Medical Surgical (132-160 Questions with Answers)

132. A client with chronic congestive heart failure should be instructed to contact the home health nurse if which finding occurs? A) Weight gain of 2 pounds or more in a 48 hour period B) Urinating 4 to 5 times each day C) A significant decrease in appetite D) Appearance of non-pitting ankle edema The correct answer is A: Weight gain of 2 pounds or more in a 48 hour period 133. The nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by A) Inserting a fenestrated catheter with a whistle tip without suction B) Completing suction pass in 30 seconds with pressure of 150 mm Hg C) Hyper oxygenating with 100% 02 for 1 to 2 minutes before and after each suction pass D) Minimizing suction pass to 60 seconds while slowly rotating the lubricated catheter The correct answer is C: Hyper oxygenating with 100% O2 for 1-2 minutes before and after each suction pass 134. A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should he to A) Suggest 3 to 4 warm sitz baths per day B) Cleanse the genitalia twice a day with soap and water C) Spray warm water over genitalia after urination D) Apply heat or cold to lesions as desired The correct answer is A: Encourage 3 to 4 warm sitz baths per day 135. Which finding would be the most characteristic of an acute episode of reactive airway disease? A) Auditory gurgling B) Inspiratory laryngeal stridor C) Auditory expiratory wheezing D) Frequent dry coughing The correct answer is C: Wheezing on expiration 154. A nurse caring for premature newborns in an intensive care setting carefully monitors oxygen concentration. What is the most common complication of this therapy? A) Intraventricular hemorrhage B) Retinopathy of prematurity C) Bronchial pulmonary dysplasia D) Necrotizing enterocolitis The correct answer is B: Retinopathy of prematurity 155. A nurse manager is using the technique of brainstorming to help solve a problem. One nurse criticizes another nurse's contribution and begins to find objections to the suggestion. The nurse manager's best response is to A) Let's move on to a new action that deals with the problem. B) I think you need to reserve judgment until after all suggestions are offered. C) Very well thought out. Your analytic skills and interest are incredible. D) Let's move to the 'what if...' as related to these objections for an exploration of spin off ideas. The correct answer is D: Let's move to the 'what if..." as related to these objections for an exploration of spin off ideas. 156. The nurse is caring for an acutely ill 10 year-old client. Which of the following assessments would require the nurses immediate attention? A) Rapid bounding pulse B) Temperature of 38.5 degrees Celsius C) Profuse Diaphoresis D) Słow, irregular respirations The correct answer is D: Slow, irregular respirations 157. A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure? A) Playing with toys in a back yard flower garden B) Eating small amounts of grass while playing "farm" C) Playing with cars on the pavement near burning leaves D) Throwing a ball to a neighborhood child who has poison ivy The correct answer is C: Playing with cars on the pavement near burning leaves 158. The nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first? A) Weight reduction B) Stress management C) Physical exercise D) Smoking cessation The correct answer is D: Smoking cessation