Medical surgical Exam 1 (NSG 123)

Correct Answer: Measure the patient's blood pressure and heart rate.

Rationale:

IV sedatives (e.g., midazolam, propofol) can cause respiratory depression, hypotension, and changes in heart rate. Monitoring vital signs before and after administration helps assess the patient’s hemodynamic stability and detect potential adverse effects of sedation. A licensed practical nurse (LPN) can appropriately measure and report vital signs, making this the most appropriate delegation.

Why the Other Options Are Incorrect:

Educate the patient about the procedure

Patient education should occur before sedation, when the patient is alert and able to process information. Once sedated, the patient’s ability to understand and retain information is impaired. Teaching is typically the responsibility of the registered nurse (RN), not an LPN.

Give the patient small sips of water only 

Patients must remain NPO (nothing by mouth) before a bronchoscopy to prevent aspiration during the procedure. IV sedatives relax the airway muscles, increasing aspiration risk if the patient ingests fluids. The correct action is to ensure the patient remains NPO. 

Take the patient to the bathroom one more time

Sedated patients should not ambulate without assistance due to fall risk and potential dizziness. If the patient needs to void, a bedpan or urinal should be used instead.

Summary:

The best task for the LPN is to measure the patient’s blood pressure and heart rate, as IV sedatives can cause hypotension and respiratory depression. Patient education should be done before sedation, fluids are contraindicated (NPO status), and ambulation is unsafe after sedation.

Correct Answer: Overweight

Explanation: 

BMI (Body Mass Index) is a widely used tool to assess a person's weight category based on their height and weight. The standard BMI classifications are:

Underweight: BMI < 18.5

Normal weight: BMI 18.5 – 24.9

Overweight: BMI 25.0 – 29.9

Obese: BMI ≥ 30.0

Since the client's BMI is 27.5 kg/m², it falls within the overweight category (25.0 – 29.9). Therefore, the nurse should document the client's weight as overweight.

Why Are the Other Choices Incorrect?

Extremely obese 

The classification of extreme or severe obesity (often called Class III obesity) applies when BMI is 40.0 or greater. Since the client's BMI is 27.5, they do not meet this criterion.

Normal 

The normal weight range is 18.5 – 24.9. The client’s BMI of 27.5 is above this range, placing them in the overweight category.

Underweight 

A BMI of less than 18.5 is considered underweight. Since the client's BMI is 27.5, they are far above this range.

Summary

The client’s BMI of 27.5 kg/m² falls within the overweight category (25.0 – 29.9) according to standard BMI classifications. This means the correct answer is Overweight. The other options—Extremely obese, Normal, and Underweight—are incorrect because they fall into different BMI ranges.

Correct Answer: D. Sit in a high-seat chair for a flexion of less than 90 degrees

Rationale:

After a total hip replacement (THR), it is critical to prevent hip dislocation. Sitting in a high-seat chair helps keep the hip at an angle of less than 90 degrees, preventing excessive flexion that could lead to dislocation. Patients should also avoid low chairs and deep-seated furniture to minimize stress on the hip joint.

Explanation of Incorrect Options:

A. Keep abduction pillow in place between legs at all times

Partially correct but not always required:

An abduction pillow is used immediately postoperatively to maintain proper hip alignment, but it is not needed at all times. It is primarily used when the patient is in bed or turning to prevent excessive adduction and dislocation. Not the best choice over option D, which specifically addresses positioning when seated.

B. Cough and deep breathe at least every 4-5 hours

Deep breathing and coughing should be done every 1-2 hours, not every 4-5 hours, to prevent atelectasis (lung collapse) and pneumonia after surgery. While important, this is not the priority instruction for preventing hip dislocation.

C. Turn to both sides every 2 hours to prevent pressure ulcers

After a THR, turning to the affected side is usually not recommended in the early postoperative period. Patients should typically lie on their back or turn to the non-operative side with support to maintain proper hip alignment. Frequent repositioning is important, but not in a way that risks hip dislocation.

Summary:

The most critical postoperative teaching to prevent hip dislocation is keeping hip flexion less than 90 degrees, which is why sitting in a high-seat chair (option D) is the best answer.

Correct Answer: B) "How long have you had this pain?"

Rationale:

Mr. Palmer is experiencing symptoms suggestive of a pulmonary embolism (PE) or myocardial infarction (MI), both of which require immediate intervention. Determining the duration of pain is crucial because:

If the pain started suddenly and intensely, it is more likely to be a pulmonary embolism (especially given his recent surgery and anticoagulation therapy).

If the pain has been gradually worsening, it may be a myocardial infarction or another cardiac event.

The timing of the pain can help the healthcare team decide whether immediate interventions such as fibrinolytics, anticoagulation adjustments, or further diagnostic tests are needed.

Why the Other Options Are Incorrect:

A) "Have you ever had this type of chest pain before?"

While this question helps compare the current pain to past experiences, it does not determine the urgency of the situation. Even if Mr. Palmer has had chest pain before, the current event may still require emergency intervention.

C) "What pain medication do you usually take?"

