BSN266 Med-Surg 41843

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Sample questions from BSN266 Med-Surg 41843

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.In the emergency department, a client with a history of heart failure reports sudden severe shortness of breath and is coughing pink, frothy sputum. Which action should the nurse take first?

   • A.Obtain a daily weight before beginning other interventions.
   • B.Place the client upright with the legs dependent and apply oxygen as prescribed.
   • C.Assist the client to lie flat and elevate the legs.
   • D.Encourage the client to drink water to thin respiratory secretions.

   Rationale: Pink, frothy sputum and sudden dyspnea suggest acute pulmonary edema, which requires immediate support of oxygenation and reduced venous return. Sitting upright with the legs dependent can ease breathing and decrease preload while oxygen is applied as prescribed. Fluids can worsen congestion, lying flat increases venous return, and a daily weight is not an immediate intervention.

2. 2.Refer to the client's chart. Which actions should the nurse take in response to the client's current findings? Select all that apply.

   • A.Prepare to administer a prescribed vasodilator while monitoring blood pressure.
   • B.Encourage the client to drink oral fluids to reduce the blood pressure.
   • C.Apply oxygen as prescribed and reassess oxygen saturation and work of breathing.
   • D.Administer the prescribed IV loop diuretic and monitor urine output.
   • E.Place the client supine with the legs elevated.
   • F.Place the client in an upright position.

   Rationale: The client's worsening dyspnea, crackles, falling oxygen saturation, and radiographic pulmonary edema indicate acute heart failure with pulmonary congestion; upright positioning and prescribed oxygen support breathing. The prescribed IV loop diuretic reduces fluid volume, and a prescribed vasodilator can reduce cardiac workload when blood pressure is monitored. Oral fluids and supine positioning can aggravate congestion, and fluids do not treat hypertension.

3. 3.Which finding in a client taking digoxin requires the nurse to withhold the dose and notify the health care provider?

   • A.Respiratory rate of 18 breaths/min.
   • B.Blood pressure of 138/82 mm Hg.
   • C.Potassium level of 4.1 mEq/L.
   • D.Apical pulse of 54 beats/min in an adult.

   Rationale: An adult apical pulse below 60 beats/min is a reason to withhold digoxin and notify the provider because digoxin can further slow the heart rate. The blood pressure and respiratory rate listed are not, by themselves, reasons to hold the medication. A potassium level of 4.1 mEq/L is within the usual reference range; hypokalemia, rather than this value, increases the risk of digoxin toxicity.

4. 4.At change of shift, a nurse receives report on four clients. Which client should the nurse assess first?

   • A.A client with chest pain who has new ST-segment elevation on the monitor.
   • B.A client with chronic heart failure who has unchanged bilateral ankle edema.
   • C.A client scheduled for discharge who needs teaching about a low-sodium diet.
   • D.A client with stable angina whose pain resolved after prescribed nitroglycerin.

   Answer and rationale are in the full material.

5. 5.A client's potassium is 6.2 mEq/L, and the ECG shows tall, peaked T waves. Which prescribed intervention should the nurse anticipate as the immediate priority?

   • A.Encourage foods high in potassium.
   • B.Administer a loop diuretic and delay cardiac monitoring.
   • C.Administer IV calcium gluconate.
   • D.Give oral potassium chloride.

   Answer and rationale are in the full material.