Exam 4 med surg possible questions

The nurse is caring for a patient who has just returned from the ERCP removal of gallstones. The nurse should monitor the patient for signs of what complications? A) Pain and peritonitis B) Bleeding and perforation C) Acidosis and hypoglycemia D) Gangrene of the gallbladder and hyperglycemia

B) Bleeding and perforation

The nurse is assessing a patient admitted with renal stones. During the admission assessment, what parameters would be priorities for the nurse to address? Select all that apply. A) Dietary history B) Family history of renal stones C) Medication history D) Surgical history E) Vaccination history

A) Dietary history B) Family history of renal stones C) Medication history

Which laboratory data supports the patient's diagnosis of liver failure? 1) Decreased AST 2) Elevated albumin 3) Elevated ammonia 4) Decreased total bilirubin

3) Elevated ammonia

The nurse is evaluating care provided to a patient recovering from surgery for colorectal cancer. Which assessment data indicates the need for further intervention by the nurse? 1)Patient has an hourly urine output of 45 mL. 2)Patient performs morning care with assistance. 3)Patient states family members will care for the ostomy at home. 4)Patient tolerates a full liquid diet and is requesting solid food.

3)Patient states family members will care for the ostomy at home.

During an interview with a client afflicted with hepatitis B, the nurse obtains the following data: Ten kg weight loss is noted from the client's last visit 4 months ago. Review of systems reveals 1) limiting fatigue, 2) not well enough for sexual intercourse but doubts if her husband will be willing to use a condom, 3) drinks 3-5 mixed drinks weekly socially, 4) RUQ pain rated at 6/10, and 5) "constant" pruritus. Prioritize the nursing diagnoses formulated for this client. 1. Imbalanced Nutrition 2. Impaired Skin Integrity 3. Acute Pain 4. Deficient Knowledge

3. Acute Pain 4. Deficient Knowledge 1. Imbalanced Nutrition 2. Impaired Skin Integrity

The nurse is providing care to a patient who is diagnosed with gallstones. Which preferred treatment method should the nurse include in the teaching session? 1) Lithotripsy 2) Low-fat diet 3) Oral agents to dissolve the stones 4) Laparoscopic cholecystectomy

4) Laparoscopic cholecystectomy

A client diagnosed with frequent urinary tract infections is seen in the urology clinic. The nurse reviews the client's medical history and determines that the client is at risk for acute kidney injury. Which items in the client's history support this conclusion? Select all that apply. A) Dehydration B) Renal calculi C) Ineffective wound healing D) Low serum albumin E) Hypertension

A) Dehydration B) Renal calculi E) Hypertension

What are nursing interventions you should implement on a patient who has suspected bleeding of esophageal varices?

- Establish IV access with large bore needle - Monitor vital signs - Monitor hematocrit - Type and crossmatch for possible blood transfusion - Monitor overt and occult bleeding

Which assessment data indicates to the nurse that the patient may be experiencing decreased clotting factors as a complication of cirrhosis? 1) Epistaxis 2) Yellow skin 3) Clay-colored stool 4) Personality changes

1) Epistaxis

Which is a common cause of death for a patient who presents for care in the emergency department (ED) with liver trauma suffered as a result of a motor vehicle accident? 1) Infection 2) Hemorrhage 3) Cardiac arrest 4) Respiratory arrest

2) Hemorrhage

When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately? A. Weight loss of 2 pounds in 3 days B. Change in the client's handwriting and/or cognitive performance C. Anorexia for more than 3 days D. Constipation for more than 2 days

B. Change in the client's handwriting and/or cognitive performance

The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which of the following would be an indication that hepatic encephalopathy is developing? a. decreased mental status b. elevated blood pressure c. decreased urine output d. labored respirations

a. decreased mental status

Which statement indicates a need for further teaching by a student nurse about nutritional therapy in patients with acute pancreatitis? a. "I should feed the patient through a nasojejunal tube." b. "I should monitor the patient's blood triglyceride levels." c. "I should give small quantities of food frequently to the patient." d. "I should include fat-rich food substances in the patient's dietary plan.

d. "I should include fat-rich food substances in the patient's dietary plan.

A client with advanced cirrhosis has been diagnosed with hepatic encephalopathy. The nurse expects to assess for: A. Hand tremors. B. Malaise. C. Stomatitis. D. Weight loss.

A. Hand tremors

A nurse teaches a patient who is at risk for fecal impaction. Which statements would the nurse include in this patient's teaching? A. "Take a laxative every evening to improve motility." B. "Take Metamucil or other bulk-forming products." C. "Eat a high-fiber diet including raw fruits and vegetables." D. "Drink prune juice to stimulate peristalsis." Blueprint: Taking care of pt recovering from sx for colorectal

C. "Eat a high-fiber diet including raw fruits and vegetables."

The nurse is preparing care for a patient recovering from surgery for colorectal cancer. Which interventions should the nurse use when creating a pain management plan for this patient? Select all that apply. 1) Provide pain medication upon request 2) Assess surgical site for inflammation 3) Assess bowel sounds 4) Administer pain medication after painful procedures 5) Instruct to use a pillow to splint when deep breathing and coughing

2) Assess surgical site for inflammation 3) Assess bowel sounds 5) Instruct to use a pillow to splint when deep breathing and coughing

Which data collected by the nurse after a liver biopsy indicates the need for immediate action by the nurse? 1) The patient is awake and alert. 2) The patient's blood pressure is 90/60 mm Hg. 3) The patient's heart rate is 80 beats per minute. 4) The patients respiratory rate is 16 breaths per minute.