This question is not a priority because it does not address the cause of the pain or guide immediate interventions. Pain medication history is secondary to assessing for life-threatening conditions.

D) "What were you doing before the pain began?"

While activity before pain onset may provide clues, it is not the most important question in an emergency. Whether he was resting or exerting himself does not change the need for immediate assessment and intervention.

Summary:

The correct answer is B) "How long have you had this pain?" because it helps differentiate between sudden vs. gradual onset, which is critical in identifying whether Mr. Palmer is experiencing a pulmonary embolism, myocardial infarction, or another acute event.

Correct Answer:  PaO2 level 55%

Explanation:

In patients with chronic obstructive pulmonary disease (COPD), maintaining appropriate oxygen levels is crucial. A PaO2 level (partial pressure of oxygen in arterial blood) of 55 mm Hg or below indicates severe hypoxemia, which suggests that the current oxygen therapy is inadequate to meet the patient's oxygenation needs. COPD patients often have a higher baseline CO2 level due to chronic respiratory issues, and their bodies adapt to a lower oxygen saturation. However, a PaO2 of 55 mm Hg is considered too low, and it indicates that the oxygen therapy may need to be adjusted, either by increasing the flow rate or adjusting the method of oxygen delivery to ensure better oxygenation.

Why the Other Options Are Incorrect:

Bilateral wheezing auscultated in lungs: Wheezing could indicate bronchospasm, airway narrowing, or an exacerbation of COPD, but it is not necessarily an indication that the oxygen therapy itself needs to be revised. Wheezing requires evaluation for possible bronchodilator administration or other treatments, but it doesn't directly suggest a need to alter oxygen levels.

Decreased effort noted when using incentive spirometer: This might be a sign of fatigue, weakness, or difficulty with lung expansion, but it doesn't specifically indicate that oxygen therapy is inadequate. The patient may need encouragement to continue using the incentive spirometer, but it doesn’t suggest a problem with oxygenation levels.

SpO2 level 90%: An SpO2 level of 90% can be considered acceptable for many patients with COPD. COPD patients are typically managed with slightly lower oxygen saturation goals (usually 88-92%) to avoid suppressing their respiratory drive, which can be sensitive to oxygen administration. Thus, a SpO2 of 90% is within the acceptable range for most COPD patients.

Summary:

A PaO2 of 55% indicates severe hypoxemia, and oxygen therapy may need to be adjusted to improve the patient's oxygenation. The other findings (wheezing, incentive spirometer effort, and SpO2 of 90%) do not indicate the immediate need for a revision of oxygen therapy.

Correct Answer: A. Temperature 99.9˚F

Rationale:

Osteomyelitis is an infection of the bone, often caused by bacteria. Fever is a common sign of infection, and even a low-grade fever can be a warning sign of worsening infection or sepsis in patients with osteomyelitis. A temperature of 99.9˚F is concerning because it could indicate systemic infection or that the infection is not being effectively managed. Temperature 99.9˚F is significant in the context of osteomyelitis. Even though it is a mild fever, it may indicate the spread or worsening of the infection. Prompt reporting is crucial so that the nurse can assess the situation further and initiate any necessary interventions (e.g., antibiotics or further diagnostic tests).

Why the Other Options Are Incorrect:

B. Blood pressure 136/80

 A blood pressure of 136/80 is within the normal range for most adults and is not of immediate concern for a patient with osteomyelitis. It does not require urgent reporting.

C. Heart rate 96/minute

 A heart rate of 96/min is considered mildly elevated but is not typically an immediate concern unless it is accompanied by other symptoms such as fever, infection, or pain. It’s not as urgent to report as a significant change in temperature.

D. Respiratory rate 24/minute

 A respiratory rate of 24/min is slightly elevated but not critical. The normal respiratory rate for adults is typically between 12 and 20 breaths per minute, but this mild elevation doesn't necessarily warrant immediate reporting unless the patient shows signs of respiratory distress or other complications.

Summary:

In the context of osteomyelitis, a fever (option A) is the vital sign that warrants immediate attention as it may indicate an active or worsening infection. The other vital signs, while slightly elevated, do not indicate an immediate issue that requires urgent reporting.

Correct Answer: A. "You have a slow-growing cancer that rarely spreads."

Rationale:

Squamous cell carcinoma (SCC) is one of the most common types of non-small cell lung cancer (NSCLC). It typically originates in the bronchi, the larger airways of the lungs. The following key points explain the rationale for the correct answer:

Slow-growing cancer: Compared to other types of lung cancer, squamous cell carcinoma tends to grow at a slower rate. While it can still spread to other parts of the body (metastasize), it is generally considered less aggressive than small cell lung cancer (SCLC). This makes A the correct statement.

Rarely spreads: While SCC has the potential to metastasize, it often remains localized in the lungs longer compared to more aggressive types of lung cancer like small cell carcinoma. It tends to spread more slowly than other types of cancer, which is why A is the best response.

