MED SURGE EAQ QUESTIONS

The nurse is caring for a child with Reye syndrome. Which interventions should be included in the care plan of the child? Select all that apply.

Monitoring seizure activity Educating the parents about Reye syndrome Monitoring the blood gas concentration and intracranial pressure Reye syndrome may cause encephalopathy. Because of this risk, managing seizures is an important intervention. Reye syndrome is caused by the administration of aspirin to children and teenagers. Therefore parents should be educated about this syndrome to preventing further instances. The client's blood gas concentration and intracranial pressure should be monitored to prevent further complications. The head end of the bed should be elevated to prevent an increase in the intracranial pressure. Acetylsalicylic acid should not be used because it can cause Reye syndrome.

A client has been diagnosed as brain dead. The nurse understands that this means that the client has what?

No cortical functioning with some reflex breathing A client who is declared as being brain dead has no function of the cerebral cortex and a flat electroencephalogram (EEG). The client may have some spontaneous breathing and a heartbeat. The guidelines established by the American Association of Neurology include coma or unresponsiveness, absence of brainstem reflexes, and apnea. There are specific assessments to validate the findings. No spontaneous reflexes, shallow and slow breathing, and deep tendon reflexes only and no independent breathing do not fit the definition of brain dead.

A nurse is teaching menu planning to a client who has a high triglyceride level. Which item avoided by the client indicates that teaching about foods that are high in saturated fat is understood?

Red Meat Red meat is high in dense saturated fats and should be avoided. Fruits do not contain saturated fats. Grains do not contain saturated fats. Vegetable oils contain unsaturated fats.

A client with Cushing syndrome asks why a low-sodium, high-potassium diet has been prescribed. What is the best response by the nurse?

"Excessive aldosterone and cortisone cause the retention of sodium and loss of potassium." Clients with Cushing syndrome or those receiving cortical hormones must limit their intake of sodium and increase their intake of potassium, because the kidneys are retaining sodium and excreting potassium. Although sodium retention causes fluid retention and weight gain, the need for increased potassium must be considered as well. An excessive secretion of adrenocortical hormones in Cushing syndrome, not inadequate potassium intake, is the problem. This type of diet has no direct effect on the client's emotional status.

Which assessment data provides the most accurate determination of proper placement of a nasogastric tube?

Examining a chest x-ray after the tubing was inserted This is the absolute best indicator used to determine proper NG tube placement.

The registered nurse is teaching hurricane victims about the precautions to be taken to prevent infections. Which statements made by a victim indicate the need for further teaching? Select all that apply.

If electricity and gas are unavailable, use of ultraviolet pens can filter the drinking water. Toilet liners should be used to enhance toiler hygiene. In the absence of electricity, outdoor grills and camp stoves can be used to boil water for drinking. Drinking boiled water helps prevent many waterborne diseases. Mixing chemicals in sewage should be avoided to prevent toxic gas reactions. The addition of 10-20 drops of chlorine bleach in a gallon of water will purify the water.

A client is postoperative from open heart surgery. What should the nurse do to decrease or control the sensory and cognitive disturbances?

Plan for maximum periods of rest Sleep deprivation alone can cause these disturbances because of the interruption in rapid eye movement (REM) sleep. Lack of contact with significant others increases anxiety and feelings of isolation, which can lead to disturbances in rest. Pain limits or interrupts periods of sleep and rest. Analgesics should be administered as prescribed. Constant light increases cerebral arousal and limits sleep.

A client has a low hemoglobin level that is attributed to an iron deficiency. Which foods should the nurse recommend that the client increase in the diet? Select all that apply.

Spinach and Beef Liver Spinach and beef liver contain high amounts of iron. Grapes, oranges, and cantaloupe are low in iron.

The registered nurse delegates the tasks related to caring for a client who has undergone surgery. What are the benefits of delegation in this situation? Select all that apply.

