MEDSURG-BC Dumps
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ANCC Medical-Surgical Nursing Certification
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A patient is scheduled for a diagnostic test that requires fasting. Which nursing action is appropriate to ensure patient safety during the test?
Administer the patient's regular medications as scheduled.
Provide clear instructions about the fasting requirements.
onitor vital signs every 30 minutes during the fasting period. wer: B
anation: To ensure patient safety during a diagnostic test that requires ng, the nurse should provide clear instructions about the fasting rements. This includes informing the patient about the duration of fas ctions on food and drink, and any specific preparations or restrictions ed to their medications. Clear instructions help prevent complications re accurate test results.
tient with a recent diagnosis of major depressive disorder is at risk for de. Which nursing intervention would be the highest priority?
ncouraging the patient to participate in group therapy sessions onitoring the patient's vital signs regularly
Encourage the patient to drink plenty of fluids before the test.
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Initiating a safety plan and closely monitoring the patient's whereabouts
Administering an antidepressant medication as prescribed Answer: C
Explanation: The highest priority nursing intervention for a patient at risk for suicide is to initiate a safety plan and closely monitor the patient's whereabouts.
This is crucial to ensure the patient's immediate safety and prevent self-harm. While other interventions, such as group therapy, vital sign monitoring, and medication administration, may also be important aspects of the patient's care, addressing the immediate safety concerns takes precedence in this situation.
ng diagnosis should be prioritized for a patient with a postoperative w
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isk for Infection related to surgical site
mpaired Physical Mobility related to surgical procedure cute Pain related to surgical incision
eficient Knowledge related to wound care wer: A
anation: The nursing diagnosis that should be prioritized for a patient stoperative wound drain is "Risk for Infection related to surgical site." cause the presence of a wound drain creates a potential route for infec reventing infection is crucial in postoperative care. While other diag as impaired physical mobility, acute pain, and deficient knowledge, a mportant to address, the risk for infection takes priority due to its pot ct on the patient's overall recovery and well-being.
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A patient with a cognitive impairment is admitted to the medical-surgical unit. What is the nurse's priority when providing care for this patient?
Promote independence in activities of daily living.
Ensure a safe environment to prevent falls and injuries.
Administer cognitive-enhancing medications as prescribed.
Provide emotional support and social interaction. Answer: B
espond to their surroundings. By creating a safe environment, the nur ces the risk of accidents and promotes the patient's well-being.
tient is prescribed multiple medications for various chronic conditions recognizes the importance of assessing for potential medication
actions. Which action should the nurse take to minimize the risk of ad interactions?
ncourage the patient to consult with a pharmacist regarding potential actions.
eview the patient's medication list with the healthcare provider at eac
ducate the patient about potential drug interactions and their symptom onitor the patient's laboratory values for signs of adverse drug effects
wer: B
Explanation: When caring for a patient with cognitive impairment, the nurse's priority is to ensure a safe environment to prevent falls and injuries. Cognitive impairments can affect a patient's judgment, orientation, and ability to perceive and r se
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Explanation: To minimize the risk of adverse drug interactions in a patient taking multiple medications, the nurse should review the patient's medication list with the healthcare provider at each visit. This allows for a comprehensive assessment of potential interactions and provides an opportunity to make necessary adjustments to the medication regimen. While encouraging the patient to consult with a pharmacist, educating the patient about potential
interactions, and monitoring laboratory values are all important aspects of medication safety, reviewing the medication list with the healthcare provider ensures a collaborative approach to preventing and managing drug interactions.
rences?
he patient's level of health literacy he patient's cultural background
he patient's age and developmental stage
he patient's previous experience with diabetes wer: C
anation: When considering a newly diagnosed diabeticpatient's learni rences, the nurse should prioritize the patient's age and developmenta Different age groups have varying learning styles and preferences, a ring the teaching approach to match the patient's developmental stage nce learning outcomes. While factors such as health literacy, cultural ground, and previous experience with diabetes are also important to ider, the patient's age and developmental stage should be given priorit ituation.
A nurse is providing patient teaching to a newly diagnosed diabetic patient. Which factor should the nurse prioritize when considering the patient's learning prefe
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A patient with a history of heart failure is scheduled for a cardiac catheterization. Which nursing action is essential in preparing the patient for the procedure?