Why the Other Options Are Incorrect:

B. "In terms of prognosis, you may have only a few months to live."

This statement is too definitive and pessimistic. The prognosis for someone with squamous cell carcinoma depends on various factors, including the stage at diagnosis, the patient's overall health, and the treatment approach. Early-stage SCC can be treated with surgery, radiation, and chemotherapy, leading to better outcomes than this statement implies.

C. "Squamous cell cancer is a very rapidly growing cancer."

This statement is incorrect because squamous cell carcinoma is generally known for being slow-growing, as compared to small cell lung cancer or other aggressive cancers.

D. "The cancer has generally metastasized by the time diagnosis is made."

While metastasis can occur in squamous cell carcinoma, this is not always the case at the time of diagnosis. Local or regional spread is common, but it does not necessarily mean that metastasis has already occurred. Early-stage squamous cell carcinoma can often be detected before widespread metastasis, and treatment may help prevent further spread.

Summary:

Squamous cell carcinoma of the lung is a slow-growing cancer compared to other types of lung cancer. While it can spread to other areas, it tends to spread more slowly. Therefore, the most accurate statement regarding the condition is A. The other options either present a too negative prognosis or misrepresent the typical growth rate and spread of this type of cancer.

The correct answer is D) A 20-year-old female client with a history of menorrhagia and consumes a strict vegetarian diet.

Why this answer is correct:

Iron deficiency anemia (IDA) occurs due to insufficient iron intake, poor iron absorption, or excessive blood loss. The two most common causes of IDA are:

Chronic blood loss, often due to heavy menstrual bleeding (menorrhagia) in young women.

Dietary deficiency, especially in those who do not consume iron-rich foods, such as strict vegetarians.

This 20-year-old female has two major risk factors for IDA:

Menorrhagia (heavy menstrual periods) can lead to chronic blood loss, depleting iron stores.

A strict vegetarian diet may lack heme iron, which is found in animal products and is more easily absorbed by the body than non-heme iron from plant-based sources.

Why the other options are incorrect:

A) A 24-year-old female who is 6 months pregnant and is taking prescribed prenatal vitamins.

Incorrect because while pregnancy increases iron demand due to fetal growth and expanded blood volume, this client is already taking prescribed prenatal vitamins, which contain iron. If the client were not taking iron supplements, she would be at risk, but since she is, her risk is lower.

B) A 42-year-old male with a history of hypertension who exercises three times a week.

Incorrect because hypertension is not directly linked to iron deficiency anemia. This client is also not described as having any dietary restrictions, gastrointestinal disorders, or chronic blood loss, which are key contributors to IDA.

C) A 37-year-old male client who works 16 hours a day and consumes a high carbohydrate diet.

Incorrect because while working long hours may contribute to fatigue, it does not directly cause iron deficiency anemia. A high-carbohydrate diet may lack iron-rich foods, but without evidence of low iron intake or blood loss, this client is not at high risk.

Summary:

The correct answer is D) A 20-year-old female client with a history of menorrhagia and a strict vegetarian diet because chronic blood loss and a lack of dietary iron increase the risk of iron deficiency anemia.

Option A is incorrect because the pregnant client is taking prenatal vitamins with iron, reducing her risk.

Option B is incorrect because hypertension and exercise do not directly cause IDA.

Option C is incorrect because working long hours and eating a high-carb diet do not necessarily lead to IDA unless iron intake is severely deficient.

Correct Answer: C. It is a hypotonic solution so it can cause cell expansion.

Explanation of the Correct Answer:

0.33% normal saline (NaCl) is a hypotonic solution, meaning that the concentration of solutes (such as sodium) is lower than that of the cells. When administered intravenously, it causes water to move into the cells by osmosis, which leads to cell expansion or swelling. This is because the water in the hypotonic solution moves to the area of higher solute concentration (inside the cell), leading to an increase in intracellular fluid volume.

Why the Other Options Are Incorrect:

A. It is a colloid solution that maintains solutes in and out of the cell.

This statement is incorrect because 0.33% normal saline is a crystalloid solution, not a colloid. Colloid solutions contain large molecules like proteins that cannot cross the cell membrane, whereas crystalloid solutions contain small molecules like electrolytes that can cross the membrane and influence fluid balance.

B. It is a hypertonic solution so it can cause cell lysis.

This is incorrect because 0.33% normal saline is hypotonic, not hypertonic. Hypertonic solutions (like 3% saline) have a higher solute concentration than the cells, which can cause cells to shrink, not expand. Also, hypertonic solutions can cause cell damage, but not the swelling or lysis described in this statement.

D. It is isotonic so it facilitates movement of solutes inside the cell.

This statement is incorrect because 0.33% normal saline is hypotonic, not isotonic. Isotonic solutions have the same solute concentration as the cell's interior, meaning they do not cause water to move into or out of the cells significantly. Therefore, they do not facilitate solute movement into cells.

Summary:

The nurse's statement that "It is a hypotonic solution so it can cause cell expansion" is correct because 0.33% normal saline is a hypotonic solution that leads to fluid moving into cells, causing them to expand. The other options are incorrect because they mischaracterize the solution or its effects on the cells.