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Rn Adult Medical Surgical 2023 Proctored Exam
Total Questions : 96
Showing 10 questions, Sign in for moreA nurse is caring for a client who is receiving vancomycin IV. Which of the following findings should the nurse document as an adverse reaction to this medication?
Type 1 diabetes mellitus since the age of 15 that is well- controlled with NPH insulin injections, diet, and exercise.
Mild diabetic neuropathy to lower extremities
Admission:
1400:
Oriented to time, place, and self. Client is lethargic and reports headache and fatigue.
Skin is warm and moist with decreased turgor. Mucous membranes are dry and client reports thirst.
Pulse is rapid, S₁ and S₂ heard on auscultation. Peripheral pulses palpable. Capillary refill less than 2 seconds.
Respirations deep and rapid. Fruity odor noted to breath.
Rhonchi to right lung on auscultation and frequent nonproductive cough noted.
Bowel sounds x 4 quadrants; client denies diarrhea or vomiting.
Client reports frequent urination with no difficulty.
Admission
1400:
- Temperature 38° C (100,4° F)
- Heart rate 107/min
- Respiratory rate 26/min
- Blood pressure 118/72 mm Hg
- Spo2 saturation 93% on room air
1900:
- Temperature 38.3° C (101° F)
- Heart rate 122/min
- Respiratory rate 28/min
- Blood pressure 108/68 mm Hg
- Spo2 saturation 96% on 2 L/min per nasal cannula
Chest x-ray: Posterior, anterior, and lateral chest x-rays show right lower lobe pleural effusion, which indicates pneumonia.
Urine ketones positive (Negative)
Basic Metabolic Profile (BMP):
Sodium 130 mEq/L (136 to 145 mEq/L)
Potassium 5.2 mEq/L (3.5 to 5 mEq/L)
Glucose 480 mg/dL (74 to 106 mg/dL)
BUN 22 mg/dL (10 to 20 mg/dL)
Creatinine 1 mg/dL (0.5 to 1 mg/dL)
HbA1c 6.5% (Good diabetic control less than 7%)
ABGS:
pH 7.32 (7.35 to 7.45)
PCO2 32 mm Hg (35 to 45 mm Hg)
HCO2 19 mEq/L (22 to 26 mEq/L)
PO2 92 mm Hg (80 to 100 mm Hg)
Click to highlight the findings below that require immediate follow-up. To deselect a finding, click on the finding again.
|
Body System |
Findings |
|
Cardiovascular
|
Pulse is rapid, S1 and S2 on auscultation. Peripheral pulses palpable. Capillary refill less than 2 seconds. Blood pressure |
|
Respiratory |
Respirations deep and rapid. Fruity odor noted to breath. Rhonchi to right lung on auscultation, frequent nonproductive cough noted. Respiratory rate ABGS |
|
Genitourinary |
Client reports frequent urination with no difficulty. Urine ketones BUN level |
Explanation
This client with type 1 diabetes mellitus presents with severe hyperglycemia, infection (pneumonia), and metabolic decompensation. Findings such as fruity breath odor, deep rapid respirations, positive urine ketones, and abnormal ABGs indicate diabetic ketoacidosis (DKA) likely triggered by infection. DKA is a life-threatening emergency characterized by insulin deficiency, ketosis, metabolic acidosis, and compensatory respiratory changes. Immediate follow-up is required for findings indicating worsening acid-base imbalance, respiratory compensation, and ongoing ketone production.
Rationale for correct findings:
• Cardiovascular (rapid pulse): A rapid pulse indicates compensatory tachycardia due to dehydration, fever, and metabolic stress associated with DKA and infection. Fluid loss from osmotic diuresis leads to decreased circulating volume, triggering increased heart rate to maintain perfusion. This may progress to hemodynamic instability if untreated. Therefore, cardiovascular changes require immediate follow-up.
• Blood pressure decreasing from 118/72 to 108/68 mm Hg, combined with a heart rate rising from 107 to 122/min, signals progressive intravascular volume depletion and impending hypovolemic shock due to profound osmotic diuresis.