Administering anticoagulant medications preoperatively
Assessing the patient's allergies to contrast dye
Providing preoperative teaching on the procedure and expected sensations
Ensuring the patient has an empty bladder before the procedure Answer: B
gies to contrast dye. Contrast dye is commonly used during cardiac eterization procedures to enhance visualization of the blood vessels. gies to contrast dye can lead to severe allergic reactions, including hylaxis, so it is crucial to identify any allergies beforehand. Administ oagulant medications, providing preoperative teaching, and ensuring a y bladder are important aspects of preparation but are not as essential sing for allergies to contrast dye.
tient is prescribed multiple medications for different health conditions is concerned about potential drug interactions and adverse effects. W n should the nurse take?
onsult with the pharmacist regarding potential interactions. iscontinue all the medications and notify the healthcare provider. ducate the patient about potential adverse effects and monitor closely.
dminister the medications as prescribed and monitor for adverse effec
Explanation: When preparing a patient with a history of heart failure for a cardiac catheterization, it is essential for the nurse to assess the patient's aller
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Explanation: In a situation where a patient is prescribed multiple medications, and there is concern about potential drug interactions and adverse effects, the nurse should consult with the pharmacist regarding potential interactions. Pharmacists are experts in medication management and can provide valuable
information on potential interactions, contraindications, and adverse effects. Collaborating with the pharmacist ensures patient safety and helps prevent medication-related complications.
ddress the most life-threatening conditions first.
ocus on the patient's most significant medical diagnosis. rioritize nursing diagnoses related to psychosocial needs.
ive priority to nursing diagnoses identified by the healthcare provider. wer: A
anation: When prioritizing nursing diagnoses for a patient, the nurse ld address the most life-threatening conditions first. This approach ens mmediate and critical patient needs are addressed promptly. By itizing life-threatening conditions, the nurse can provide timely ventions to stabilize the patient's condition and prevent further ioration.
tient with a chronic illness is being discharged from the hospital. Whe
When prioritizing nursing diagnoses for a patient, which principle should guide the nurse's decision-making?
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providing patient teaching, the nurse should consider:
The patient's learning preferences and barriers.
The nurse's personal teaching style and preferences.
Using complex medical terminology to enhance understanding.
Providing all teaching materials in written format only.
Explanation: When providing patient teaching to a patient with a chronic illness, the nurse should consider the patient's learning preferences and barriers. Each patient has unique learning needs and preferences.
tient with chronic pain is interested in exploring complementary and native medicine (CAM) for pain management. Which nursing action i opriate in this situation?
ducating the patient about potential risks and benefits of CAM therapi iscouraging the patient from pursuing CAM therapies due to lack of tific evidence
eferring the patient to a CAM practitioner without further assessment ollaborating with the patient to develop an individualized pain agement plan
wer: A
anation: In a situation where a patient with chronic pain is interested i oring complementary and alternative medicine (CAM) for pain agement, the appropriate nursing action is to educate the patient about ntial risks and benefits of CAM therapies. This allows the patient to m
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informed decisions regarding their healthcare and promotes patient autonomy. While it is important to discuss the scientific evidence of CAM therapies, discouraging the patient without consideration of their preferences may not be the most effective approach. Referring the patient to a CAM practitioner without further assessment can bypass a comprehensive evaluation of the patient's needs. Collaborating with the patient to develop an individualized pain management plan incorporates their preferences and goals into the overall care
A nurse is conducting a health promotion session for a group of adults. Which topic should the nurse prioritize to address the prevention of chronic diseases?
rategies for stress management and mental well-being creening guidelines for early detection of common cancers utritional recommendations for maintaining a healthy weight
wer: A
anation: When addressing the prevention of chronic diseases in a heal motion session, the nurse should prioritize the topic of the importance o ar physical activity and exercise. Regular physical activity has been s ve numerous health benefits and is a key factor in preventing chronic ses such as cardiovascular diseases, diabetes, and certain types of can
e strategies for stress management, cancer screening guidelines, and tional recommendations are also important, regular physical activity s oundational aspect of chronic disease prevention.
