Medical surgical Exam 1 (NSG 123)

The correct answer is D) Report to your healthcare provider if you experience any constipation or abdominal pain.

Why this answer is correct:

Amlodipine (Norvasc) is a calcium channel blocker (CCB) used to treat hypertension and angina by relaxing blood vessels, which lowers blood pressure and improves blood flow. Common side effects of amlodipine include peripheral edema, dizziness, flushing, headache, and gastrointestinal symptoms such as constipation and abdominal pain. While mild constipation may be managed with dietary changes, severe or persistent constipation and abdominal pain should be reported to the healthcare provider as they may indicate a more serious adverse reaction.

Why the other options are incorrect:

A) "This medication makes your kidneys work harder, so you may experience increased urine production."

This is incorrect because amlodipine is a vasodilator, not a diuretic. It does not directly increase urine production or force the kidneys to work harder. Instead, it relaxes the smooth muscles in the blood vessels, lowering blood pressure without affecting the kidney’s filtration process in the same way that diuretics do. Increased urination is not a typical effect of calcium channel blockers.

B) "Stop taking the medication immediately if you notice any edema in your legs."

This is incorrect because peripheral edema is a common side effect of amlodipine due to vasodilation and fluid accumulation in the lower extremities. However, stopping the medication abruptly without consulting a healthcare provider can be dangerous and may lead to rebound hypertension. Instead, the patient should report edema to their healthcare provider, who may adjust the dosage, prescribe a diuretic, or switch the patient to a different antihypertensive medication.

C) "You will need to have monthly blood specimens obtained to check your potassium level."

This is incorrect because amlodipine does not typically affect potassium levels. Routine potassium monitoring is necessary for patients taking diuretics (especially potassium-wasting diuretics like furosemide) or renin-angiotensin system inhibitors (ACE inhibitors or ARBs), but not for calcium channel blockers. Unless the patient is taking other medications that affect potassium or has an underlying condition, frequent potassium monitoring is unnecessary.

Summary:

The correct answer is D, as constipation and abdominal pain are potential side effects of amlodipine that should be reported to the healthcare provider.

Option A is incorrect because amlodipine does not increase urine production or strain the kidneys.

Option B is incorrect because peripheral edema is a common side effect of amlodipine, but the medication should not be stopped abruptly without consulting a healthcare provider.

Option C is incorrect because amlodipine does not significantly impact potassium levels, so routine potassium monitoring is not required.

Correct Answer: Atelectasis

Why this is the correct answer?

Atelectasis is the partial or complete collapse of the lung, which is often caused by shallow breathing, inadequate lung expansion, or not using an incentive spirometer. This can lead to decreased breath sounds and a lack of coughing. Postoperative clients are at a higher risk of atelectasis, particularly if they do not use an incentive spirometer, which helps to keep the lungs expanded and prevents alveolar collapse.

Incorrect Answers and Explanations

Aspiration

Aspiration occurs when food, liquid, or foreign material enters the airway and the lungs, potentially leading to infection. While aspiration can cause coughing and respiratory distress, the primary signs of aspiration are choking, coughing, and wheezing, rather than decreased breath sounds and the absence of a cough.

Hypoxemia

Hypoxemia refers to low oxygen levels in the blood and is often a consequence of atelectasis, pneumonia, or other respiratory issues. However, hypoxemia itself is not a specific diagnosis but rather a symptom. In this case, the decreased breath sounds and lack of coughing are more indicative of atelectasis rather than generalized low oxygen levels.

Pneumonia

Pneumonia is a lung infection that often presents with fever, productive cough, and crackles on auscultation. While pneumonia can also lead to decreased breath sounds and difficulty breathing, the absence of coughing and the patient's report of not using the incentive spirometer suggests that atelectasis is the more likely cause. Pneumonia typically presents with other signs of infection (e.g., fever, chills, and purulent sputum).

Summary

The nurse should recognize the findings of decreased breath sounds and a lack of cough in a postoperative client who did not use the incentive spirometer as indicating atelectasis. Atelectasis can occur after surgery if the lungs are not adequately ventilated, leading to alveolar collapse. Other conditions, such as aspiration, hypoxemia, and pneumonia, may present differently and are less likely in this scenario.

Correct Answer: D The client has reduced smoking cigarettes from 2 packs per day to 1.5 packs per day.

Explanation 

Smoking is a significant risk factor for hypertension and cardiovascular disease. Even though the client has reduced their smoking, continuing to smoke 1.5 packs per day still puts them at high risk for worsening hypertension, heart disease, and stroke. Nicotine causes vasoconstriction, which raises blood pressure and increases the workload on the heart. The nurse should prioritize smoking cessation as a key intervention, as even small reductions in smoking do not eliminate its harmful effects.

Explanation of Incorrect Answers:

A The client is obese and has been exercising for 20 minutes per day twice each week.

This is incorrect because although the client's exercise routine is below the recommended 150 minutes per week of moderate-intensity exercise, they have made an effort to start physical activity. While increasing exercise is important, it is not the most immediate concern compared to continued smoking, which has a more direct and severe impact on blood pressure.