• Respiratory (deep and rapid respirations, fruity breath, rhonchi, cough): Deep, rapid respirations (Kussmaul breathing) indicate respiratory compensation for metabolic acidosis in DKA. Fruity breath odor reflects ketone accumulation, confirming fat metabolism due to insulin deficiency. Rhonchi and cough suggest pneumonia, which is the likely precipitating infection. These combined findings represent both the cause and complication of DKA and require urgent attention.
• Respiratory rate: An increased respiratory rate reflects worsening metabolic acidosis as the body attempts to blow off CO₂ to compensate for low bicarbonate levels. In this client, the elevated rate (tachypnea) indicates progression of diabetic ketoacidosis severity. Failure to correct this may lead to respiratory fatigue and decompensation. Therefore, respiratory rate trends require immediate monitoring.
• ABGs: ABG results show metabolic acidosis (pH 7.32, HCO₃⁻ 19 mEq/L) with respiratory compensation (low CO₂). This confirms diabetic ketoacidosis with partial compensation. Worsening ABGs would indicate failure of metabolic correction and increasing severity of acid-base imbalance. Therefore, ABGs are critical for immediate follow-up and ongoing monitoring.
• Urine ketones: Positive urine ketones confirm ongoing fat metabolism due to insulin deficiency. This indicates that the body continues to break down fatty acids, producing acidic ketone bodies. Persistent ketonuria signals active or worsening DKA. Monitoring ketones helps evaluate response to insulin therapy and resolution of metabolic crisis.
Rationale for incorrect choices:
• Genitourinary (frequent urination with no difficulty): Frequent urination is an expected osmotic diuresis finding in hyperglycemia and DKA due to excess glucose in the urine. It reflects the body’s attempt to eliminate glucose and is not an immediate deterioration marker compared to acid-base imbalance or respiratory compensation. While important for fluid balance monitoring, it does not indicate acute worsening requiring urgent intervention in isolation.
• Capillary refill less than 2 seconds: Capillary refill of less than 2 seconds indicates adequate peripheral perfusion and is a normal finding in this client. It suggests that there is no current evidence of significant peripheral circulatory compromise or shock at the time of assessment. In diabetic ketoacidosis, perfusion may deteriorate as dehydration worsens, but this specific finding reflects stability rather than deterioration. Therefore, it does not require immediate follow-up compared to metabolic and respiratory abnormalities.
A nurse is caring for a client who has tuberculosis. The client has a WBC count of 5,100/mm3 (5,000 to 10,000/mm3). Which of the following types of isolation precautions should the nurse implement?
A nurse is performing an intake interview for a male client who has low testosterone levels. Which of the following findings should the nurse expect?
1100:
Client presents to the provider's office for follow-up appointment. Client has been taking new prescription medication spironolactone for 1 month.
1115:
Labs, vital signs, and ECG were obtained.
1100:
- Temperature 36.4° C (97.5° F)
- Heart rate 60/min
- Respiratory rate 20/min
- Blood pressure 98/64 mm Hg
- Oxygen saturation 97% on room air
1115:
- Temperature 36.4° C (97.5° F)
- Heart rate 64/min
- Respiratory rate 22/min
- Blood pressure 104/70 mm Hg
- Oxygen saturation 96% on room air
1130:
ECG: Peaked T waves with absent P waves. Rate 60/min
1130:
Sodium 140 mEq/L (136 to 145 mEq/L)
Potassium 6 mEq/L (3.5 to 5 mEq/L)
BUN 18 mg/dL (10 to 20 mg/dL)
Creatinine 0.8 mg/dL (0.5 to 1 mg/dL)
A nurse is preparing to directly admit a client from the provider's office and is reviewing their electronic medical record.
When assessing the client, which of the following findings should the nurse expect? Select all that apply.
A home health nurse is reviewing safety with the family of a client who uses home oxygen therapy. Which of the following information should the nurse Include?
A nurse is caring for a client who has hypothyroidism and is receiving levothyroxine. Which of the following findings should the nurse identify as an indication the client is receiving an inadequate dosage of the medication?
Provider's office, 3 months ago:
Client who has COPD being seen in office for annual physical examination. Client appears thin with barrel chest. Finger clubbing present. Sitting in forward-bending posture with arms resting on legs. Cough present; patient reports coughing up clear mucous secretions. Expiratory wheezes auscultated in all lung fields. Denies pain; states, "I get short of breath walking up and down the stairs in my house." Reports they do not wear oxygen at home. Client reports they are attempting to stop smoking but state they smoke about two packs per day.
