MedSurg Chapters 12-19

The nurse is providing care for a client with chronic obstructive pulmonary disease. When describing the process of respiration the nurse explains how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing what process?

Diffusion

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect?

Respiratory acidosis

The ICU nurse is caring for a client who experienced trauma in a workplace accident. The client is reporting dyspnea because of abdominal pain. An ABG reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3- 23 mEq/L. The nurse should recognize the likelihood of what acid-base disorder?

Respiratory acidosis

A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?

Respiratory alkalosis

The home health nurse is developing a plan of care for a client who will be managng his chronic pain at home. Using the nursing process, on which concepts should the nurse focus the client teaching

Self-care and safety

The nurse is caring for a postsurgical client who speaks very little English. How should the nurse most accurately assess this client's pain?

Use a chart with English on one side of the page and the client's native language on the other so he can rate his pain.

The nurse is caring for a preoperative client who is exceptionally anxious prior to surgery. What should the nurse increase with this client to decrease her anxiety?

Therapeutic touch

The nurse is preparing to change a client's abdominal dressing. The nurse recognizes the first step is to provide the client with information regarding the procedure. Which of the following explanations should the nurse provide to the client?

"During the dressing change, I will provide privacy at a time of your choosing. It should not be painful, and you can look at the incision and help with the procedure if you want to."

An unlicensed nursing assistant (NA) reports to the nurse that a postsurgical client rates her pain as 8 on a 0-to-10 point scale. The NA tells the nurse that he thinks the client is exaggerating and does not need pain medication. What is the nurse's best response?

"Unless there is strong evidence to the contrary, we should take the client's report at face value.'"

A presurgical client asks, "Why will I go to the PACU instead of just going straight up to the postsurgical unit?" What is the nurse's best response?

"The PACU allows you to recover from the effects of anesthesia, and you'll stay in the PACU until you're oriented, have stable vital signs, and are without complications."

One of the things a nurse has taught to a client during preoperative teaching is to have nothing by mouth for the specified time before surgery. The client asks the nurse why this is important. What is the most appropriate response for the client?

"You will need to have food and fluid restricted before surgery so you are not at risk for choking."

When planning the care of a client with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur?

Hydrostatic pressure resulting from the pumping action of the heart

The nurse is creating the plan of care for a client status postsurgery for reduction of a femur fracture. What is the most important short-term goal for this client?

Adequate respiratory function

The recovery room nurse is admitting a client from the OR following the client's successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted client?

Airway patency

The nurse is performing the shift assessment of a postsurgical client. The nurse finds the client's mental status, level of consciousness, speech, and orientation are intact and at baseline, but the client appears unusually restless. What should the nurse do next?

Assess the client's oxygen levels.

The nurse is assessing an 86-year-old postoperative client who has an unexpressive demeanor. The client is curled into the fetal position, vital signs are elevated and he is diaphoretic. On a ten-point scale, the client indicates a pain level of "three or so." How should the nurse treat this client's pain?

Believe what the client says, reinforce education, and reassess often.

The nurse is preparing a client for surgery. The client states that she is very nervous and really does not understand what the surgical procedure is for or how it will be performed. What is the most appropriate nursing action for the nurse to take?

Call the physician to review the procedure with the client.

A medical nurse is appraising the effectiveness of a client's current pain control regimen. The nurse is aware that if an intervention is deemed ineffective, goals need to be reassessed and other measures need to be considered. What is the role of the nurse in obtaining additional pain relief for the client?

Client advocate

The surgeon's preoperative assessment of a client has identified that the client is at a high risk for venous thromboembolism. Once the client is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the client's risk of this complication?

Encourage early ambulation.

Two clients have recently returned to the postsurgical unit after knee arthroplasty. One client is reporting pain of 8 to 9 on a 0-to-10 pain scale, whereas the other client is reporting a pain level of 3 to 4 on the same pain scale. What is the nurse's most plausible rationale for understanding the clients' different perceptions of pain?

Endorphin levels may vary between clients, affecting the perception of pain.

When assessing a postsurgical client's risk for deep vein thrombosis, the nurse should prioritize what assessment parameter?

Hydration status

The nurse admits a client to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the client's blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the client's skin is cold, moist, and pale. Of what is the client showing signs?

Hypovolemic shock

The nurse is evaluating a newly admitted client's laboratory results, which include several values that are outside of reference ranges. Which of the following alterations would cause the release of antidiuretic hormone (ADH)?

Increased serum sodium

The nurse is performing an admission assessment on an older adult client newly admitted for end-stage liver disease. What principle should guide the nurse's assessment of the client's skin turgor?

Inelastic skin turgor is a normal part of aging.

The nurse caring for a client post colon resection is assessing the client on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. What assessment finding would suggest that the client's potassium levels are too low?

Large amounts of dilute urine

The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The child's parents are thought to be en route to the hospital but have not yet arrived. No other family members are present and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to save her life. How should the need for informed consent be addressed?

Surgery should be done without informed consent

The nurse is checking the informed consent for an older adult client who requires surgery and who has recently been diagnosed with Alzheimer disease. When obtaining informed consent, who is legally responsible for signing?

The client

The nurse is caring for a postoperative client who needs daily dressing changes. The client is 3 days postoperative and is scheduled for discharge the next day. Until now, the client has refused to learn how to change her dressing. What would indicate to the nurse the client's possible readiness to learn how to change her dressing? Select all that apply.

The client expresses interest in the dressing change. The client expresses dislike of the surgical wound. The client assists in opening the packages of dressing material for the nurse.

The nurse is caring for a victim of a motor vehicle accident with a fractured pelvis and a ruptured bladder. The nurse's aide (NA) tells the nurse that she is concerned because the client's resting heart rate is 110 beats per minute, her respirations are 24 breaths per minute, temperature is 37.3°C (99.1°F) axillary, and the blood pressure is 125/85 mm Hg. What other information is most important as the nurse assesses this client's physiologic status?

The client's rating of her pain

A nurse educator is reviewing a client's recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis?

The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.

The perioperative nurse is providing care for a client who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The client is reluctant to ambulate, citing the need to recover in bed. For what complication is the client most at risk?

Atelectasis

The nurse is providing preoperative teaching to a client scheduled for hip replacement surgery in 1 month. During the preoperative teaching, the client gives the nurse a list of medications she takes, the dosage, and frequency. What intervention provides the client with the most accurate information?

Instruct the client to stop taking St. John's wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents.