Physiological Adaptations Quiz

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Medical Surgical Nursing ► Physiological Adaptations Quiz
Started on Thursday, 14 July 2022, 9:31 PM
State
Finished
Completed on Thursday, 14 July 2022, 9:41 PM
Time taken 9 mins 49 secs
Marks
30.00/30.00
Grade 100.00 out of 100.00
Question 1
Correct
Mark 1.00 out of
A nurse is caring for a client diagnosed with diabetes. The nurse notes that the client
has a mild tremor, slight diaphoresis and is fully oriented. Which of the following nursing
actions should have the highest priority?
1.00
Flag question
Select one:
a. Assess the client's blood glucose level.
Check the patient’s blood glucose.
Although it is most likely that this patient is experiencing hypoglycemia, the blood
glucose must be checked to confirm the problem and also to document HOW LOW
the blood glucose is, which further helps determine the best treatment. Most
facilities have protocols to treat hypoglycemia based on the blood glucose results.
In addition, we can better evaluate how our interventions work when we compare
later blood glucoses with the first blood glucose taken while the patient had
symptoms.
b. Give the client 4 ounces of orange juice.
c. Call the lab for a stat glucose level.
d. Administer 50% Dextrose via IV push.
The correct answer is: Assess the client's blood glucose level.
Question 2
Correct
Mark 1.00 out of
1.00
Flag question
A client is admitted to the surgical unit after sustaining a compound fracture of the left
femur. The client is alert and oriented with the following vital signs: T 99.4 F, P 88, R
20, B/P 94/58. The nurse notes a 4 cm. area of bright red blood on the pressure
dressing on the left lower extremity. The client is receiving intravenous fluids of normal
saline at 150 ml/hr. One hour after being admitted to the unit, the nurse finds the client
confused and combative. Which of the following is the most likely cause of the change
in the client’s condition?
Select one:
a. Fluid overload related to aggressive isotonic volume replacement
b. Hypovolemic shock related to hemorrhage from the open wound
c. Hypoxia related to fat embolism from the fractured bone.
Although the
mechanism is not really clear, it is thought that in compound long bone fractures
the internal pressure in the fracture forces fat globules from the marrow into the
systemic circulation, where they act as emboli. Initial symptoms within 24-48 hours
post-fracture include confusion and combativeness secondary to hypoxemia.
d. Infectious process related to contamination of the open wound.
The correct answer is: Hypoxia related to fat embolism from the fractured bone.
Question 3
Correct
Mark 1.00 out of
A nurse is caring for a client on the telemetry unit who is two days post coronary artery
bypass grafting (CABG). The nurse recognizes a cardiac rhythm change from normal
sinus rhythm to atrial fibrillation. Which of the following should be completed first?
1.00
Flag question
Select one:
a. Prepare a diltizem drip.
b. Notify the health care provider.
c. Prepare the client for cardioversion.
d. Assess the client’s blood pressure.
Atrial fibrillation frequently occurs after
CABG. In A-Fib the atrial kick is lost and cardiac output (C.O.) is decreased by
30%. Clients react differently to A-Fib and the decreased C.O. Some clients
become hypotensive and develop shock-like symptoms: changes in LOC; cool,
clammy skin; dyspnea; and chest pain. While other clients are normotensive
despite the decrease in C.O., they are asymptomatic or considered stable.
Treatment for A-Fib depends on the status of the client. The first action the nurse
should take with a client who has converted from NSR to A-Fib is to assess the
clients BP.
The correct answer is: Assess the client’s blood pressure.
Question 4
Correct
The nurse is planning care for a client who is prescribed antiembolic stocking following
abdominal surgery. Which of the following interventions should the nurse include?
Mark 1.00 out of
1.00
Flag question
Select one:
a. Ensure stockings are loose fitting over client’s calves.
b. Encourage client to only wear stockings when out of bed.
c. Remove stocking every 2 hours then reapply after 1 hour off.
d. Remove stockings one to three times per day for skin care and inspection.
Antiembolic stockings should be removed one to three times per day to allow for
skin care and assessment. The client’s extremities should be monitored for calf
pain, warmth, erythema and edema.
The correct answer is: Remove stockings one to three times per day for skin care and
inspection.
Question 5
Correct
Mark 1.00 out of
A nurse is teaching lifestyle modifications to a client diagnosed with hypertension.
Which of the following statements made by the client indicates a need for further
teaching?