The importance of regular physical activity and exercise
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A nurse is implementing patient safety measures in a medical-surgical unit. Which action is an example of utilizing a screening tool for fall risk assessment?
Providing regular toileting and bathroom assistance to patients
Placing nonslip mats on the floors in patient rooms and bathrooms
Conducting hourly rounding to check on patients' safety and comfort
Answer: D
e providing toileting assistance, using nonslip mats, and conducting h ding are all important fall prevention strategies, they do not specificall ve the use of a screening tool for assessment.
tient is recovering from surgery and is at risk for developing complica as deep vein thrombosis (DVT). What nursing intervention is importa reventing DVT in this patient?
dministering anticoagulant medications as prescribed. pplying warm compresses to the affected area. ssisting with early ambulation and leg exercises.
sing sequential compression devices on the lower extremities. wer: D
anation: To prevent deep vein thrombosis (DVT) in a postoperative
Explanation: Utilizing a screening tool for fall risk assessment involves administering a standardized fall risk assessment tool to all patients. This tool helps to systematically identify patients who are at a higher risk of falling, allowing nurses to implement appropriate interventions and safety measures. Whil ourly
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patient, an important nursing intervention is to use sequential compression devices (SCDs) on the lower extremities. SCDs help prevent DVT by promoting venous blood flow and preventing stasis. They provide intermittent compression to the legs, mimicking the natural pumping action of the calf muscles. This intervention is especially beneficial for patients who are immobile or have limited mobility.
A patient is scheduled for a surgical procedure. Which nursing intervention is important for preventing postoperative complications?
Administering preoperative antibiotics as prescribed.
Encouraging deep breathing and coughing exercises.
ssisting with early ambulation after surgery. wer: B
anation: To prevent postoperative complications, encouraging deep hing and coughing exercises is an important nursing intervention. De hing and coughing exercises help prevent respiratory complications s electasis and pneumonia by promoting lung expansion, clearing secret mproving oxygenation. It also aids in preventing postoperative respir plications related to anesthesia and immobility.
tient with a traumatic brain injury is experiencing cognitive deficits. ch nursing action is appropriate for promoting cognitive stimulation?
ncouraging physical exercise to improve overall brain function roviding a quiet and low-stimulus environment to reduce cognitive
Applying cold compresses to reduce swelling.
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Engaging the patient in mentally challenging activities and puzzles
Administering cognitive-enhancing medications as prescribed Answer: C
Explanation: To promote cognitive stimulation in a patient with cognitive
deficits, the nurse should engage the patient in mentally challenging activities and puzzles. This helps to activate and exercise cognitive skills, promoting cognitive improvement and recovery. While physical exercise is beneficial for overall brain health, it may not directly address cognitive deficits. Providing a quiet environment and administering cognitive-enhancing medications may be appropriate in certain situations, but engaging the patient in mentally challenging activities is specifically aimed at promoting cognitive stimulation.
ng a psychosocial assessment, the nurse identifies that a patient has a ry of substance use disorder. Which action should the nurse prioritize atient's plan of care?
mplement a safety plan to prevent relapse. rovide education on the risks of substance use.
ncourage participation in support groups or counseling. ssess the patient's readiness for change.
wer: D
anation: When a patient has a history of substance use disorder, assess atient's readiness for change should be prioritized in the plan of care. erstanding the patient's motivation and readiness to address the substa isorder is crucial for developing an effective care plan. It allows the n lor interventions and support based on the patient's individual needs a
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A patient with a history of deep vein thrombosis (DVT) is at risk for developing postoperative complications. Which nursing intervention is most effective in preventing postoperative DVT?
Administering prophylactic anticoagulant medication as prescribed
Applying sequential compression devices (SCDs) to the patient's lower extremities
Encouraging early ambulation and leg exercises postoperatively
anation: The most effective nursing intervention in preventing operative deep vein thrombosis (DVT) is administering prophylactic oagulant medication as prescribed. Anticoagulant medications help to ent blood clots from forming, reducing the risk of DVT. While applyi ential compression devices (SCDs), encouraging early ambulation and cises, and educating the patient on DVT signs and symptoms are also rtant interventions, medication administration plays a key role in enting DVT formation.
Educating the patient on the signs and symptoms of DVT Answer: A
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