Nur 215 Medical Surgical 1
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Free Nur 215 Medical Surgical 1 Questions
A charge nurse is observing a nurse insert an indwelling urinary catheter into a female patient. For which of the following actions by the nurse should the charge nurse intervene?
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The nurse provides perineal care prior to inserting the urinary catheter.
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The nurse applies the sterile drape prior to inserting the urinary catheter.
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The nurse coats the indwelling urinary catheter tip with lubricant.
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The nurse separates the patient’s labia with the dominant hand.
Explanation
Correct Answer:
The nurse separates the patient’s labia with the dominant hand.
Explanation:
During urinary catheterization, the non-dominant hand is used to separate the labia and maintain exposure of the urethral meatus. This hand is considered contaminated once it touches the patient and must remain in place. The dominant hand is used for the sterile procedure, including insertion of the catheter. Using the dominant hand to separate the labia compromises sterile technique and increases the risk of introducing infection. This is a key point where the charge nurse must intervene to maintain aseptic technique.
Why Other Options Are Wrong:
The nurse provides perineal care prior to inserting the urinary catheter.
This is correct practice. Cleaning the perineal area before catheter insertion helps minimize the risk of introducing bacteria into the urinary tract, reducing the chance of catheter-associated infections.
The nurse applies the sterile drape prior to inserting the urinary catheter.
This is standard and expected practice. Draping the area with sterile material helps establish a sterile field and maintain aseptic technique throughout the procedure.
The nurse coats the indwelling urinary catheter tip with lubricant.
Lubricating the catheter tip is essential to ease insertion and reduce patient discomfort or injury. This is a necessary and proper step in the procedure.
When performing a physical assessment of the patient’s skin, which principle should guide the nurse?
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Use layman’s terms when reporting or documenting.
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Compare symmetric parts.
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Inspect specific lesions before performing a generalized examination of the skin.
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Palpate the temperature of the skin with the fingertips.
Explanation
Correct Answer:
Compare symmetric parts.
Explanation:
During a physical assessment of the skin, nurses should compare symmetrical body parts to detect differences or abnormalities. This principle ensures a consistent and thorough evaluation of skin tone, texture, lesions, temperature, or edema. Comparing both sides helps identify unilateral conditions and provides a clearer clinical picture, which is essential for accurate documentation and decision-making. This approach is fundamental in all physical assessments.
Why Other Options Are Wrong:
Use layman’s terms when reporting or documenting.
This is incorrect because healthcare professionals are expected to use accurate medical terminology in documentation to maintain clarity and standardization across providers. While layman’s terms may be used when speaking with patients, documentation should reflect professional language.
Inspect specific lesions before performing a generalized examination of the skin.
This is not the recommended sequence. Nurses should start with a general overview of the skin before focusing on specific lesions. A broad view helps provide context and identify patterns that may not be evident if the focus is limited early in the assessment.
Palpate the temperature of the skin with the fingertips.
This is an incorrect technique. The dorsum (back) of the hand, not the fingertips, is more sensitive to temperature and is the correct method for palpating skin temperature. Using fingertips may not provide an accurate thermal assessment.
A nurse is caring for a patient who has myasthenia gravis. Which finding should the nurse expect?
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Peripheral edema
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Drooping eye lids
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Loss of cognitive function
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Fluctuations in heart rate
Explanation
Correct Answer:
Drooping eye lids
Explanation:
Ptosis, or drooping eyelids, is a hallmark symptom of myasthenia gravis due to the autoimmune destruction of acetylcholine receptors, leading to skeletal muscle weakness. Ocular symptoms such as ptosis and diplopia often appear first, especially after sustained muscle use. The weakness worsens with activity and improves with rest, which is characteristic of this disease. Recognizing early signs like ptosis is crucial for diagnosis and timely management.
Why Other Options Are Wrong:
Peripheral edema
This is not associated with myasthenia gravis. Edema is more common in conditions related to fluid imbalance, heart failure, or kidney dysfunction.
Loss of cognitive function
Myasthenia gravis affects motor neurons, not cognitive processing. Patients typically maintain normal mental status unless affected by unrelated conditions or medication side effects.
Fluctuations in heart rate
While autonomic symptoms can occur in some advanced neuromuscular disorders, they are not a common feature of myasthenia gravis. Heart rate variability is not expected in routine cases.
The nurse is providing patient teaching on the normal physiological changes of aging on the urinary system. What should the nurse include in the teaching plan?