1.00
Flag question
Select one:
a. “I don’t like to walk, but I do aerobics and work out at the gym during the week.”
b. “We have a glass of wine a couple of times a week with dinner.”
c. “Losing weight is so hard, but so far I am losing 2 pounds a week.”
d. “I will substitute mushrooms for the bacon in my daily omelets.”
Daily
omelets are not recommended as eggs are high in cholesterol and can lead to an
increase in blood pressure due to promotion of atherosclerosis.
The correct answer is: “I will substitute mushrooms for the bacon in my daily omelets.”
Question 6
Correct
A nurse is caring for a client with Addison's disease. Which of the following diets should
the nurse teach the client to follow?
Mark 1.00 out of
1.00
Flag question
Select one:
a. Low Sodium, high calcium and decreased fluids.
b. High Sodium, low potassium and increased fluids.
The client with Addison's
disease should have a diet high in sodium, low in potassium and increased fluids.
In addition, these clients should be encouraged to consume small frequent meals
to prevent hypoglycemia.
c. Low Sodium, high potassium and decreased fluids.
d. High Sodium, low calcium and increased fluids.
The correct answer is: High Sodium, low potassium and increased fluids.
Question 7
Correct
A nurse is caring for a client who is experiencing a sodium level of 119 mEq/L. Which
nursing action would be most appropriate at this time?
Mark 1.00 out of
1.00
Flag question
Select one:
a. Monitor for diminished breath sounds.
b. Administer 0.9% Normal Saline.
Administering of isotonic IV therapy would
be appropriate at this time for restoration of normal ECF volume.
c. Provide oral hygiene and comfort measures.
d. Encourage water and other fluids.
The correct answer is: Administer 0.9% Normal Saline.
Question 8
Correct
Mark 1.00 out of
A nurse is caring for a client with diabetes insipidus (DI) who has been prescribed
aqueous vasopressin. Which of the following outcomes indicates that treatment has
been effective?
1.00
Flag question
Select one:
a. Blood pressure of 90/50 mm Hg
b. Pulse rate of 126 beats/minute
c. Fluid intake of 2,400mL in 24 hours
DI is characterized by polyuria (up to
8L/day), constant thirst, and an unusually high oral intake of fluids. Treatment with
Lypressin should decrease the urine output and oral fluid intake.
d. Urine output of 200mL per hour
The correct answer is: Fluid intake of 2,400mL in 24 hours
Question 9
Correct
Which of the following should the nurse use to determine the neurological status of a
client with a head injury?
Mark 1.00 out of
1.00
Flag question
Select one:
a. Respiratory rate
b. Client’s reported pain scale
c. Manifestations of seizure activity
d. The Glasgow Coma Scale
The Glasgow Coma Scale (GCS) is used to
determine the client’s level of consciousness (LOC). This is done with a head injury
client at regular intervals, because LOC changes precede all other changes in vital
and neurological signs. Each response is scored to predetermined criteria. The
score is calculated numerically and the higher the score the higher the
functioning.
The correct answer is: The Glasgow Coma Scale
Question 10
Correct
Mark 1.00 out of
1.00
Flag question
A client is admitted to the medical unit from the convalescent center for treatment of
urosepsis. The client’s adult daughter reports to the nurse, “I don’t know what to do. I
love my mom and would like to have her live in my home, but I just can’t be with her
every minute, and that’s what she needs now.” Which of the following would be the
best approach to improve integration of the elderly mother into the family structure?
Select one:
a. Offer to refer the daughter to a counselor in an effort to better deal with her
feelings of guilt.
b. Determine if the daughter would consider having the client visit in her home one
day a week.
Even if it is not feasible for the elderly parent to live full-time with
the adult child, it may be very feasible for the parent to visit the adult child’s home
and integrate into the family structure for hours at a time, or even overnight. Using
that approach, the adult daughter could structure time to be exclusively with the
adult parent without it being full-time.
c. Suggest that the daughter move the client into the family home on a trial basis
for several weeks.
d. Assist the daughter in finding a caregiver who can assist the client in the
convalescent center.
The correct answer is: Determine if the daughter would consider having the client visit
in her home one day a week.
Question 11
Correct
A nurse is reviewing a client’s lab results. Which finding would lead the nurse to
suspect the client is experiencing dehydration?
Mark 1.00 out of
1.00
Flag question
Select one:
a. Serum sodium 130 mEq/L
b. Urine specific gravity of 1.025
c. BUN 20mg/100mL
d. Hematocrit 55%
dehydration.
An increased hematocrit level (>50%) is expected with
The correct answer is: Hematocrit 55%
Question 12
Correct
A nurse is caring for a toddler who is being treated for hypovolemia. Which of the
following demonstrates to the nurse the desired response to fluid replacement?
