Med surg exam 2
ATI Med surg exam 2
Total Questions : 67
Showing 10 questions Sign up for moreWhich of the following assessments would be most useful in determining a patient’s genetic risk for breast cancer?
Explanation
Choice A rationale
While performing self-examinations for breast cancer can help in early detection of the disease, it does not provide information about a person’s genetic risk for developing breast cancer.
Choice B rationale
Having a suspicious mammogram could indicate the presence of breast cancer or other abnormalities, but it does not provide information about a person’s genetic risk for developing the disease.
Choice C rationale
Being aware of one’s BRCA (breast cancer gene) status is directly related to understanding their genetic risk for breast cancer. Mutations in the BRCA1 and BRCA2 genes significantly increase the risk of developing breast cancer.
Choice D rationale
Noticing dimpling during a breast self-exam could be a sign of breast cancer, but it does not provide information about a person’s genetic risk for developing the disease.
A nurse is caring for a client who is experiencing chills and back pain during a blood transfusion. What should be the nurse’s priority action?
Explanation
Choice A rationale
While assessing the client’s skin for a rash could be part of the overall assessment of the client’s condition, it is not the priority action when a client is experiencing chills and back pain during a blood transfusion.
Choice B rationale
Notifying the provider is an important step when a client is experiencing a reaction to a blood transfusion, but it is not the first action that should be taken.
Choice C rationale
Covering the client with a blanket may provide comfort to the client, but it does not address the underlying issue of a potential transfusion reaction.
Choice D rationale
The priority action when a client is experiencing chills and back pain during a blood transfusion is to stop the transfusion. This is because these symptoms could indicate a transfusion reaction, which can be serious.
A nurse is caring for a client who is receiving one unit of packed red blood cells (RBCs) due to intraoperative blood loss.
The client reports chills and back pain, and their blood pressure is 80/64 mm Hg. What should be the nurse’s first action?
Explanation
Choice A rationale
If a client reports chills and back pain during a blood transfusion, and their blood pressure is 80/64 mm Hg, the nurse’s first action should be to stop the infusion of blood. These symptoms could indicate an acute intravascular hemolytic transfusion reaction, and the greatest risk to the client is injury from receiving additional blood.
Choice B rationale
Notifying the laboratory is an important step in managing a transfusion reaction, but it is not the first action that should be taken.
Choice C rationale
Obtaining a urine specimen could be part of the overall assessment of the client’s condition, but it is not the first action that should be taken when a client is experiencing a potential transfusion reaction.
Choice D rationale
Informing the provider is an important step when a client is experiencing a reaction to a blood transfusion, but it is not the first action that should be taken.
A nurse is caring for a client diagnosed with systemic scleroderma five years ago. The nurse plans to assess the client to document the disease’s progression. In addition to skin changes, which of the following findings should the nurse expect?
Explanation
Choice A rationale
Periorbital edema is not typically associated with the progression of systemic scleroderma.
Choice B rationale
Excessive salivation is not typically associated with the progression of systemic scleroderma.
Choice C rationale
Finger contractures can be expected in a client diagnosed with systemic scleroderma. As the disease progresses, it can cause tightening and hardening of the skin, which can lead to contractures.
Choice D rationale
Thinning of the skin is not typically associated with the progression of systemic scleroderma. In fact, the disease often causes the skin to thicken.
A nurse is educating a client about preventing skin cancer.
Which of the following client statements indicates a need for further teaching?
Explanation
Choice A rationale
Avoiding the use of tanning booths is an effective measure to prevent skin cancer as tanning booths emit harmful ultraviolet (UV) rays that can damage the skin and increase the risk of skin cancer.
Choice B rationale
Using sunscreen even on cloudy days is recommended as UV rays can penetrate through clouds and harm the skin.
Choice C rationale
Checking the skin monthly for any changes is a good practice as early detection of skin changes can lead to early diagnosis and treatment of skin cancer.
