Medical Surgical NCLEX RN
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Question 1 of 5.
A client has undergone a cystectomy and an ileal conduit diversion. What should the nurse incorporate into the discharge instructions? Select all that apply.
A. A limit of least 3,000 mL of fluid each day.
B. Minimize daily activities.
C. Keep urine alkaline to prevent urinary tract infections.
D. Avoid odor-producing foods, such as onions, fish, eggs, and cheese.
E. Wear snug clothing over the stoma to encourage urine flow into the drainage bag.
Explanation: An adequate fluid intake aids in the prevention of urinary calculi and infection. Odor-producing foods should be avoided as they can affect the client's lifestyle and relationships. Minimizing activities can lead to urinary stasis, promoting infection. Alkaline urine may increase infection risk, and snug clothing is not recommended as it may irritate the stoma.
Question 2 of 5.
A client is admitted with a myocardial infarction and new onset atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. The nurse should document these findings as:
A. Heart rate irregular with S3.
B. Heart rate irregular with S4.
C. Heart rate irregular with aortic regurgitation.
D. Heart rate irregular with mitral stenosis.
Explanation: An extra heart sound after S2 at the apex, constant through the respiratory cycle, is an S3, often associated with heart failure post-myocardial infarction. Atrial fibrillation causes an irregular heart rate.
Question 3 of 5.
A 58-year-old female with a family history of CAD is being seen for the annual physical examination. Fasting lab test results include: Total cholesterol 198; LDL cholesterol 120; HDL cholesterol 58; Triglycerides 148; Blood sugar 102; and C-reactive protein (CRP) 4.2. The health care provider informs the client that she will be started on a statin medication and aspirin. The client asks the nurse why she needs to take these medications. Which is the best response by the nurse?
A. The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet.'
B. The triglycerides are elevated and will be lowered to normal with these medications.'
C. The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications ordered.'
D. The medications are not indicated since your lab values are all normal.'
Explanation: Elevated CRP (4.2) indicates inflammation associated with cardiovascular risk. Statins and aspirin reduce inflammation and prevent cardiovascular events, addressing the client's risk profile.
Question 4 of 5.
The client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) to treat angina. Priority goals for the client immediately after PTCA should include:
A. Minimizing dyspnea.
B. Maintaining adequate blood pressure control.
C. Decreasing myocardial contractility.
D. Preventing fluid volume deficit.
Explanation: Maintaining adequate blood pressure post-PTCA ensures coronary perfusion and prevents complications like stent thrombosis or ischemia.
Question 5 of 5.
The nurse is admitting a 68-year-old male to the medical floor. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first?
A. Assess respiratory status.
B. Draw blood for laboratory studies.
C. Insert a Foley catheter.
D. Weigh the client.
Explanation: Edema and left ventricular enlargement suggest heart failure, which can cause pulmonary edema. Assessing respiratory status first detects signs of respiratory distress.