Mark 1.00 out of
1.00
Flag question
Select one:
a. Specific Gravity 1.025
Specific gravity falls within normal range of 1.0101.030 and indicates successful fluid replacement.
b. Apical heart rate 130 beats/min
c. Urine output 48 mL for the past 4 hours
d. Central Venous Pressure 2 mm Hg
The correct answer is: Specific Gravity 1.025
Question 13
Correct
A nurse is caring for a client recovering from an abdominal aortic aneurysm (AAA)
repair. Which of the following findings would have the highest priority?
Mark 1.00 out of
1.00
Flag question
Select one:
a. Pedal pulse amplitude 2+.
b. Respiratory rate 12 breaths/minute.
c. Urine output 28 ml/hour
d. Blood pressure 136/90 mmHg
Blood pressure is critically monitored to
maintain a normal BP so as to protect the newly placed aortic graft. This elevated
BP is the most critical assessment finding that could result in serious
consequences such as rupture of the aneurysm repair if not addressed quickly.
The correct answer is: Blood pressure 136/90 mmHg
Question 14
Correct
Mark 1.00 out of
A nurse is caring of a client recently diagnosed with diabetes mellitus (DM). Which of
the following is the physiologic basis for the polyuria manifested by individuals with
untreated DM?
1.00
Flag question
Select one:
a. Chronic stimulation of the detrusor muscle by the ketone bodies in the urine
b. Early-stage renal failure causes a loss of urine concentrating capacity
c. Inadequate secretion of antidiuretic hormone (ADH)
d. Hyperosmolarity of the extracellular fluids secondary to hyperglycemia
Hyperosmolarity of the extracellular fluids secondary to hyperglycemia: The
hyperosmolarity of the extracellular fluids causes fluid to leak out of the cells in
order to return the body to an isotonic state; hence there is increased intravascular
fluid the kidneys must excrete.
The correct answer is: Hyperosmolarity of the extracellular fluids secondary to
hyperglycemia
Question 15
Correct
Mark 1.00 out of
A client diagnosed with atrial fibrillation has a pacemaker set at a ventricular rate of 70
beats per minute. Which of the following findings should the nurse immediately report
to the provider?
1.00
Flag question
Select one:
a. HR= 96 beats/minute and irregular
b. HR= 96 beats /minute and regular
c. HR= 76 beats/minute and irregular
d. HR= 60 beats /minute and regular
The pacer should have fired when native
heart rate was less than 70. Pacers have a variety of modes but in each mode
used, the “demand” rate determines when they will begin to fire if the heart itself
has not supplied an electrical impulse.
The correct answer is: HR= 60 beats /minute and regular
Question 16
Correct
Mark 1.00 out of
A client with chronic obstructive pulmonary disease (COPD) has oxygen therapy
ordered. Which principle should guide the nurse in managing the delivery of oxygen to
this client?
1.00
Flag question
Select one:
a. The concentration of oxygen should be high since the stimulus to breathe in
clients with COPD is an elevated PaCO2.
b. Clients with COPD should receive low concentrations (2-3 L) of oxygen since
the stimulus to breathe is their low PaO2.
Clients with COPD should receive
low concentrations (2-3 L) of oxygen since the stimulus to breathe is their low PO2.
c. The concentration of oxygen should be low since the stimulus to breathe in
clients with COPD is an elevated PaCO2.
d. Clients with COPD require higher concentrations (6-8 L) of oxygen since
hypoxemia is their stimulus to breathe.
The correct answer is: Clients with COPD should receive low concentrations (2-3 L) of
oxygen since the stimulus to breathe is their low PaO2.
Question 17
Correct
Mark 1.00 out of
A nurse is caring for a client who is intubated and receiving ventilatory
assistance. The high pressure alarm is sounding on the ventilator. Which of the
following would have the highest priority?
1.00
Flag question
Select one:
a. Check the endotracheal tube (ETT) to be sure there is no disconnection.
b. Administer sedation to calm the client’s fears.
c. Assess the ETT cuff for proper inflation.
d. Assess the clients need for suctioning.
The nurse should assess the client’s
need for suctioning. The high pressure alarm will sound when the pressure
required to deliver the prescribed O2 and tidal volume exceeds set parameters.
This is caused by: occlusion or partial occlusion of the ETT tube or ventilator
tubing, mucus plug, client biting tube, kinked tube and fluid collection in the vent
tubing. The high pressure alarm may also sound when the client is "bucking" the
vent (fighting it) or coughing. ABC's are used to determine prioritization, specifically,
patent airway.
