advanced nursing final Keiser University
most common sign of colorectal cancer
#1 change of bowel habits #2 blood in stool
A client with a Q information of diverticulitis should maintain a what diet?
A diet very low in fiber the client can consume low fiber foods like white bread low fat milk yogurt with active cultures poached eggs canned soft fruit
Lactulose is what?
A laxative that decreases ammonia levels
Sigmoid: resection with colonostomy
After surgery the client quickly return to a regular diet and there are no food restrictions.
A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect?
Anorexia is a early manifestation of hepatitis A and is often severe.
Chronic pancreatitis or pancreatic cancer you should expect to find what?
Ascites-Abdominal swelling caused by accumulation of fluid, most often related to liver disease.
A nurse is assessing a client with meningitis possibly flexing neck and bringing legs up what sign is this?
Bruzinski's sign
The number one post operative with a client who had a CHOLECYSTECTOMY
COUGHING AND DEEP BREATHING EXERCSES TO PROMOTE LUNG EXPANSION
A patient with diverticulitis needs to be on a low fiber diet what food item should the nurse remove the patients meal tray
Call Saul contains raw cabbage which is high in fiber clients who are following a low fiber diet should avoid most raw vegetables.
Esophageal cancer early prevention?
Early treatment of gastric reflux disease
Interventions for intercranial pressure.
Elevate the head of the bed 20°
Respiratory alkalosis
Elevated pH and decrease PAC02
Hyper glycemia patient will exhibit what?
Excessive thirst
A client being discharged after ineffective endocarditis discharge teaching
Finish antibiotics until complete.
Boiled hamburger is an appropriate low fiber food for a client who is following a low fiber diet.
Fish and poultry are low fiber options.
To prevent an acute diverticulitis attack what foods to the nurse recommend
Foods high in fiber. The pressure leading to a stranger in bowel movements causing the development of diverticula high-fiber foods help strengthen and maintain active mobility IN GI TRACT
A client with a diagnosis of colon cancer is two days post op following a reception and Anastomosis. The nurse plans what should the nurse prioritize?
Frequent abdominal auscultation
Management of happy includes?
Frequent rest periods throughout the day.
What laboratory test would you use to determine the possibility of recent excessive alcohol use?
GGT gamma glutamyl transfers
Pain above umbilicus when assessing the client the nurse notices sister Mary St. Joseph's Najwa what health problems does this patient present with?
Gastro intestinal malignancy
Prevention of have a transmission is?
Good hand hygiene.
Complete intestinal obstruction what should the nurse expect?
Hyper active bowel sounds around the obstruction
End stage liver failure what to expect?
Increase pro thrombin time related to the in adequate supply of clotting factors in an increased or prolong thrombin time
A community health nurse is preparing an initial visit to a client that is being discharged following a total Gastroectomy from gastric cancer . what should they anticipate the plan of care to include?
Injections of B 12
Undergoing testing of a tumor of ace the small intestines what symptoms promoted the client to seek medical attention?
Intermittent pain and bloody stools
A client who is MPL and has a nasal drip gastric tube to suction. When the client reports nausea which of the following actions should the nurse take?
Irrigate the tube with normal saline
A patient with dumping syndrome should
It's small and frequent meals and do not have liquids at meal times.
Late manifestations of hepatitis A
Jaundice dark urine pale feces
The nurse should expect to find a positive KEHRS sign in a client who has what type of trauma?
Liver trauma
Postulation of pleurisy is what type of breath sound?
Loud scratching sound rubbing
Canned fruit is an appropriate diet choice for which of the following diets
Low fiber
Dumping syndrome following a gastric bypass surgery four days ago which of the following recommendations should the nurse include in the teaching
Maintain a supine position after meals to slow the rapid emptying of food into the small intestine.
A nurse in a community health clinic is caring for a client with a headache and stiff neck what should she evaluate?
Neurological status
What are the following is a late sign of ICP
Nonreactive dilated pupils
Cirrhosis
Obtain the clients PT and INR measurements admin lactose 30 mL four times a day and abdominal girth measurements daily multivitamin
What medication would you administer for intercranial pressure?
Osmotic diuretics such as mannitol to reduce the edema of the brain
The nurse should expect a phone Gastro intestinal bleeding in a client who has what type of cancer?
Pancreatic cancer
A nurse is caring for a client in late stage esophageal cancer what assessments are characterics of this disease?
Perforation of the mediastinum erosion great vessels obstruction obstruction of esophagus
Play Pasa with a peg tube is receiving intermittent feedings. Prior to initiating the feeding which of the following actions should the nurse take first?
Place the client in semi Fowler's position.
A nurse is caring for a client who is a quadriplegic who has severe headache and a blood pressure of 210/108 and suspects autonomic dysreflexia what should the nurse do?
Please client high Fowlers
A nurse is caring for a client who had a gastric resection to treat adenocarcinoma of the stomach. The client tells the nurse in the PACU that he does not remember why the surgeon said he had to have a tube in his nose. The nurse should explain that the NG tube service which of the following purposes?
Prevents excessive pressure on suture lines
a nurse is caring for a patient following treatment for supraventorial brain tumor which of the following interventions should the nurse do?
Raise the head of the bed 30°
Kehr's sign
Referred pain down the left shoulder; indicative of a ruptured spleen.
What manifestations of Gerd sure the nurse expect?