Increased efficiency Improved quality of client care Increased professional skills of UAP The benefits of the delegation include direct client care and professional benefits. Delegating the task of providing care to the other members of the health care team helps conserve time and improve the quality of client care. Increasing the professional skills of unlicensed assistive personnel is also a benefit of delegating tasks. "Right supervision" dictates that the authority to supervise and delegate is only conferred to the registered nurse or another qualified delegator, not to the licensed practical nurse or licensed vocational nurse.

A nurse gives a nasogastric feeding to a preterm male infant. As the mother watches, she asks, "Would it hurt my baby to suck on a pacifier during the feeding?" How should the nurse best respond?

"Sucking on a pacifier during tube feedings may help him associate sucking with food so that he'll adjust better to oral feedings." The pacifier may satisfy non-nutritive sucking needs and stimulate flow of saliva and digestive juices. Protruding ("buck") teeth are associated with thumb sucking. Sucking on a pacifier promotes adaptation later to the breast or bottle; it does not hamper it. There is no evidence that a preterm infant's care is jeopardized by non-nutritive sucking.

The nurse is admitting an 8-month-old infant with suspected bacterial meningitis to the hospital. List in order of priority the nursing actions that should be taken.

1. Institute Respiratory Isolation 2. Insert an IV access device 3. Assist with lumbar puncture 4. Administer prescribed antibiotics 5. Monitor for signs of increased intracranial pressure Bacterial meningitis is transmitted through respiratory droplets. The nurse should first ensure that all who come in contact with the child are appropriately gowned, gloved, and masked. A circulatory access device provides an avenue to administer prescribed fluids and medications; also, it provides a circulatory access in case of an emergency. The next priority is to obtain a sample of cerebrospinal fluid (CSF). This will help determine whether the cause is viral or bacterial, permitting prescription of the appropriate pharmacological therapy by the healthcare provider. An antibiotic is usually not administered until the lumbar puncture is completed and CSF specimen is sent for culture. Complications, such as increased intracranial pressure and seizures, should be monitored for after the infant is admitted, placed on isolation, and antibiotics are started.

The nurse mixes 50 mg of Nipride in 250 mL of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/mL, how many drops per minute should the client receive? A) 31 B) 62 C) 93 D) 124

124 is the correct calculation Convert lbs to kg (182/2.2) = 82.73 Determine the dosage for this client: 5mcg x 82.73 = 413.65 mcg/min. Determine how many mcg are contained in 1 mL: 250/50,000 mcg = 200 mcg/mL. The client is to receive 413.65 mcg/min, and there are 200 mcg/mL; so the client is to recieve 2.07 mL per minute resulting in 124 gtt/min

A nurse is assessing a client with the diagnosis of hemorrhoids. Which factors in the client's history most likely played a role in the development of the client's hemorrhoids? Select all that apply.

Constipation Numerous Pregnancies Straining at stool increases intraabdominal, systemic, and portal venous pressures that promote the development of hemorrhoids. The enlarging uterus from pregnancies puts pressure on the inferior vena cava that leads to increased portal venous pressure, causing anorectal varicosities. Hypertension does not contribute to the development of hemorrhoids; however, portal hypertension can precipitate hemorrhoids. Spicy foods may irritate hemorrhoids but do not cause them. Bowel incontinence is unrelated to the development of hemorrhoids.

A client is receiving a 2-gram sodium diet. The family members ask whether they can bring snacks from home. Which food item will the nurse suggest?

Fresh Orange Wedges An orange contains only trace amounts of sodium. Dairy products such as ice cream and cheese are high in sodium and should be avoided. Peanut butter cookies are high sodium.

A client admitted to the hospital for chest pain is diagnosed with stable angina. Which information should the nurse include in the teaching session?

It is relieved by rest Anginal pain commonly is relieved by immediate rest because rest decreases the cardiac workload and oxygen need. Angina usually is precipitated by exertion, emotion, or a heavy meal. Anginal pain usually is described as tightness, indigestion, or heaviness. Nitroglycerin, a vasodilator and a standard treatment for angina, dilates coronary arteries, which increases oxygen to the myocardium, decreasing pain.