The correct answer is: Assess the clients need for suctioning.
Question 18
Correct
Mark 1.00 out of
One hour ago, a nurse administered morphine sulfate 4 mg IVP to a client who
reported pain of 9 on a scale of 10. The client now reports pain of a 7 on a scale of 10.
What is the priority intervention at this time?
1.00
Flag question
Select one:
a. Notify the provider of client’s report.
Nurses have a priority responsibility for
the continual assessment of a client’s pain level and to provide individualized
interventions. Because the prescribed therapy is not effective, the nurse should
notify the provider for further assistance.
b. Reassess pain level in 30 minutes.
c. Reposition the client.
d. Administer antiemetic as prescribed.
The correct answer is: Notify the provider of client’s report.
Question 19
Correct
Mark 1.00 out of
A client has undergone an aortofemoral bypass for the treatment of peripheral arterial
disease. Which of the following findings should be reported to the surgeon
immediately?
1.00
Flag question
Select one:
a. Systolic blood pressure 160 mmHg
Following an aortofemoral bypass, the
nurse should monitor the client’s blood pressure for hypotension or
hypertension.Hypotension may result in an increased risk of clotting or graft
collapse,while hypertension increases the risk for bleeding from sutures.
b. Systolic blood pressure 110 mmHg
c. Redness of the incision line
d. Edema of the affected limb
The correct answer is: Systolic blood pressure 160 mmHg
Question 20
Correct
A client is prescribed warfarin daily. Which of the following statement made by the
client indicates to the nurse a need for further teaching?
Mark 1.00 out of
1.00
Flag question
Select one:
a. “I have been eating more salads and other green, leafy vegetables to prevent
constipation.”
Warfarin inhibits the synthesis of vitamin K dependent clotting
factors (factors II, VII, IX, and X). Green leafy vegetables contain vitamin K which
is an antagonist to Coumadin. The patient can eat foods with vitamin K but the
intake must remain consistent not “more” as stated in this answer. Foods low in
vitamin K include roots, bulbs, fleshy parts of nuts, and fruit juices.
b. "Instead of a safety razor, I have been using an electric razor to shave.”
c. “I will report any sign of Purple Syndrome to my physician.”
d. “I have two pairs of anti-embolic stockings so that one pair can be washed each
day.”
The correct answer is: “I have been eating more salads and other green, leafy
vegetables to prevent constipation.”
Question 21
Correct
A client comes to the emergency department reporting epistaxis. Which of the following
medications should the nurse suspect as contributing to the epistaxis?
Mark 1.00 out of
1.00
Flag question
Select one:
a. ibuprofen
of bleeding.
Ibuprofen (Motrin) inhibits clotting and therefore increases the risk
b. alprazolam
c. montelukast
d. furosemide
The correct answer is: ibuprofen
Question 22
Correct
Mark 1.00 out of
A client is admitted to the hospital for treatment of an acute asthma attack. The client is
receiving an aminophylline infusion. Which of the following assessment findings
indicate the client is experiencing the desired effect of aminophylline?
1.00
Flag question
Select one:
a. Decreased wheezing
improved air movement.
This indicates increased bronchial dilation and
b. Increased blood pressure
c. Decreased heart rate
d. Increased mucous production
The correct answer is: Decreased wheezing
Question 23
Correct
Mark 1.00 out of
A nurse is caring for a client who has had a gastric resection to treat peptic ulcer
disease. What is the priority intervention when caring for the client in the immediate
postoperative period?
1.00
Flag question
Select one:
a. Inspect the operative site for redness or swelling.
b. Monitor pain levels.
c. Assess NG tube for patency.
Close assessment of the NG tube for patency,
along with carefully securing the tube according to agency policy to prevent
movement is critical for preventing the retention of gastric secretions. The nurse
should monitor the amount of blood draining from the tube closely. Only a scant
amount of blood should be present and abdominal distension should not develop.
If these problems occur, they should be immediately reported to the surgeon. The
NG tube should not be irrigated or repositioned unless specifically requested. A
clogged NG tube may lead to acute gastric dilation after surgery.
d. Auscultate the lungs for adventitious sounds.
The correct answer is: Assess NG tube for patency.
Question 24
Correct
Mark 1.00 out of
1.00
A client presents to the emergency department with an abdominal stab wound. The
nurse visualizes intestines protruding through the wound. Which of the following is an
appropriate action for the nurse?
Flag question
Select one:
a. Apply pressure to the wound with wet sterile sponges.
b. Cover the wound with warm saline-soaked gauze.