Today, 0640:
Client admitted from the emergency department with reports of increasing fatigue, cough, and decreased appetite. Client appears thin with barrel chest. Reports 11.3 kg (25 lb) weight loss over past 4 weeks. Client reports they were diagnosed with COPD 6 years ago but continue to smoke two packs of cigarettes per day.
Today, 0700:
Client resting comfortably in bed. Expiratory wheezes with decreased breath sounds noted in all lung fields. Light skin tone, color ash gray with cyanosis noted around mouth. Finger clubbing noted. Client has cough with moderate amount of purulent sputum. Abdomen soft with positive bowel sounds. S1 and S2 heart tones auscultated. Oxygen in place via nasal cannula. Client states, "I hope I am discharged soon. We are supposed to attend a large family wedding next weekend."
3 months ago:
- Temperature 37.1°C (98.8° F)
- Heart rate 98/min
- Respiratory rate 22/min
- Blood pressure 114/74 mm Hg
- Oxygen saturation 91% on room air
Today, 0645:
- Temperature 37.1° C (98.8° F)
- Heart rate 112/min
- Respiratory rate 40/min
- Blood pressure 100/62 mm Hg
- Oxygen saturation 86% on room air
For each nursing action, click to specify if the nursing action is indicated or not indicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.
Explanation
This client has advanced chronic obstructive pulmonary disease (COPD) with acute worsening characterized by hypoxemia, tachypnea, purulent sputum, weight loss, and cyanosis. The presentation is consistent with an acute COPD exacerbation likely triggered by infection and ongoing smoking. COPD management focuses on improving oxygenation without suppressing respiratory drive, promoting energy conservation, preventing further lung damage, and supporting nutrition due to increased metabolic demand. Nursing care must balance oxygen therapy, airway clearance, and long-term lifestyle modification.
Rationale for correct choices:
• Maintain client in supine position: The supine position decreases lung expansion and increases work of breathing in COPD clients. It can worsen dyspnea by limiting diaphragmatic movement and promoting airway compression. These clients typically benefit more from high Fowler’s or tripod positioning. Therefore, supine positioning is contraindicated.
• Educate on smoking cessation: Smoking is the primary cause of COPD progression and continued smoking worsens airway inflammation, mucus production, and lung destruction. Ongoing exposure to cigarette smoke accelerates decline in lung function and increases exacerbation frequency. Education on cessation is essential to slow disease progression and improve outcomes. This is a foundational long-term management intervention.
• Encourage participation in community activities: COPD can lead to social isolation, depression, and decreased quality of life due to chronic dyspnea and fatigue. Encouraging safe participation in community or family activities supports psychosocial well-being and improves coping. Activity should be paced and within oxygen tolerance limits. This promotes emotional health and functional independence.
• Administer supplemental oxygen to maintain oxygen saturation at 98% to 100%: In COPD, excessive oxygen administration can suppress the hypoxic respiratory drive and worsen carbon dioxide retention, leading to CO₂ narcosis. Target oxygen saturation is typically 88% to 92%, not near-normal saturation levels. Over-oxygenation increases the risk of respiratory acidosis and respiratory failure. Therefore, maintaining 98–100% oxygen saturation is unsafe in this client.
• Provide four to six small meals per day: Clients with COPD often experience increased work of breathing, which elevates caloric expenditure and reduces appetite. Small, frequent meals reduce diaphragmatic pressure and prevent fatigue during eating. This approach improves nutritional intake and helps prevent further weight loss and muscle wasting. Nutrition is critical in maintaining respiratory muscle strength.
• Allow for adequate rest periods: Rest periods reduce oxygen demand and prevent fatigue in clients with compromised lung function. COPD exacerbations increase work of breathing, making energy conservation essential. Scheduled rest helps reduce dyspnea and improves tolerance for activities of daily living. This supports overall respiratory efficiency and recovery.
A nurse is assessing a client who is receiving morphine for pain and has a respiratory rate of 8/min and a blood pressure of 80/40 mm Hg. Which of the following medications should the nurse administer?
A nurse is caring for a client who has a burn injury that has resulted in contractures of their fingers. For which of the following interprofessional team members should the nurse initiate a referral?
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