HESI-Med Surg I final study guide

Which medication should the nurse anticipate being prescribed for a client with C. difficile-associated disease (CDAD)?

-Fidaxomicin Ciprofloxacin -Metronidazole -Vancomycin

Which leukocytes should the nurse include when teaching about antibody-mediated immunity? .

Memory cells & B-lymphocytes Memory cells and B-lymphocytes are involved in antibody-mediated immunity. Monocytes are involved in inflammation. Helper T cells and cytotoxic T cells are involved in cell-mediated immunity.

A client has an abdominal perineal resection with the formation of a colostomy for cancer of the rectum. The nurse evaluates that teaching about colostomy care is understood when the client makes what statement?

"I will call the clinic and report if I have difficulty inserting the irrigating tube into the stoma." Difficulty inserting the irrigating tube into the stoma occurs with stenosis of the stoma; forcing insertion of the tube may cause injury. Loss of sensation to touch in the stomal tissue is expected; there is no need to call the clinic. Mucus exiting the stoma between irrigations is expected; there is no need to call the clinic. Expulsion of flatus while irrigating fluid is running out is expected; feces and flatus accompany fluid expulsion.

A client with achalasia is to undergo bougienage to dilate the lower esophagus and cardiac sphincter. Which clinical manifestations should the nurse assess in the client after the procedure? .

-Abdominal pain -increased heart rate -increased BP R:A complication of this procedure is perforation of the esophagus. Pain is related to the trauma of perforation. The sympathetic nervous system response causes an increase in the heart rate to increase oxygen to body cells. The sympathetic nervous system response causes an increase in the blood pressure because of vasoconstriction. With the autonomic nervous system response, the face will appear pale because the peripheral arterial system constricts. Feelings of fullness are not associated with this procedure.

The nurse is caring for a hospitalized immunosuppressed client. Which interventions will be beneficial for safe and effective care of this client?

-Avoid using supplies from common areas -Encourage activity at an appropriate level -Use alcohol-based hand rubs before touching the client R:Supplies from common areas should not be used for neutropenic clients to prevent contracting infection. Physical activity at a level appropriate for client's condition should be encouraged to promote health. Alcohol-based hand rubs should be used before touching the client to decrease the risk of infection. Immunosuppressed clients should avoid eating raw fruits and vegetables; they should eat low-bacteria diet. Gauge-containing wound dressings should be changed on a daily basis, not on alternative days, to prevent infection.

The registered nurse is teaching a group of nursing students about the characteristics of the five percussion notes. Which statements made by a student nurse indicate effective learning?

-Dullness can be percussed over a consolidated lung." -Tympanic notes over the lung usually indicate a large pneumothorax." -Flatness percussed over the lung fields indicates massive pleural effusion

The nurse suspects the Jarisch-Herxheimer reaction in a client with syphilis who is on antibiotic therapy. Which symptoms in the client support the nurse's suspicion?

-Fever -Generalized ache -pain at the injection site Fever, generalized ache, and pain at the injection site are signs of the Jarisch-Herxheimer reaction in a client with syphilis receiving antibiotic therapy. This reaction is caused by the rapid release of products from the disruption of cells of the organism. Hypotension because of vasodilatation and declining peripheral resistance, not hypertension and vasoconstriction, are additional signs of Jarisch-Herxheimer reaction.

What are the uses of pulmonary function tests (PFT)?

-Pulmonary function tests (PFT) can measure lung volume. -Pulmonary function tests (PFT) can assess responses to bronchodilators. -Pulmonary function tests (PFT) can diagnose pulmonary disease. R:Pulmonary function tests (PFT) can help assess lung volume, evaluate the responses to bronchodilators, and detect pulmonary disease. A mediastinoscopy is used to detect lung cancer. A positron emission tomography (PET) scan is used to inspect pulmonary nodules.

A client with tuberculosis is prescribed isoniazid. What statements should the nurse tell the client?