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Kidneys are able to concentrate urine
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Patient may experience urinary frequency, urgency, and nocturia
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Kidney is easily palpated
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Patient will eventually require wearing a brief at all times
Explanation
Correct Answer:
Patient may experience urinary frequency, urgency, and nocturia
Explanation:
With aging, several normal physiological changes occur in the urinary system. Decreased bladder capacity, reduced bladder tone, and weakened sphincter muscles contribute to urinary frequency, urgency, and nocturia. These changes are not necessarily signs of disease but are common in the older adult population. Educating patients on these expected changes helps set realistic expectations and promotes early detection of abnormal patterns.
Why Other Options Are Wrong:
Kidneys are able to concentrate urine
This is incorrect because aging kidneys actually have a reduced ability to concentrate urine. This can contribute to dehydration and electrolyte imbalance in older adults.
Kidney is easily palpated
Normally, the kidneys are not easily palpated unless they are enlarged or displaced. In healthy aging, this is not an expected finding and may indicate pathology.
Patient will eventually require wearing a brief at all times
This is an overgeneralization. While incontinence may increase with age, not all elderly individuals require briefs, and many manage urinary function independently or with minimal support.
The nurse is teaching a patient with myasthenia gravis how to prevent a myasthenic crisis. What topic is most important to include?
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Wear gloves when handling frozen food items
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Avoid warm climates
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Receive an annual influenza vaccination
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Increase intake of protein
Explanation
Correct Answer:
Receive an annual influenza vaccination
Explanation:
Preventing infections is a critical part of managing myasthenia gravis because illnesses such as the flu can trigger a myasthenic crisis—a life-threatening exacerbation of muscle weakness. An annual influenza vaccination helps protect patients from respiratory infections that may compromise respiratory muscles already weakened by the disease. Vaccination is a proactive step to reduce the risk of systemic illness and serious complications. It is a key aspect of long-term disease management.
Why Other Options Are Wrong:
Wear gloves when handling frozen food items
This may help with conditions like Raynaud’s phenomenon, but it has no direct impact on preventing myasthenic crisis. It is unrelated to infection control or neuromuscular health in this context.
Avoid warm climates
While heat may cause discomfort or fatigue in some patients with neurological conditions, avoiding warm climates is not a primary or evidence-based intervention to prevent myasthenic crisis.
Increase intake of protein
Protein is important for general health but is not specifically linked to preventing myasthenic crisis. The focus should be on avoiding infection and managing medications, not adjusting macronutrient intake unless prescribed for another reason.
A nurse is assisting during a lumbar puncture. How should the nurse position the patient for this procedure?
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Prone with the head turned to the right
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Supine with the knees raised toward the chest
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Lateral recumbent with chin resting on flexed knees
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Prone with right leg flexed
Explanation
Correct Answer:
Lateral recumbent with chin resting on flexed knees
Explanation:
The lateral recumbent position with the patient’s back arched and chin resting on flexed knees allows maximum separation of the vertebrae. This positioning facilitates access to the subarachnoid space for the lumbar puncture. It also helps the patient remain still during the procedure, reducing the risk of needle misplacement. Correct positioning is essential to ensure safety and obtain accurate cerebrospinal fluid (CSF) samples.
Why Other Options Are Wrong:
Prone with the head turned to the right
The prone position does not adequately separate the vertebrae and is not standard for lumbar puncture. It also makes needle placement more difficult and less controlled.
Supine with the knees raised toward the chest
This position does not offer the same degree of spinal flexion as the lateral recumbent position. It is not ideal for accessing the lumbar subarachnoid space.
Prone with right leg flexed
Again, the prone position is incorrect for this procedure, and flexing just one leg does not aid spinal access. This posture may actually increase patient discomfort without benefit.
The nurse educates a patient diagnosed with a UTI. Which diet choices should be avoided to prevent bladder irritation?
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Breads
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Fresh fruits
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Caffeine
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Cheeses
Explanation
Correct Answer:
Caffeine
Explanation:
Caffeine is known to irritate the bladder lining and can worsen urinary tract infection (UTI) symptoms such as urgency, frequency, and discomfort. It is a diuretic and bladder stimulant that increases urine output and may exacerbate irritation during a UTI. Patients with UTIs are advised to avoid caffeinated beverages like coffee, tea, and cola to help reduce symptoms and promote healing. Hydration with water and bladder-friendly fluids is recommended instead.
Why Other Options Are Wrong:
Breads
Plain breads do not contain bladder irritants and are generally well tolerated during a UTI. They do not impact urinary tract health negatively.