Choice D rationale
Eating a high fiber diet does not reduce the risk for developing skin cancer. While a healthy diet is important for overall health, it does not directly prevent skin cancer. Hypokalemia Explore
A nurse is caring for a client who has a prescription for a stool test for guaiac.
The nurse understands the purpose of the test is to check the stool for which of the following substances?
Explanation
Choice A rationale
A stool guaiac test is a simple check to find blood in your stool. It involves smearing a tiny amount of your stool on a special card, which is then tested for hidden blood. This test helps detect problems like bleeding ulcers or colon cancer in an early stage when they might not show other symptoms. The stool guaiac test looks for hidden (occult) blood in a stool sample. It can find blood even if you cannot see it yourself. It is a common type of fecal occult blood test (FOBT). Guaiac is a substance from a plant that is used to coat the FOBT test cards to make them able to detect blood.
Choice B rationale
Steatorrhea refers to the presence of excess fat in the stool. While this can be a symptom of various digestive disorders, it is not what a stool guaiac test is designed to detect. The primary purpose of a stool guaiac test is to identify hidden blood in the stool, which can be an indicator of conditions such as gastrointestinal bleeding or colon cancer.
Choice C rationale
While bacteria can be present in the stool and certain tests are designed to detect them, a stool guaiac test is not one of these. The stool guaiac test is specifically designed to detect the presence of hidden blood in the stool. The presence of blood can indicate a variety of conditions, including gastrointestinal bleeding or colon cancer.
Choice D rationale
Yeast can be present in the stool, and certain tests can detect it. However, a stool guaiac test is not designed to detect yeast. The primary purpose of a stool guaiac test is to identify hidden
blood in the stool, which can be an indicator of conditions such as gastrointestinal bleeding or colon cancer.
A nurse is caring for four clients who have drainage tubes.
Which of the following clients should the nurse recognize as being at risk for hypokalemia?
Explanation
Choice A rationale
Patients with a nasogastric (NG) tube to suction are at risk for hypokalemia. Hypokalemia, or low potassium levels, can occur due to increased losses from the gastrointestinal tract, which can occur with NG tube suction. Potassium is an essential electrolyte that plays a vital role in many bodily functions, particularly in the heart and cardiovascular system. Therefore, any condition or intervention that leads to a significant loss of potassium, such as NG tube suction, can potentially lead to hypokalemia.
Choice B rationale
A tracheostomy tube attached to humidified oxygen is primarily used to help a patient breathe. It does not typically contribute to potassium loss or imbalance. Therefore, it is not likely to increase the risk of hypokalemia.
Choice C rationale
An indwelling urinary catheter to gravity drainage is used to drain urine from the bladder. While the kidneys do play a role in maintaining potassium balance, the use of a urinary catheter itself does not typically lead to significant potassium loss or increase the risk of hypokalemia.
Choice D rationale
A chest tube to water seal is used to remove air, fluid, or pus from the pleural space to help the lungs expand properly. It does not typically contribute to potassium loss or imbalance.
Therefore, it is not likely to increase the risk of hypokalemia.
Which body substance should the nurse observe to evaluate the effectiveness of pancreatic enzyme replacement for a patient with chronic pancreatitis?
Explanation
Choice A rationale
The effectiveness of pancreatic enzyme replacement therapy in patients with chronic pancreatitis can be evaluated by observing the patient’s stool. Pancreatic enzyme replacement therapy (PERT) is used to improve digestion and absorption of nutrients in patients with pancreatic insufficiency, a common complication of chronic pancreatitis. One of the primary goals of PERT is to reduce steatorrhea, or fatty stools, which is a common symptom of pancreatic insufficiency. Therefore, observing changes in the patient’s stool, such as a reduction in fat content, can help evaluate the effectiveness of PERT567.