A client reports pain during urination and a profuse, yellowish-green penile discharge. After an assessment, the primary healthcare provider schedules the client for a nucleic acid amplification test (NAAT). Which organism may be the cause of the client's condition?

Neisseria gonorrhoeae A client with pain during urination and a profuse, yellowish-green penile discharge may have gonorrhea caused by Neisseria gonorrhoeae. The NAAT is highly sensitive and specific to gonorrhea. Organisms such as Escherichia coli may cause pelvic inflammatory disease. Signs include lower abdominal and pelvic pain. Treponema pallidum, which causes syphilis, is manifested by chancres and rashes. Mycoplasma hominis is a bacterium that produces bacterial vaginosis, which is manifested by upper genital tract infections.

A nurse is assessing a 55-year-old client who is experiencing postmenopausal bleeding. The tentative diagnosis is endometrial cancer. Which findings in the client's history are risk factors associated with endometrial cancer? Select all that apply.

Obesity, Family Hx of endometrial cancer, and previous hormone replacement therapy Rationale: Obesity is a risk factor for endometrial cancer, because adipose cells store estrogen; the extent of exposure to estrogen is the most significant risk factor. Nulliparity, not multiparity, is a risk factor for endometrial cancer because of the increased exposure to estrogen. Cigarette smoking has not been identified as a risk factor for endometrial cancer. Late, not early, onset of menopause is a risk factor for endometrial cancer because of the increased exposure to estrogen. Although endometrial cancer has not been proved to have a genetic predisposition, it is more common in families who have gene mutations for hereditary nonpolyposis colon cancer.

The nurse observes that a male client has removed the ice pack applied to his knee. What action should the nurse take first? A) Observe the appearance of the skin under the ice pack B) Instruct the client regarding the need for the covering. C) Reapply the covering after filling with fresh ice. D) Ask the client how long the ice was applied to the skin.

Observe the appearance of the skin under the ice pack. The first action taken by the nurse should be to assess the skin for any possible thermal injury. If no injury to the skin has occurred, the nurse can take the other actions as needed.

A nurse is caring for a client with continuous bladder irrigation. Which action should the nurse take?

Subtract irrigant from output to determine urine volume The total amount of irrigation solution instilled into the bladder is eliminated with urine and therefore must be subtracted from the total output to determine the volume of urine excreted. An accurate specific gravity cannot be obtained when irrigating solutions are instilled into the bladder. Hourly outputs are indicated only if there is concern about renal failure or oliguria. A 24-hour urine test is not accurate if the client is receiving continuous bladder irrigations

A client who is recovering from an acute myocardial infarction reports not being happy about the lack of salt with meals. Which information should the nurse share with the client about the purpose of salt restriction?

This prevents further fluid accumulation, which increases the workload of the heart. An increase in total body fluid causes an increase in intra-vascular volume and cardiac workload. Salt in the diet contributes to fluid retention and edema. Fluid in the interstitial compartment will not increase blood pressure. Excess fluid in the intra-vascular compartment will increase blood pressure. Limiting sodium will not have a diuretic effect; it will reduce additional fluid retention. Diuretics, not a sodium-restricted diet, reduce the amount of edema present, which interferes with heart action.

Arrange the order of steps in which a nurse conducts a research project.

When conducting a research project, the nurse should first identify the problem. The nurse should then develop a hypotheses based on this problem. Next, the nurse should design the research study. After designing the study, the nurse conducts the study, which involves obtaining the required approvals, recruiting research subjects and implementing the study protocol. The nurse should then analyze the outcomes after conducting the study and interpret the demographics of the study population, analyze every research hypothesis and interpret the conclusions and limitations of the study. The last step of the research process is using the findings of the study. At this stage, the nurse formulates recommendations for conducting further research and determines the implications of the research for nursing.