Fresh fruits
Most fresh fruits are helpful due to their hydration and vitamin content. Exceptions include highly acidic ones like citrus, but in general, fruits support immune health and are not blanket irritants.
Cheeses
Cheese is not associated with bladder irritation. Unless a patient has another condition such as lactose intolerance or dietary restriction, cheese can be safely consumed during a UTI.
The nurse is aware that which patients are at risk for a skin alteration? (Drag the correct answers.)
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The patient who had numbness in the right arm that resolved several hours ago
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A patient who has been newly diagnosed with diabetes
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A patient who has had vomiting and diarrhea for several days and lost 12 pounds
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The patient who has paralysis and unable to move in the bed
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A roofer who spends a lot of time outdoors
Explanation
Correct Answer:
A patient who has been newly diagnosed with diabetes
A patient who has had vomiting and diarrhea for several days and lost 12 pounds
The patient who has paralysis and unable to move in the bed
A roofer who spends a lot of time outdoors
Explanation:
Patients at risk for skin alteration often have underlying conditions or exposures that compromise skin integrity. Diabetic patients are at increased risk due to impaired circulation and sensation. Dehydration from vomiting and diarrhea affects skin turgor and resilience. Immobility, as seen in paralyzed patients, leads to pressure injuries due to sustained pressure and poor circulation. Roofers experience prolonged sun exposure and sweat buildup, both of which can weaken skin and increase the risk of breakdown.
Why Other Option Is Wrong:
The patient who had numbness in the right arm that resolved several hours ago
Transient numbness without lasting sensory impairment or immobility does not significantly raise the risk of skin breakdown. Once sensation returns, normal skin protection mechanisms are restored.
The nurse educates a patient diagnosed with a urinary tract infection (UTI) that adequate fluid intake provides what benefit?
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Creatinine levels are more stable but unpredictably useful.
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Kidneys are less irritable, but bacteria has time to colonize and multiply.
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Hydration status is not beneficial but may help if combined with high caloric intake.
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Dilutes urine and often flushes out bacteria before colonization.
Explanation
Correct Answer:
Dilutes urine and often flushes out bacteria before colonization.
Explanation:
Increasing fluid intake during a UTI helps dilute the urine, which can reduce irritation of the urinary tract and assist in flushing out bacteria before they can adhere to the uroepithelial lining and colonize. This reduces the bacterial load and supports the body’s immune defense. Adequate hydration is a simple but effective non-pharmacologic measure to support treatment and reduce symptom severity. Encouraging patients to drink fluids is standard patient education in UTI care.
Why Other Options Are Wrong:
Creatinine levels are more stable but unpredictably useful.
This is misleading. While hydration may influence creatinine levels, the statement is vague and unrelated to UTI-specific benefits. Stability of creatinine isn’t the primary goal or benefit of fluid intake during a urinary tract infection, making this choice incorrect.
Kidneys are less irritable, but bacteria has time to colonize and multiply.
This is inaccurate. While adequate fluids can reduce irritation, increased urination actually helps prevent bacterial colonization. This option incorrectly suggests that hydration delays bacterial clearance, which contradicts the purpose of fluid therapy in UTIs.
Hydration status is not beneficial but may help if combined with high caloric intake.
This is incorrect and misleading. Hydration is indeed beneficial independently of caloric intake, especially in flushing bacteria from the urinary tract. Caloric intake does not significantly affect the flushing or dilution of urine in UTI management, making this choice factually wrong.
The nurse is caring for a patient following a cystoscope. Which assessment finding would the nurse report to the provider as a complication after the procedure?
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Bright red blood in urine
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Urinary frequency
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Pink-tinged urine
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Burning on urination
Explanation
Correct Answer:
Bright red blood in urine
Explanation:
Bright red blood in the urine following a cystoscopy may indicate active bleeding and should be reported immediately. While some mild hematuria (pink-tinged urine) is expected, bright red bleeding suggests a complication such as trauma or vessel injury during the procedure. This finding requires prompt evaluation by the provider to rule out serious issues and initiate appropriate treatment. It goes beyond expected post-procedure symptoms.
Why Other Options Are Wrong:
Urinary frequency
This is a common and expected side effect after cystoscopy due to bladder irritation. It typically resolves without intervention and does not signal a serious complication.
Pink-tinged urine
Mild hematuria is normal post-procedure and results from minor mucosal irritation. It usually subsides within a day or two and doesn’t require reporting unless it worsens.
Burning on urination
Dysuria can occur after cystoscopy as the urethra may be irritated. This symptom should be monitored, but it is not necessarily a complication unless accompanied by signs of infection or worsening discomfort.
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