-take on an empty stomach -"Take daily multiple vitamins that contain B-complex." -"Report darkening of the urine or a yellowish skin discoloration." R:Isoniazid should be taken on an empty stomach because food prevents absorption of the drug. Multiple vitamins that contain the vitamin B-complex should be taken along with isoniazid because the drug depletes vitamin B. A client on isoniazid should report darkening of the urine and yellowish skin discoloration because these conditions are signs of liver toxicity. A client on ethambutol should be taught to report changes in vision. A client on pyrazinamide is instructed to wear protective clothing if he or she will be exposed to sunlight.

A nurse is providing teaching to a client who is learning how to self-administer gastrostomy tube feedings. What should the teaching include?

Administering water after the feeding is completed R:Water is administered after the tube feeding to prevent the thicker feeding solution from obstructing the lumen of the tube. To prevent regurgitation and aspiration, a Fowler position is recommended. Tube feedings are tolerated best at body temperature. Instilling fluid before the feeding to ensure that the tube is in the stomach is unsafe; gastric contents should be aspirated from the stomach to determine placement.

A nurse is caring for a client with cirrhosis of the liver. Which laboratory test should the nurse monitor that, when abnormal, might identify a client who may benefit from neomycin enemas?

Ammonia level Increased ammonia levels indicate that the liver is unable to detoxify protein by-products. Neomycin reduces the amount of ammonia-forming bacteria in the intestines. Culture and sensitivity testing is unnecessary; cirrhosis is an inflammatory, not infectious, process. Increased white blood cell count may indicate infection; however, this will have no relationship to the need for neomycin enemas. ALT, also called serum glutamic-pyruvic transaminase (SGPT), assesses for liver disease but has no relationship to the need for neomycin enemas.

Name the characteristics that support chronic persistent stage of Lyme disease

Arthritis Chronic fatigue R: Systemic infectious disease caused by Spirochete Borrelia Burgdorferi.

A primary healthcare provider prescribes three stool specimens for occult blood for a client who complains of blood-streaked stools and a 10-pound (4.5 kg) weight loss in one month. To ensure valid test results, what instructions should the nurse give the client?

Avoid eating red meat before testing R:Red meat can react with reagents used in the test to cause false-positive results. Testing the specimen while it is still warm may apply for testing for ova and parasites, but not for occult blood. If the correct procedure is followed, discarding the first specimen is unnecessary. Random stool testing can be done but must be on three different bowel movements during the screening period.

A client is recovering from a kidney transplant. Which medications should the nurse expect to be prescribed for this client's maintenance therapy?

Azathioprine Prednisone Cyclosporine Antithymocyte globulin-equine Maintenance therapy is the continuous immunosuppression used after a solid organ transplant. The drugs used for routine therapy after solid organ transplantation include an antiproliferative agent such as azathioprine, a corticosteroid such as prednisone, and a calcineurin inhibitor such as cyclosporine. Baxiliximab is a monoclonal antibody used to treat acute rejection episodes. Antithymocyte globulin-equine is a polyclonal antibody used to treat acute rejection episodes.

The nurse instructs a client with a new colostomy to avoid foods and drinks that produce a large amount of gas, specifically to avoid the intake of what?

Cabbage R:Cabbage is a gas-producing food that can cause a client with a colostomy problems with odor control and ballooning of the ostomy bag, which may break the device seal and allow leakage. Milk, cheese, and coffee should not cause excessive gas problems in moderation. The client with a new colostomy should slowly introduce new foods into the diet to test toleration.

While assessing a client with presence of neurotoxicity, lymphoma, and hypertension, the medical history reveals that the client is on immunosuppressant drug therapy. Which drug class might have caused these conditions?

Calcineurin inhibitors R: Calcineurin inhibitors such as cyclosporine act on T helper cells to prevent production and release of IL-2 and γ-interferon. This class of medications can cause adverse effects such as nephrotoxicity, lymphoma, hypertension, gingival hyperplasia, and hirsutism. Corticosteroids may cause peptic ulcer, osteoporosis, and hyperglycemia. Cytotoxic drugs may cause bone marrow suppression, hypertension, diarrhea, and nausea. Monoclonal antibodies may cause pulmonary edema, hypersensitivity reactions, fever/chills, and chest pain.