Cover the wound with
warm saline-soaked gauze. The saline soaked gauze keeps the intestine from
becoming dry. The warmth helps to prevent vasoconstriction which will in
turn decreases the risk of ischemia or necrosis. The gauze should then be
covered by an ABD and the nurse should position the client in a low to semifowlers position to prevent tension on the wound and protruding organs and then
notify the health care provider.
c. Irrigate the wound with a normal saline solution.
d. Place sterile gauze and an abdominal binder over the wound.
The correct answer is: Cover the wound with warm saline-soaked gauze.
Question 25
Correct
A nurse is caring for a client who has reported difficulty sleeping. Which statement
made by the client requires further assessment?
Mark 1.00 out of
1.00
Flag question
Select one:
a. “I try not to nap during the day, even though I’m tired.”
b. “I have been really stressed out at work lately.”
Assessment of the related
factor or probable cause of the sleep disturbance is a key step in caring for a client
who has difficulty sleeping. These causes become the focus of interventions for
minimizing or eliminating the problem. Therefore, the client’s statement about
increased stress requires further investigation so that appropriate interventions for
treating the cause of the sleep disturbance can be implemented
c. “I make a point of getting to bed at the same time every night.”
d. “I drink a cup of chamomile tea to help relax at bedtime.”
The correct answer is: “I have been really stressed out at work lately.”
Question 26
Correct
A nurse is caring for a client with a partial hearing impairment. The nurse understands
which of the following is the best way to communicate with this client?
Mark 1.00 out of
1.00
Flag question
Select one:
a. Provide assessment questions in a written format.
b. Speak slowly in a low-pitched voice.
Speaking slowly in a low-pitched voice
and facing the client promotes understanding for a client with a partial hearing
impairment.
c. Conduct only the physical assessment at this time.
d. Have a family member present.
The correct answer is: Speak slowly in a low-pitched voice.
Question 27
Correct
Mark 1.00 out of
1.00
Flag question
A client is admitted to the emergency room after falling outside his home. The client is
complaining of a severe headache with pain above his left eye. The client is restless
and intermittently losses consciousness. Pupils are dilated; pulse 56 and BP 168/98.
An x-ray of the head confirms a skull fracture. Which of the following is a priority
assessment?
Select one:
a. Changes in level of consciousness
b. Blood alcohol and toxicology screening
c. Pupillary changes
d. Respiratory Status
Correct: Respiratory status is the priority assessment.
The brain is dependent upon oxygen to maintain function and has little reserve
available if oxygen is deprived. Brain function begins to diminish after 3 minutes of
oxygen deprivation.
The correct answer is: Respiratory Status
Question 28
Correct
A nurse is caring for a client following a spinal cord injury (SCI). Which of the following
findings would alert the nurse to the development of neurogenic shock?
Mark 1.00 out of
1.00
Flag question
Select one:
a. Hypoglycemia
b. Hypotension
Correct. Neurogenic shock occurs after a SCI and can cause
total loss of voluntary and autonomic function for several days to weeks.
Hypotension, dependent edema, and loss of temperature regulation are common
symptoms.
c. Hypertension
d. Hyperglycemia
The correct answer is: Hypotension
Question 29
Correct
Mark 1.00 out of
During a home visit, a 10-day postpartum client reports pain and tenderness with
redness and swelling to her right breast. A localized hard mass is also noted upon
palpation. How should the nurse respond to this client?
1.00
Flag question
Select one:
a. Please mention this to your HCP at your 2-week check-up.
b. You will need to stop breastfeeding immediately until the swelling and redness
subside.
c. This is normal breast engorgement and should subside within another week or
two.
d. These symptoms suggest an inflammatory or infectious process and require
immediate notification to your health care provider (HCP).
Correct: These
symptoms are suggestive of mastitis and should be reported to HCP. These
symptoms are not signs of normal breast engorgement.
The correct answer is: These symptoms suggest an inflammatory or infectious process
and require immediate notification to your health care provider (HCP).
Question 30
Correct
Mark 1.00 out of
A nurse is caring for a client who has just undergone a bone marrow transplant.
Neutropenic precautions are implemented to prevent infection. Which of the following is
not a precautionary neutropenic measure?
1.00
Flag question
Select one:
a. Monitor platelets
Correct: The monitoring of platelets is not a neutropenic
precaution. Platelets are monitored to prevent injury. WBC is monitored to prevent
infection.
b. Restrict foods that may be contaminated with bacteria
c. Frequent, thorough hand hygiene
d. Screen visitors
The correct answer is: Monitor platelets
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