Choice B rationale
While saliva plays a role in the initial stages of digestion, it is not typically used to evaluate the effectiveness of pancreatic enzyme replacement therapy in patients with chronic pancreatitis. PERT is primarily aimed at improving the digestion and absorption of nutrients in the intestines, and changes in saliva are not indicative of the effectiveness of this therapy.
Choice C rationale
Nasal mucus is not typically used to evaluate the effectiveness of pancreatic enzyme replacement therapy in patients with chronic pancreatitis. PERT is primarily aimed at improving the digestion and absorption of nutrients in the intestines, and changes in nasal mucus are not indicative of the effectiveness of this therapy.
Choice D rationale
Urine is not typically used to evaluate the effectiveness of pancreatic enzyme replacement therapy in patients with chronic pancreatitis. PERT is primarily aimed at improving the digestion and absorption of nutrients in the intestines, and changes in urine are not indicative of the effectiveness of this therapy.
A nurse is caring for an older adult patient who has just been admitted to the intensive care unit with a diagnosis of confusion/delirium.The patient has an end-stage liver failure diagnosis with increasing ascites.
Their spouse Questions the nurse about the patient’s mental status because they state that the patient is usually lucid. Which of the following is likely the contributing factor for the admitting diagnosis?
Explanation
Choice C rationale
Hepatic encephalopathy is a condition that can cause confusion or delirium in patients with end-stage liver disease and increasing ascites. It occurs when the liver is unable to remove toxins from the blood, such as ammonia, which can then accumulate in the brain and affect mental function. This condition is common in patients with cirrhosis or end-stage liver disease, and can manifest as confusion, changes in sleep patterns, mood alterations, and, in severe cases, coma.
Choice A rationale
While dementia can cause confusion and changes in mental status, it is typically a progressive condition that develops over time. In the context of a patient with end-stage liver failure and
increasing ascites who is usually lucid, a sudden onset of confusion or delirium is more likely to be due to a condition related to their liver disease, such as hepatic encephalopathy.
Choice B rationale
Schizophrenia is a chronic mental disorder characterized by distortions in thinking, perception, emotions, language, sense of self, and behavior. It is not typically associated with end-stage liver disease or ascites. In the context of a patient with end-stage liver failure and increasing ascites who is usually lucid, a sudden onset of confusion or delirium is more likely to be due to a condition related to their liver disease, such as hepatic encephalopathy.
Choice D rationale
While a urinary tract infection (UTI) can cause confusion, especially in older adults, it would not typically be the primary suspect in a patient with end-stage liver failure and increasing ascites. In such a patient, hepatic encephalopathy is a more likely cause of confusion or delirium.
A nurse admits a patient to the emergency department who reports nausea and vomiting that worsens when he lies down.
Antacids do not help.
The provider suspects acute pancreatitis.
Which of the following laboratory test results should the nurse expect to see?
Explanation
Choice C rationale
In the context of suspected acute pancreatitis, an increase in serum amylase is one of the key laboratory findings. Pancreatitis is associated with inflammation of the pancreas, which can result in the release of digestive enzymes such as amylase and lipase into the bloodstream.
Therefore, elevated levels of these enzymes are often used as markers for acute pancreatitis.
Choice A rationale
Decreased serum lipase is not typically associated with acute pancreatitis. In fact, an increase in serum lipase is more commonly seen in acute pancreatitis. Lipase is a digestive enzyme produced by the pancreas, and its levels in the blood can rise when the pancreas is inflamed.
Choice B rationale
Increased serum calcium is not typically associated with acute pancreatitis. While hypercalcemia, or high calcium levels, can be a cause of pancreatitis, it is not a typical finding in the blood tests of patients with acute pancreatitis.
Choice D rationale
Decreased white blood cell (WBC) count is not typically associated with acute pancreatitis. In fact, an increase in WBC count can sometimes be seen in acute pancreatitis due to the body’s inflammatory response to the condition. Hypothyroidism Explore
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