Adult Health 1 PrepU Quizzes

The surgical nurse is preparing to send a client from the presurgical area to the OR and is reviewing the client's informed consent form. What are the criteria for legally valid informed consent? Select all that apply.

1. Consent must be freely given. 2. Consent must normally be obtained by a physician. 3. Signature must be witnessed by a professional staff member.

The nurse suspects "compartment syndrome" for a casted extremity. What characteristic symptoms would the nurse assess that would confirm these suspicions? (Select all that apply.)

1. Decreased sensory function 2. Excruciating pain 3. Loss of motion

Which intervention should the nurse implement with the client who has an external fixator? Select all that apply.

1. Perform pin care as ordered. 2. Supervise the client during transfers. 3. Perform neurovascular assessment. 4. Inspect pin sites for signs of infection.

A nurse providing education about hypertension to a community group is discussing the high risk for cardiovascular complications. Which of the following are risk factors for cardiovascular problems in clients with hypertension? Choose all that apply.

1. Smoking 2. Diabetes mellitus 3. Physical inactivity

A surgical client has been in the PACU for the past 3 hours. What are the determining factors for the client to be discharged from the PACU? Select all that apply.

1. Stable blood pressure 2. Sufficient oxygen saturation 3. Adequate respiratory function

The nurse is providing instructions to a patient scheduled for a gastroscopy. What should the nurse be sure to include in the instructions? (Select all that apply.)

1. The patient must fast for 8 hours before the examination. 2. The throat will be sprayed with a local anesthetic. 3. After gastroscopy, the patient cannot eat or drink until the gag reflex returns (1 to 2 hours).

A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply.

1. To provide adequate transport of oxygen in the blood 2. To decrease the work of breathing 3. To reduce stress on the myocardium

When fluid intake is normal, the specific gravity of urine should be

1.010 - 1.025

When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of:

1.5 to 2.5 times the baseline control

An older adult patient had a hip replacement. When should the patient begin with assisted ambulation with a walker?

24 hours

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?

<30 mL

An older adult client visits the clinic for a blood pressure (BP) check. The client's hypertension is not well controlled, and a new blood pressure medicine is prescribed. What is important for the nurse to teach this client about the blood pressure medicine?

A possible adverse effect of blood pressure medicine is dizziness when you stand.

The nurse teaches a client scheduled for a colonoscopy. Which instruction should be included as part of the preparation for the procedure?

Follow the dietary and fluid restrictions and bowel preparation procedures.

A nurse is applying an ostomy appliance to the ileostomy of a client with ulcerative colitis. Which action is appropriate?

Gently washing the area surrounding the stoma using a facecloth and mild soap

A nurse is presenting a safety program to a group of older adults at a continuing care retirement community. The nurse emphasizes measures to reduce the risk of falls based on the understanding that which type of fracture is the most common?

Hip

The nurse is providing care for a client who has recently been diagnosed with COPD. When educating the client about exacerbations, the nurse should prioritize what topic?

Identifying specific causes of exacerbations

The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result?

Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing

The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis?

Incentive spirometry

A client reports urinary frequency, urgency, and dysuria. Which of the following would the nurse most likely suspect?

Infection

After undergoing retropubic prostatectomy, a client returns to his room. The client is on nothing-by-mouth status and has an IV infusing in his right forearm at a rate of 100 ml/hour. The client also has an indwelling urinary catheter that's draining light pink urine. While assessing the client, the nurse notes that his urine output is red and has dropped to 15 ml and 10 ml for the last 2 consecutive hours. How can the nurse best explain this drop in urine output?

It is an abnormal finding that requires further assessment.

A client asks about the purpose of withholding food and fluid before surgery. Which response by the nurse is appropriate?

It prevents aspiration and respiratory complications.

A nurse is providing preoperative teaching to a client who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a client leg exercises prior to surgery?

Leg exercises improve circulation and prevent venous thrombosis.

The nurse is providing discharge instructions to a client with heart failure preparing to leave the following day. What type of diet should the nurse request the dietitian to discuss with the client?

Low sodium diet

With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by:

Lowering the limb so it is dependent

A patient has had surgery to create an ileal conduit for urinary diversion. What is a priority intervention by the nurse in the postoperative phase of care?

Monitor urine output hourly and report output less than 30 mL/hr.

The nurse is providing discharge education to a client diagnosed with heart failure. What should the nurse teach this client to do to assess fluid balance in the home setting?

Monitor weight daily

A nurse has been asked to speak to a local women's group about preventing cystitis. Which of the following would the nurse include in the presentation?

Need to urinate after engaging in sexual intercourse

Students are preparing a class presentation on elder abuse. Which of the following would they include as the most common type of elder abuse?

Neglect

The nurse teaches the client which intervention to avoid hip dislocation after replacement surgery?

Never cross the affected leg when seated

A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe?

Older adults often lack the classic signs and symptoms of pneumonia.

Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention?

Oxygen saturation of 82%

An elderly client who lives in a retirement community is having a mild depressive episode over the past few weeks. The nurse intervenes by recommending

Participation in a social activity

A client has experienced occasional urinary incontinence in the weeks since his prostatectomy. In order to promote continence, the nurse should encourage which of the following?

Pelvic floor exercises

A client is on call to the OR for an aortobifemoral bypass and the nurse administers the prescribed preoperative medication. After administering a preoperative medication to the client, what should the nurse do?

Place the bed in a low position with the side rails up.