A client had an abdominal cholecystectomy. The nurse is caring for the client 24 hours after the surgery and notes 150 mL of bile drainage from a client's T-tube. What is the next action the nurse should take?

Check the tube for kinks because the drainage is less than expected. Bile drainage for the first 24 hours usually is 300 to 400 mL; kinks in the tubing hinder the flow of bile. Drainage of 150 mL is less than expected in the first 24 hours. Clamping the tube is contraindicated during the first 24 hours. Further intervention is necessary because this amount of bile is less than expected.

A primary health care provider prescribes airborne precautions for a client with tuberculosis. After being taught about the details of airborne precautions, the client is seen walking down the hall to get a glass of juice from the kitchen. What is the most effective nursing intervention?

Explore what the precautions mean to the client. Communication facilitates joint solution of the problem; the nurse must first determine the client's understanding and perceptions before solutions to the problem can be attempted. Ensuring regular visits by staff members will not collect data about why the client is leaving the room. Reporting the situation to the infection control nurse abdicates the responsibility of the primary nurse. Reteaching the concepts of airborne precautions to the client may be done, but not until further assessment is performed to determine the reason why the client is leaving the room.

symptoms of Prodomal stage w/inhalation of anthrax.

Fatigue Mild chest pain dry cough R:The manifestations include low-grade fever; fatigue; mild chest pain; and a dry, harsh cough. Inhalation anthrax is a two-stage illness, prodromal and fulminant. The prodromal stage is the early stage and is difficult to distinguish from influenza or pneumonia. A special feature of inhalation anthrax is that it is not accompanied by upper respiratory manifestations of sore throat or rhinitis.

Which pulmonary function test provides a more sensitive index of obstruction in smaller airways?

Forced expiratory flow over the 25% to 75% volume of the forced vital capacity Forced expiratory flow over the 25% to 75% volume of the forced vital capacity is the measure that provides a more sensitive index of obstruction in smaller airways. Forced vital capacity indicates respiratory muscle strength and ventilator reserve. Functional residual capacity is normal or decreased in restrictive pulmonary diseases and increased in obstructive pulmonary diseases. Forced expiratory volume in 1 second is reduced in certain obstructive and restrictive disorders.

A nurse is caring for a client who just had a liver biopsy. After the procedure, the nurse should monitor for which common complication associated with the biopsy?

Hemorrhage R:In the impaired liver, blood-clotting mechanisms are disrupted, and hemorrhage may occur from the trauma of this invasive procedure. A liver biopsy will not cause the stomach to empty more slowly. Because clotting mechanisms are prolonged, emboli usually are not a complication. A collapsed lung can occur if the needle is not inserted properly; however, this is not a common occurrence.

A nurse discovers the condition depicted in the image upon assessment of a client. Which organism may lead to this condition?

Human herpes virus-8 The client in the image has Kaposi's sarcoma (KS). The risk for KS appears to be related to co-infection with human herpes virus-8. KS is the most common acquired immune deficiency syndrome-related malignancy. Cytomegalovirus may lead to retinitis, encephalitis, pneumonitis, adrenalitis, hepatitis, and disseminated infection. Varicella-zoster virus causes chicken pox and shingles. Human papilloma virus causes multiple types of malignancies such as cervical and anal cancer.

Which is the first antibody formed after exposure to an antigen?

IgM IgM (immunoglobulin M) is the first antibody formed by a newly sensitized B-lymphocyte plasma cell. IgA has very low circulating levels and is responsible for preventing infection in the upper and lower respiratory tracts, and the gastrointestinal and genitourinary tracts. IgE has variable concentrations in the blood and is associated with antibody-mediated hypersensitivity reactions. IgG is heavily expressed on second and subsequent exposures to antigens to provide sustained, long-term immunity against invading microorganisms.

Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus?

Impaired neural functioning Paralytic ileus occurs when neurologic impulses are diminished as a result of anesthesia, infection, or surgery. Interference in blood supply will result in necrosis of the bowel. Perforation of the bowel will result in pain and peritonitis. Obstruction of the bowel initially will cause increased peristalsis and bowel sounds.