2) The patient's blood pressure is 90/60 mm Hg

A patient has just been told that a colectomy and ileostomy are needed to treat a new diagnosis of colon cancer. Which diagnosis should the nurse use to plan this patient's preoperative nursing care? 1) Knowledge Deficit 2) Risk for Disuse Syndrome 3) Risk for Perioperative-Positioning Injury 4) Anticipatory Grieving

4) Anticipatory Grieving

: A 45-year-old man with diabetic nephropathy has end-stage renal failure and is starting dialysis. He asks for information about hemodialysis. What would the nurse include in the teaching for this patient? A) Hemodialysis is a treatment option that is required three times a week. B) Hemodialysis is a treatment option that is required daily. C) You will have surgery and a catheter will need to be inserted into the abdomen. D) Hemodialysis is a treatment that is used for a few months until your kidney heals and starts to produce urine again

A) Hemodialysis is a treatment option that is required three times a week.

A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply. A) Immunization B) Use of standard precautions C) Consumption of a vitamin-rich diet D) Annual vitamin K injections E) Annual vitamin B12 injections

A) Immunization B) Use of standard precautions

A nurse assesses a client recovering from a cystoscopy. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.) a. Decrease in urine output b. Tolerating oral fluids c. Prescription for metformin d. Blood clots present in the urine e. Burning sensation when urinating

a. Decrease in urine output d. Blood clots present in the urine

the nurse provides discharge instructions to a patient who is post op for an appendectomy. Which patient statement indicates a need for additional teaching? A. I can go home as soon as I am able to urinate B. I will get up and walk around as much as I can C. I will take the antibiotics until I no longer have a fever D. I will use the incentive spirometer 10 times an hour while awake

C. I will take the antibiotics until I no longer have a fever

: A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, "I do not want to take this medication because it causes diarrhea." How should the nurse respond? a. "Diarrhea is expected; that's how your body gets rid of ammonia." b. "You may take Kaopectate liquid daily for loose stools." c. "Do not take any more of the medication until your stools firm up." d. "We will need to send a stool specimen to the laboratory."

a. "Diarrhea is expected; that's how your body gets rid of ammonia."

: The nurse teaches a community group ways to prevent Escherichia coli infection. Which statements would the nurse include in this group's teaching? (Select all that apply.) a. "Wash your hands after any contact with animals." b. "It is not necessary to buy a meat thermometer." c. "Stay away from people who are ill with diarrhea." d. "Use separate cutting boards for meat and vegetables." e. "Avoid swimming in backyard pools and using hot tubs.

a. "Wash your hands after any contact with animals." d. "Use separate cutting boards for meat and vegetables."

: A nurse inserts a nasogastric (NG) tube for an adult client who has a bowel obstruction. Which actions does the nurse perform correctly? (Select all that apply.) a. Performs hand hygiene and positions the client in high-Fowlers position, with pillows behind the head and shoulders b. Instructs the client to extend the neck against the pillow once the NG tube has reached the oropharynx c. Checks for correct placement by checking the pH of the fluid aspirated from the tube d. Secures the NG tube by taping it to the clients nose and pinning the end to the pillowcase e. Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent

a. Performs hand hygiene and positions the client in high-Fowlers position, with pillows behind the head and shoulders c. Checks for correct placement by checking the pH of the fluid aspirated from the tube e. Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent

An infection control nurse develops a plan to decrease the number of health care professionals who contract viral hepatitis at work. Which ideas should the nurse include in this plan? (Select all that apply.) a. Policies related to consistent use of Standard Precautions b. Hepatitis vaccination mandate for workers in high-risk areas c. Implementation of a needleless system for intravenous therapy d. Number of sharps used in client care reduced where possible e. Postexposure prophylaxis provided in a timely manner

a. Policies related to consistent use of Standard Precautions c. Implementation of a needleless system for intravenous therapy d. Number of sharps used in client care reduced where possible e. Postexposure prophylaxis provided in a timely manner

The nurse is caring for a client who had a liver biopsy apron 15 minutes ago. The client is supine in bed, the nurse notes that the client's skin is pale and cool, and he reports lightheadedness. The nurse's immediate response is to do which of the following? select all a. place the client on his right side b. leave client in supine position c. obtain vital signs d. check urine output e. call emergency response team

a. place the client on his right side c. obtain vital signs

After treating several young women for urinary tract infections (UTIs), the college nurse plans an educational offering on reducing the risk of getting a UTI. What information does the nurse include? (Select all that apply.) a. Void before and after each act of intercourse. b. Consider changing to spermicide from birth control pills. c. Do not douche or use scented feminine products. d. Wear loose-fitting nylon panties. e. Wipe or clean the perineum from front to back

a. Void before and after each act of intercourse. e. Wipe or clean the perineum from front to back

The nurse is planning care for a client being admitted with bleeding esophageal varices. Vital signs are: P: 100 R 22 BP 100/58. The nurse should prepare the client for which of the following? select all that apply a. administration if IV octreotide b. endoscopy c. administration of a blood product d. minnesota tube insertion e. TIPS procedure f. immediate endotracheal intubation

a. administration if IV octreotide b. endoscopy c. administration of a blood product

The client has just had a liver biopsy. Which of the following nursing actions would be the priority after the biopsy. a. monitor pulse and BP every 30 minutes b. ambulate every 4 hours for the first day as long as client can tolerate this c. measure urine specific gravity every 8 hours for the next 48 hours d. maintain NPO status for 24 hours post-biopsy

a. monitor pulse and BP every 30 minutes

A nurse cares for a client with hepatitis C. The client's brother states, "I do not want to contract this infection, so I will not go into his hospital room." How should the nurse respond? a. "If you wear a gown and gloves, you will not get this virus." b. "Viral hepatitis is not spread through casual contact." c. "This virus is only transmitted through a fecal specimen." d. "I can give you an update on your brother's status from here."

b. "Viral hepatitis is not spread through casual contact."

: After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the clients understanding. Which menu selection indicates that the client correctly understands the dietary teaching? a. Ham sandwich on white bread, cup of applesauce, glass of diet cola b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice c. Grilled cheese sandwich, small banana, cup of hot tea with lemon d. Baked tilapia, fresh green beans, cup of coffee with low-fat milk

b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice

A nurse assesses a client who has liver disease. Which laboratory findings should the nurse recognize as potentially causing complications of this disorder? (Select all that apply.) a. Elevated aspartate transaminase b. Elevated international normalized ratio (INR) c. Decreased serum globulin levels d. Decreased serum alkaline phosphatase e. Elevated serum ammonia f. Elevated prothrombin time (PT)

b. Elevated international normalized ratio (INR) e. Elevated serum ammonia f. Elevated prothrombin time (PT

After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a. Some medications have been known to cause hepatitis A. b. I may have been exposed when we ate shrimp last weekend. c. I was infected with hepatitis A through a recent blood transfusion. d . My infection with Epstein-Barr virus can co-infect me with hepatitis A

b. I may have been exposed when we ate shrimp last weekend.

A nurse cares for a patient who has a chronic inflammatory bowel disease. Which actions would the nurse take to prevent skin excoriation? (Select all that apply.) a. Cleanse the perineum with an antibacterial soap. b. Use medicated wipes instead of toilet paper. c. Identify foods that decrease constipation. d. Apply a thin coat of aloe cream to the perineum. e. Gently pat the perineum dry after cleansing.

b. Use medicated wipes instead of toilet paper. d. Apply a thin coat of aloe cream to the perineum. e. Gently pat the perineum dry after cleansing.

A nurse is caring for a client who has advanced cirrhosis with worsening hepatic encephalopathy. Which of the following is an expected assessment finding? select all a. anorexia b. change in orientation c. asterixis d. ascites e. fetor hepaticus

b. change in orientation c. asterixis e. fetor hepaticus

The nurse is providing care to a patient who states, "My doctor says I am experiencing nocturia. What does that mean?" Which response by the nurse is most appropriate? a "It means you have pain radiating to your groin." b "It means you have the sudden urge to void immediately." c "It means you are getting up frequently at night to urinate." d "It means you are unable to completely empty your bladder."

c "It means you are getting up frequently at night to urinate."

: A patient with metastatic colorectal cancer is scheduled for both chemotherapy and radiation therapy. Patient teaching regarding these therapies for this patient would include an explanation that: a. Chemotherapy can be used to cure colorectal cancer b. Radiation is routinely used as adjuvant therapy following surgery c. Both chemotherapy and radiation can be used as palliative treatments d. The patient should expect few if any side effects from chemo-therapeutic agents

c. Both chemotherapy and radiation can be used as palliative treatments

A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first? a. Sedate the client to prevent tube dislodgement. b. Maintain balloon pressure at 15 and 20 mm Hg. c. Irrigate the gastric lumen with normal saline d. Assess the client for airway patency.

d. Assess the client for airway patency.

The nurse teaches a client about continuous ambulatory peritoneal dialysis (CAPD). Which client statement reflects an appropriate understanding of this type of dialysis? a. I will be sure to inform my HCP of my AV fistula b. If my heart failure worsens, I will need to switch to hemodialysis c. If I am careful, I can run errands during a dialysis exchange as long as I finish at home d. I will need to set aside time in my schedule for 5 different episodes of dialysis per day

d. I will need to set aside time in my schedule for 5 different episodes of dialysis per day