The nurse is evaluating care provided to a client with disseminated intravascular coagulation (DIC). Which finding indicates care has been successful for this client?

Questions 14

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Medical Surgical Nursing Concepts and Practice Test Bank Questions

Question 1 of 9

The nurse is evaluating care provided to a client with disseminated intravascular coagulation (DIC). Which finding indicates care has been successful for this client?

Correct Answer: D

Rationale: Disseminated intravascular coagulation (DIC) is a serious condition characterized by both excessive clotting and bleeding throughout the body. The primary goal of care for a client with DIC is to manage and balance the clotting and bleeding tendencies. A key indicator of successful care for a client with DIC is the absence of bleeding, as this suggests that the coagulation process has been stabilized and there is no ongoing clot breakdown leading to bleeding. Monitoring for signs of bleeding, such as petechiae, purpura, ecchymosis, hematuria, and gastrointestinal bleeding, is essential in evaluating the effectiveness of care in a client with DIC. Therefore, the absence of bleeding is the most significant finding that indicates successful care in a client with DIC.

Question 2 of 9

A baby will be having surgery to correct a congenital heart defect. On which topic should the parents be instructed regarding the care of the child before surgery?

Correct Answer: B

Rationale: It is crucial for parents to be instructed on preventing exposure to infection before their baby's surgery to correct a congenital heart defect. Infections can pose a serious risk to individuals, especially those with preexisting medical conditions like a congenital heart defect. Infection control measures, such as handwashing, avoiding sick contacts, and keeping the environment clean, can help reduce the risk of postoperative complications due to infections. This instruction is important to help ensure the successful outcome of the baby's surgery and recovery process. It is essential for parents to be vigilant in maintaining a hygienic environment and taking necessary precautions to prevent their baby from getting sick prior to the surgery.

Question 3 of 9

What is the most common clinical manifestation of coronary artery disease?

Correct Answer: A

Rationale: The most common clinical manifestation of coronary artery disease is chest pain, also known as angina pectoris. This pain is typically described as a pressure, squeezing, tightness, or heaviness in the chest that may radiate to the arms, neck, jaw, shoulders, or back. It is usually triggered by physical exertion or emotional stress and is relieved by rest or medications such as nitroglycerin. Chest pain occurs due to reduced blood flow to the heart muscles caused by atherosclerosis in the coronary arteries. While dyspnea (shortness of breath), irritability, and tachycardia (rapid heart rate) can also be associated with coronary artery disease, chest pain is the hallmark symptom that often prompts individuals to seek medical attention for further evaluation.

Question 4 of 9

The nurse is reviewing objective data obtained during the assessment of a pregnant woman in her 34th week of gestation. Which finding would be cause for concern?

Correct Answer: C

Rationale: In a pregnant woman, a hematocrit level of 24% is cause for concern as it is lower than the normal range during pregnancy. A lower than normal hematocrit level may indicate anemia in the pregnant woman, which can lead to complications for both the mother and the baby. Anemia during pregnancy can result in inadequate oxygen reaching the tissues, fatigue, increased risk of preterm birth, and low birth weight for the baby. Therefore, this finding should be further evaluated and managed promptly to ensure the well-being of the pregnant woman and her baby.

Question 5 of 9

The nurse is discussing the goals of treatment with a patient experiencing an end-stage renal disease. Which goal should the nurse identify as being appropriate for this patient?

Correct Answer: C

Rationale: For a patient experiencing end-stage renal disease, it is important for the nurse to discuss the advantages and disadvantages of different renal replacement therapies. This goal is crucial to help the patient make informed decisions about their treatment options. Patients with end-stage renal disease often face choices between hemodialysis, peritoneal dialysis, and kidney transplantation. Understanding the advantages and disadvantages of each therapy can empower the patient to actively participate in their treatment decision-making process and achieve the best possible outcomes for their health. It is essential for the nurse to promote patient education and shared decision-making to ensure that the patient's preferences and values are respected throughout their care journey.

Question 6 of 9

The nurse is caring for a client with a new tracheostomy. After completing a teaching session on tracheostomy care, what should the nurse include in the documentation?

Correct Answer: C

Rationale: Documenting the client's questions after the teaching session is important because it demonstrates the client's understanding of the information provided during the teaching session. It also helps to identify any areas where the client may need further clarification or education. This information is crucial for evaluating the effectiveness of the teaching session and ensuring that the client is able to perform tracheostomy care safely and effectively. Additionally, documenting the client's questions allows for continuity of care by providing insight into the client's concerns and educational needs.

Question 7 of 9

A client diagnosed with peripheral vascular disease (PVD) is obese, has a 30-year history of cigarette smoking, and works as a contractor. When discussing risk factors for PVD, which statement by the nurse is appropriate?

Correct Answer: A

Rationale: The statement "Nicotine causes vasospasms, which reduce blood flow to the legs" is the most appropriate response when discussing risk factors for PVD with a client who is obese, has a history of smoking, and works as a contractor. Nicotine in cigarette smoke can lead to constriction or narrowing of blood vessels, including those in the legs, which can reduce blood flow to the lower extremities. This can contribute to the development and progression of peripheral vascular disease (PVD) in individuals with a history of smoking. Identifying and educating the client about this specific risk factor related to their smoking history is important in managing their condition and preventing further complications.

Question 8 of 9

The nurse is caring for a patient with newly diagnosed hypothyroidism. What should the nurse expect when assessing this patient’s skin?

Correct Answer: A

Rationale: Patients with hypothyroidism often exhibit rough, dry skin as a result of decreased thyroid hormone levels impacting the skin's ability to retain moisture. This condition, known as myxedema, can lead to skin changes such as dryness, scaling, and thickening. The skin may also appear pale or yellowish due to reduced blood flow. Therefore, the nurse should expect the patient with newly diagnosed hypothyroidism to present with rough, dry skin during assessment.

Question 9 of 9

A patient is diagnosed with a renal system disorder that is believed to be the result of genetic and environmental factors. Which health problem is the patient most likely experiencing?

Correct Answer: C

Rationale: Bladder cancer is a health problem that can result from a combination of genetic and environmental factors. Genetic mutations can predispose individuals to developing bladder cancer, while environmental factors such as smoking, exposure to certain chemicals, and chronic bladder irritation can also contribute to the development of the disease. Hematuria (blood in the urine) can be a symptom of bladder cancer, but it is not specific to this type of cancer and can also occur in other renal system disorders. Incontinence and kidney infections are not typically associated with genetic predisposition as much as bladder cancer.

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