It is important for the nurse to monitor serum electrolytes in a patient with acute diarrhea. Select the electrolyte result that should be immediately reported.

Potassium of 2.8

A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which of the following assessment findings for this client?

Pulmonary congestion

During a community health fair, a nurse is teaching a group of seniors about promoting health and preventing infection. Which intervention would best promote infection prevention for senior citizens who are at risk of pneumococcal and influenza infections?

Receive vaccinations

A woman comes to her health care provider's office with signs and symptoms of kidney stones. Which of the following should be the primary medical management goal?

Relieve the pain

Based on a client's vague explanations for recurring injuries, the nurse suspects that a community-dwelling older adult may be the victim of abuse. What is the nurse's primary responsibility?

Report the findings to adult protective services

A client with Alzheimer's disease is admitted for hip surgery after falling and fracturing the right hip. The client's spouse tells the nurse about feeling guilty for letting the accident happen and reports not sleeping well lately because the spouse has been getting up at night and doing odd things. Which nursing diagnosis is most appropriate for the client's spouse?

Risk for caregiver role strain related to increase client care needs

Which is an accurate rationale for why older adults are more susceptible to serious infections?

They have less efficient defense mechanisms

A client comes to the clinic for a follow-up visit. During the interview, the client states, "Sometimes when I have to urinate I can't control it, and do not reach the bathroom in time." The nurse suspects that the client is experiencing which type of incontinence?

Urge

A client with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the health care provider to prescribe?

Venturi mask

The nurse teaches the client with a high risk for osteoporosis about risk-lowering strategies, including which action?

Walk or perform weight bearing exercises

The nurse is planning discharge instructions for the client with osteomyelitis. What instructions should the nurse include in the discharge teaching?

You will receive IV antibiotics for 3 to 6 weeks.

Which nursing instruction is correct to provide the client following a barium enema?

The stools may be white or clay colored

Which client requires immediate nursing intervention? The client who:

presents with a rigid, boardlike abdomen.

A client is scheduled for a transurethral rescection of the prostate (TURP). Which statement demonstrates that the expected outcome of "client demonstrates understanding of the surgical procedure and aftercare" has been met?

"The surgeon is going to insert a scope through my urethra to remove a portion of the gland."

A nurse in a busy emergency department provides care for many clients who present with contusions, strains, or sprains. What are treatment modalities that are common to all of these musculoskeletal injuries? Select all that apply.

1. Applying ice 2. Compression dressings 3. Resting the affected extremity 4. Elevating the injured limb

The nurse is providing care for a client who has had a below-the-knee amputation. The nurse enters the client's room and finds the client resting in bed with his residual limb supported on pillow. What is the nurse's most appropriate action?

Explain the risks of flexion contracture to the client.

An older adult develops sudden onset of confusion and is hospitalized. The family expresses concern that their loved one is developing Alzheimer disease. What response by the nurse is most appropriate?

"Several possible underlying factors could be causing the confusion. Alzheimer's usually does not present with sudden confusion."

A client who had abdominal surgery 4 days ago reports that "something gave way" when he sneezed. The nurse observes a wound evisceration. Which nursing action is the first priority?

Apply a sterile, moist dressing

The wife of a patient who was admitted 3 days ago with an exacerbation of chronic obstructive pulmonary disease (COPD) states that she is worried about her husband because he appears to be breathing "really hard." The nurse performs a respiratory assessment. Which of the following findings would indicate a need for further interventions? (Select all that apply.)

BP 122/80, HR 116, R 24, pale and clammy skin, temp 101.3 degrees F

Which drug is considered a stimulant laxative?

Bisacodyl

Which of the following is a characteristic of an arterial ulcer?

Border regular and well demarcated

Which is the most common presenting symptom of colon cancer?

Change in bowel habits

A registered nurse who is responsible for coordinating and documenting client care in the operating room is a

Circulating nurse

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia?

Encourage increased fluid intake

An age-related change associated with the cardiovascular system is

Decreased cardiac output

Which factor alters urinary elimination patterns in older adults?

Decreased muscle tone

An 84-year-old client has returned from the post-anesthetic care unit (PACU) following hip arthroplasty. The client is oriented to name only. The client's family is very upset because, before having surgery, the client had no cognitive deficits. The client is subsequently diagnosed with postoperative delirium. What should the nurse explain to the client's family?

Delirium of this type is treatable and her cognition will return to previous levels.

Which of the following is the most important nursing diagnosis for an elderly patient diagnosed with osteoporosis?

Risk for injury related to fractures due to osteoporosis

A nurse is planning the care of a client with emphysema who will soon be discharged. What teaching should the nurse prioritize in the plan of care?

Setting realistic short- and long-term goals

A patient is to undergo surgery on his kidney. The patient would be placed in which position for the surgery?

Sims position

Which principle applies to the client in traction?

Skeletal traction is never interuppted

A nurse caring for a patient with regional enteritis knows to assess for this most serious systemic complication. What is that complication?

Small bowel obstruction

A patient informs the nurse that every time she sneezes or coughs, she urinates in her pants. What type of incontinence does the nurse recognize the patient is experiencing?

Stress incontinence

A patient has a serum study that is positive for the rheumatoid factor. What does the nurse understand is the significance of this test result?

Suggestive of RA

A client realizes that regular use of laxatives has greatly improved his bowel pattern. However, the nurse cautions this client against the prolonged use of laxatives for which reason?

The client's natural bowel function may become sluggish.

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect:

left calf circumference 1" (2.5 cm) larger than the right.