B The client has reduced sodium intake from 5 grams per day to 3.5 grams per day.

This is incorrect because, while high sodium intake can contribute to hypertension, the client has made progress in reducing their intake. The recommended daily limit for sodium is 2.3 grams per day (or ideally 1.5 grams for those with hypertension), so further reduction is needed, but it is not as urgent as addressing continued smoking.

C The client drinks 1 to 2 glasses of wine with dinner a few nights per week.

This is incorrect because moderate alcohol consumption (up to one drink per day for women and two drinks per day for men) does not necessarily worsen hypertension. However, excessive alcohol intake can raise blood pressure, so monitoring and limiting alcohol consumption further may still be advised.

Summary:

The correct answer is D The client has reduced smoking cigarettes from 2 packs per day to 1.5 packs per day. While the client has made some improvements in lifestyle changes, continued smoking is the most pressing issue due to its strong association with hypertension and cardiovascular disease. The other choices, such as limited exercise, moderate sodium reduction, and alcohol intake, are important but not as immediately critical as the need for complete smoking cessation.

Correct Answer: Maintain fluid balance.

Rationale:

The main goal of treatment for acute glomerulonephritis is to maintain fluid balance. This condition often leads to fluid retention due to kidney dysfunction, which can cause edema and hypertension. Monitoring and managing fluid balance is crucial to prevent complications such as heart failure or worsening kidney damage.

Why the Other Options Are Incorrect:

Encourage activity:

While some level of activity may be encouraged later in the treatment process, during the acute phase of glomerulonephritis, the patient may need to limit physical activity to allow the kidneys to heal and to avoid excessive strain on the cardiovascular system.

Encourage high protein intake:

High protein intake is generally not recommended in acute glomerulonephritis, especially if there is evidence of kidney impairment. In some cases, protein intake may need to be restricted to prevent further kidney damage and manage proteinuria (excess protein in the urine).

Teach intermittent urinary catheterization:

Intermittent urinary catheterization is typically used for patients with issues related to urinary retention or obstruction, not as a primary intervention for glomerulonephritis. The primary focus is on managing kidney function and fluid balance.

Summary:

For acute glomerulonephritis, the main goal of treatment is to maintain fluid balance, ensuring that the kidneys are not overwhelmed by fluid retention, which can lead to complications. Proper management of fluid intake and output, along with addressing other symptoms, is key to the patient's recovery.

The correct answer is A) "How has your energy level been?"

Why this answer is correct:

Energy levels are a direct indicator of cardiac output and functional capacity in clients with heart failure. Fatigue and activity intolerance are hallmark symptoms of heart failure due to poor oxygen delivery to tissues. If treatment is effective, the client should report improved energy levels and better tolerance for daily activities. If the client still experiences excessive fatigue, it may suggest worsening heart failure or inadequate treatment response.

Why the other options are incorrect:

B) "How many pillows are you using to sleep?"

This question assesses orthopnea, a symptom of heart failure where clients experience difficulty breathing while lying flat. While a decrease in pillow use may suggest improvement, it is not the best measure of treatment effectiveness. Some clients may adjust their sleeping position for reasons unrelated to heart failure, such as acid reflux or habit.

C) "Have you been exercising regularly?"

While exercise is beneficial for heart failure management, it does not necessarily reflect treatment effectiveness. Many factors, such as fear of exertion, comorbidities, or personal preferences, can influence a client’s exercise habits. A client may avoid exercise even if their heart failure is improving or may push through exercise despite worsening symptoms.

D) "Have you had any chest pain?"

Chest pain is not a primary symptom of heart failure. It is more commonly associated with coronary artery disease (CAD) or acute cardiac events. The presence or absence of chest pain does not directly reflect how well heart failure is being managed.

Summary:

The best way to assess treatment effectiveness in heart failure is to evaluate energy levels, as this reflects the heart’s ability to pump blood and deliver oxygen to tissues. Option A ("How has your energy level been?") is correct because it directly measures functional improvement. Option B ("How many pillows are you using?") is incorrect because it focuses on orthopnea rather than overall function. Option C ("Have you been exercising?") is incorrect because exercise habits can be influenced by multiple factors beyond heart failure. Option D ("Have you had chest pain?") is incorrect because chest pain is not a key indicator of heart failure progression.

The correct answer is: C) Right-sided diastolic

Explanation:

Diastolic heart failure occurs when the heart muscle becomes thickened and stiff, preventing proper filling of the ventricles during diastole (the relaxation phase). This leads to reduced stroke volume and cardiac output, despite a normal ejection fraction (EF). Since the nurse states that the right side of the heart is affected and the issue is inadequate filling, this describes right-sided diastolic heart failure rather than systolic failure, which involves weakened contraction.

Why the Other Options Are Wrong:

A) Right and left-sided diastolic 

The nurse specifically mentions only the right side of the heart being affected. If both sides were involved, the client would likely have bilateral symptoms, such as pulmonary congestion from left-sided failure and peripheral edema from right-sided failure.

B) Right-sided systolic and diastolic

Systolic heart failure occurs when the heart muscle is weakened and cannot contract effectively, leading to reduced ejection fraction (EF) and poor blood pumping. The nurse describes a thickened muscle and poor filling, which is characteristic of diastolic heart failure, not systolic.