Regurgitation nausea belching heartburn
A nurse is assessing a client with a head injury in a brief level of consciousness which of the following should the nurse report?
Small drop of clear fluid in left ear.
HYPOXIA
TACHYCARDIA
A client with an infection will have an increased what?
Temperature
A nurse is caring for a client who has a Trumatic brain injury which of the following findings for indications of ICP?
The greatest risk to this client is injury from increased intracranial pressure. Therefore, the nurse's priority action is to maintain the PaCO2 at approximately 35 mm Hg to prevent hypercarbia and subsequent vasodilation effects that lead to increase in intracranial pressure.
A client with continuous tube feeding through a pump at 75 mL per hour. When the nurse assesses a client at 8:00 AM following find findings requires intervention?
The head of the bed is elevated at 20°. The head of the bed should be Élevage at least 30° semi Fowler's position while the two fitting is administered this position is a scrubby to help the feeding move through the digestive system unless there's a possibility of regurgitation
What happens if you turn total prenatal nutrition TPN therapy off?
The patient will have diaphoresis and the potential to develop hypo glycemia due to the sudden withdrawal of TPN solution. In addition to diaphoresis other potential manifestations of hyperglycemia I can include weakness anxiety confusion and hunger
A patient is having a tonic clonic seizure what action should the nurse take?
Turn the clients head to the side. Lower the patient from sitting position to the ground Remove all restrictive clothing Remove hard objects away from the patient place pillow under patients head assess air ways patency
A nurse is caring for a client who has acute diverticulitis. While the client has active information the nurse should instruct the client to include which of the following foods in her diet?
White bread and plain yogurt
White bread is an appropriate low fiber food for a client who is following a low fiber diet.
Whole grain bread contains more fiber.
A nurse is planning care for a client with cirrhosis of the liver to prevent ascites diet?
a low sodium diet administration of furosemide or spilactrone - diuretics measurements of abdominal girth daily
Irregular palpitations dizziness rapid and irregular ousels deficit . what will nurse find on EKG?
a-fib
pulmonary embolism `
admin O2
ARDS (acute respiratory distress syndrome)
admin vecuronium to facilitate ventilation
aspirin
anti platelet drug
Early signs of Gastric cancer
are not alarming or unusual
Abdominal swelling caused by accumulation of fluid, most often related to liver disease.
ascities
lacerated spleen osculate decrease breath sounds in lower lobes
atelectasis
cardiac enzymes
blood test to determine the level of enzymes specific to heart muscles in the blood
Cholecystitis findings `
blumbergs sign
Admitted with pheochromocytoma after adrenalectomy. assessment that is most concerning
bp 169/98, tumors on adrenal gland increases blood pressure
1 day post op trantonoidal hyposisectomy with clear drainage coming from nose what is nurses action?
check drainage for glucose
no bubbling in chest tube chamber
check for suction leaks 1
cardiac Cath on left AC
check left radial pulse cardiac
alcohol use and frequent bruises and nose bleeds are caused by what?
cirrhosis
close chest tube water seal suction check for
continuous bubbling in seal chamber
lactate dehydrogenase
converts pyruvate to lactate
the albumin levels with end stage liver failure
decrease 4-36 u/L---normal levels
cardiac emzymes
degree of damage to heart tissue
dumping syndrome
eat small meals frequently at same intervals
tonsillectomy
gag reflex excessive swallowing = hemorrhage
post operative care
get up and ambulate ASAP use incentive spirometer SCD's leg exercises passive and active range motion
Caring for a patient with questions on treatment options for new diagnosis of basal carcinoma what treatment should be included?
gyro therapy electrotherapy radiation micrographic surgery
laryngeal cancer
hoarseness
post op to prevent pulmonary embolism
incentive spirometry
Atelectasis/Post -op complication
increased dyspnea
end stage liver failure ammonia levels
increased with ESLF
lactate dehydrogenase in end stage liver failure
indicative of
A nurse in the ER has a patient with myasthenia gravis patient in crisis which of the following causes of crisis?
infection
Cholecystitis
inflammation of the gallbladder
Tumor of small intestine
intermittent pain and bloody stool
patient with colorectal cancer are prescribed cephalexin (kelfex) to reduce what
intestinal bacterial levels `
mona b
morphine oxygen nitro aspirin beta blockers
mi manifestations
nausea tachycardia diaphoresis
atrial fibrillation
occurs when the normal rhythmic contractions of the atria are replaced by rapid irregular twitching of the muscular heart wall
esophageal cancer late stage
perforation of the mediastinum erosion great vessels obstruction of esophagus
cath interventions
peripheral pulses in hip and leg extended remain in bed for 6hoursz keep affected leg straight and extended
The nurse finds a patient on the floor following a clonic phase of clinic type seizure what action should the nurse take?
place pillow under her head
liver failure
prothrombin prolonged
atrial fibrillation
rapid, random, ineffective contractions of the atrium
blumbergs sign for cholecystitis
rebound tenderness
Cephalexin (Keflex)
reduces intestinal bacterial levels
Kehr sign is defined as:
referred pain to the shoulder following injury to the liver or spleen.
ARDS (acute respiratory distress syndrome)
respiratory insufficiency marked by progressive hypoxia
pleurisy
scratch sound in lungs
Troponin 1
specific to heart
Always keep the chest tube below the level of what body part
waist
