprednisolone sodium succinate is typically used to manage acute rejection episodes but is not effective for hyperacute rejection. The rapid onset and severity of hyperacute rejection necessitate the removal of the transplanted organ rather than relying on immunosuppressive medications.

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Question 10:

The nurse is caring for a trauma patient who has the following arterial blood gas (ABG) results: pH 7.52, PaCO2 55, HCO3 30 me/L. How will the nurse interpret these results?

A. Respiratory alkalosis with partial compensation B. Metabolic alkalosis with partial compensation C. Metabolic alkalosis with no compensation D. Metabolic acidosis with partial compensation

Answer and Explanation

Choice A:

Respiratory alkalosis with partial compensation is characterized by a high pH, low PaCO2, and a compensatory decrease in HCO3. In this case, the pH is high (alkaline), PaCO2 is high, and HCO3 is elevated, indicating that the primary disorder is metabolic alkalosis, not respiratory alkalosis.

Choice B:

Metabolic alkalosis with partial compensation is indicated by a high pH (alkaline), high HCO3 (bicarbonate), and a high PaCO2 (carbon dioxide) as a compensatory mechanism by the respiratory system. In this case, the pH is 7.52 (alkaline), PaCO2 is 55 mmHg, and HCO3 is 30 mEq/L, which fits the profile of metabolic alkalosis with the respiratory system attempting to compensate by retaining CO2.

Choice C:

Metabolic alkalosis with no compensation would present with a high pH and high HCO3, but normal PaCO2. In this case, the PaCO2 is elevated, indicating that there is some level of respiratory compensation occurring, which rules out the "no compensation" scenario.

Choice D:

Metabolic acidosis with partial compensation would present with a low pH, low HCO3, and low PaCO2 as a compensatory mechanism. In this case, the pH is high (alkaline), not low, which is inconsistent with metabolic acidosis.

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