D) Right-sided systolic

Systolic failure involves weakened contraction, leading to reduced blood ejection from the right ventricle. The nurse describes thickening of the muscle and impaired filling, which aligns with diastolic failure rather than systolic.

Summary:

The correct answer is right-sided diastolic heart failure, as the nurse describes a thickened heart muscle that prevents proper filling. The other options are incorrect because systolic failure involves poor contraction, and left-sided involvement was not mentioned.

Correct Answer: B) Allergens and radiation

Rationale:

External factors that subject the skin to injury include physical, chemical, and environmental agents that can damage or weaken the skin's protective barrier.

Allergens: Cause irritation, inflammation, and allergic reactions (e.g., contact dermatitis from chemicals, pollen, or latex).Weaken skin integrity, making it more prone to injury.

Radiation: Ultraviolet (UV) radiation from the sun causes burns, DNA damage, and skin cancer. Medical radiation therapy can lead to radiation burns, increased skin sensitivity, and delayed wound healing.

Why the Other Options Are Incorrect:

A) Emaciation and infections 

Emaciation (extreme thinness) results in fragile skin, but it is an internal factor (related to nutrition and body condition). Infections occur when the skin is already compromised; they do not initially cause injury but worsen existing damage.

C) Radiation and emaciation

Radiation is external, but emaciation is an internal factor, making this answer partially incorrect.

D) Allergens and infections

Allergens are external irritants, but infections result from internal factors like weakened immunity or bacterial exposure. Infections are a consequence, not a primary cause, of skin injury.

Summary:

External factors include allergens and radiation, which directly damage the skin. Emaciation and infections are internal factors, affecting skin integrity indirectly.

Correct Answer: B. Forcing fluids of at least 2-3 L per day after nausea has subsided

Rationale:

After a ureterolithotomy (surgical removal of a kidney stone from the ureter), the nephrostomy tube helps drain urine directly from the kidney while the ureter heals. Adequate fluid intake (2-3 L/day) is crucial to:

Flush the urinary system

Prevent further stone formation

Reduce the risk of infection

Ensure proper kidney function

Once nausea resolves, the patient should increase oral fluid intake to maintain good urine output and promote kidney function.

Why the Other Options Are Incorrect

A. Encouraging the patient to drink fruit juices and milk

Some fruit juices (e.g., cranberry, orange, grapefruit) and milk can contribute to stone formation depending on the type of stone (e.g., calcium oxalate, uric acid). Instead, patients should be encouraged to drink water and non-calcium-containing fluids unless otherwise directed by a dietitian.

C. Irrigating the nephrostomy tube with 10 mL of normal saline solution as needed 

Nephrostomy tube irrigation is only done with a physician’s order and should be performed cautiously to prevent kidney damage or infection. Routine irrigation is not recommended unless there is an obstruction or reduced drainage.

D. Notifying the physician if nephrostomy tube drainage is more than 30 mL per hour

A nephrostomy tube should drain at least 30-50 mL per hour, similar to normal kidney function. Decreased output (<30 mL/hr) is more concerning and should be reported as it may indicate an obstruction, infection, or kidney dysfunction. High output is not necessarily a problem, especially with increased fluid intake.

Summary:

​​​​​​​Forcing fluids (2-3 L/day) after nausea subsides is the most appropriate intervention to maintain kidney function and prevent complications, making Option B the correct answer.

Correct Answer: A. The client's serum blood urea nitrogen (BUN) is 27 mg/dL.

Explanation of the Correct Answer:

The statement about the client's BUN level of 27 mg/dL indicates the need for teaching because an elevated BUN can be indicative of dehydration, kidney dysfunction, or other conditions that may not align with fluid volume excess. In cases of fluid volume excess, the BUN level typically decreases due to dilution of the blood, as excess fluid increases plasma volume. An elevated BUN in the context of fluid volume excess may suggest other issues, such as renal impairment or other factors, and should be clarified or reassessed.

Why the Other Options Are Incorrect:

B. The client should be instructed about a low sodium diet.

This statement is correct and aligns with the treatment for fluid volume excess. Sodium retention can exacerbate fluid volume overload, so instructing the client about a low sodium diet is appropriate and does not require further teaching.

C. The client has bilateral crackles.

Bilateral crackles (rales) in the lungs are a common finding in fluid volume excess, especially if pulmonary edema is present. This is a significant sign that indicates excess fluid in the lungs and is consistent with the nurse's assessment of fluid volume excess.

D. The client has 2+ pitting edema of both legs.

Pitting edema is a common sign of fluid volume excess, and the presence of 2+ edema (moderate indentation when pressed) is consistent with this condition. This finding does not require further teaching, as it is a typical manifestation of fluid overload.

Summary:

The statement about the BUN level of 27 mg/dL raises a concern because it is elevated, which may not align with fluid volume excess and could suggest kidney dysfunction or dehydration. This warrants further investigation. The other findings, including the need for a low sodium diet, crackles, and pitting edema, are appropriate for fluid volume excess and do not indicate a need for additional teaching.