Which statements indicate a nurse has a correct understanding of interleukin-2?

It enhances natural killer cells. It is used to treat various malignancies. It stimulates differentiation of T-lymphocytes. Interleukin-2 is used clinically to enhance natural killer cells, treat various malignancies, and stimulate differentiation of T-lymphocytes. Interleukin-1 is used as an anti-inflammatory agent. The antiviral effect is produced by interferons.

On the third postoperative day after a subtotal gastrectomy, a client reports having severe abdominal pain. The nurse palpates the client's abdomen and determines rigidity. What should be the nurse's first action?

Obtain the Pt's vitals Rigidity and pain are hallmarks of bleeding from the suture line or of peritonitis; vital signs provide supporting data. Ambulation is indicated if pain was the result of flatulence; however, rigidity is associated with bleeding or peritonitis, and additional data are needed. An analgesic may mask the symptoms, thereby delaying diagnosis. Encouraging use of the incentive spirometer is unrelated to the symptoms presented.

When does the nurse's teaching say that the client's new sigmoid colostomy should be irrigated?

Once stool is formed, peristalsis needs to be stimulated to promote the passage of the stool. The sitting, not side-lying, position is the position of choice for a colostomy irrigation because it facilitates evacuation of the bowel via gravity. Contamination is avoided because fecal elimination flows through the sleeve of the colostomy appliance directly into the commode. The perineal wound may take weeks to heal, and irrigations must be started when the stool is formed.

Which diseases can be transmitted from client to client by droplet infection?

Pertussis and Diphtheria

After a subtotal gastrectomy a client is returned to the surgical unit. Which is the best nursing action to prevent pulmonary complications?

Promoting frequent turning and deep breathing to mobilize secretions To promote drainage of different lung regions, clients should turn every two hours. Deep breathing inflates the alveoli and promotes fluid drainage. During physical effort, individuals with abdominal incisions often revert to shallow breathing. Oxygen administration is a dependent function and generally is not required unless there is underlying cardiac or respiratory disease. The airway is expelled when the gag reflex returns.

A client was diagnosed with ulcerative colitis. Two months after the diagnosis, the client is readmitted for an exacerbation of the illness. The client is weak, thin, and irritable. The client states, "I am now ready for surgery to create an ileostomy." Which nursing intervention will best meet the client's priority need?

Replace the Pt's fluid and electrolytes R:Fluid and electrolyte replacement is a life-saving strategy; it must be done before surgery is performed. Helping the client regain former body weight is not the priority at this time. The client is neither physically nor cognitively ready to learn the psychomotor skill of how to manage an ileostomy. The client is not demonstrating a readiness for contact with other persons with ileostomies at this time

Which are examples of a type IV hypersensitivity reaction?

Sarcoidosis and poison ivy In type IV hypersensitivity, the inflammation is caused by a reaction of sensitized T cells with the antigen and the resultant activation of macrophages due to lymphokine release. Myasthenia gravis is an example of a type II or cytotoxic hypersensitivity reaction. Rheumatoid arthritis and systemic lupus erythematosus are examples of type III immune complex-mediated reactions.

What is a common characteristic of Sjögren's syndrome (SS)?

dry eyes Sjögren's syndrome (SS) is a group of problems that often appear with other autoimmune disorders. Problems include dry eyes, which are caused by autoimmune destruction of the lacrimal glands. Muscle cramping, urinary tract infection, and elevated blood pressure are not common characteristics of Sjögren's syndrome (SS).

A client with gastroesophageal reflux disease reports having difficulty sleeping at night. What should the nurse instruct the client to do?

elevate the head of the bed on blocks. R:Elevating the head of the bed on blocks raises the upper torso and minimizes reflux of gastric contents. Increasing the content of the stomach before lying down will aggravate the symptoms associated with gastroesophageal reflux. Eliminating carbohydrates from the diet will have no effect on the reflux of gastric contents. The effect of antacids is not long-lasting enough to promote a full night's sleep; sodium bicarbonate is not recommended as an antacid.