Evolve Med-Surg EAQ 2

A client has surgery for the creation of a colostomy. Postoperatively, what color does the nurse expect a viable stoma to be? Brick red Pale pink Light gray Dark purple

Brick red Brick red describes a stoma that has adequate vascular perfusion. Pale pink indicates inadequate perfusion of the stoma. Light gray is indicative of poor tissue perfusion. Dark purple indicates inadequate perfusion of the stoma.

Which structure is a component of the auditory ossicles? Malleus Vestibule Tympanic membrane External acoustic meatus

Malleus The malleus along with the incus and stapes constitutes the auditory ossicles. The vestibule is present in the inner ear and is an organ of balance. The tympanic membrane (eardrum) is a part of the middle ear. The external acoustic meatus is a component of the external ear.

A client begins therapy with a new medication. One month later the client notices blood in the urine. Which drug does the nurse anticipate as the cause? Warfarin Nifedipine Nitrofurantoin Phenazopyridine

Warfarin Warfarin is an anticoagulant medication and could result in blood in urine, a condition known as hematuria. Nifedipine is a calcium channel blocker that could affect the ability of the urinary bladder or sphincter to contract and relax normally. Nitrofurantoin is used to treat urinary tract infections but can cause alteration in urine color to a dark yellowish-brown. Phenazopyridine, a bladder analgesic used to treat pain associated with urinary tract conditions, changes the color of urine to orange or red.

A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? Dull sound on percussion Vocal fremitus on palpation Rales with rhonchi on auscultation Absence of breath sounds on auscultation

Absence of breath sounds on auscultation The left lung is collapsed; therefore, there are no breath sounds. A tympanic, not a dull, sound will be heard with a pneumothorax[1][2]. There is no vocal fremitus because there is no airflow into the left lung as a result of the pneumothorax. Rales with rhonchi will not be heard because there is no airflow into the left lung as a result of the pneumothorax.

A client with cancer of the colon is admitted to the hospital for a hemicolectomy. What does the nurse expect the preoperative plan of care to include? Giving oil-retention enemas daily for two days preoperatively Administering cleansing enemas and then neomycin Having a Sengstaken-Blakemore tube at the bedside A high-protein and high-carbohydrate regular diet for two days preoperatively

Administering cleansing enemas and then neomycin After the bowel is cleansed, neomycin is given to decrease gram-negative bacteria in the colon, which should limit postoperative infection. Oil-retention enemas are used to alleviate constipation; oil-retention enemas are not prescribed before surgery because they contaminate the bowel with oil. A Sengstaken-Blakemore tube is used for a client with ruptured esophageal varices, not for a client having a hemicolectomy. A diet to decrease bulk and empty the colon generally is prescribed; usually it is a clear liquid diet.

Which urodynamic study provides information on bladder capacity, bladder pressure, and voiding reflexes? Radiography Renal arteriography Electromyography (EMG) Cystometrography (CMG)

Cystometrography (CMG) Cystometrography (CMG) is an urodynamic study that provides information on bladder capacity, bladder pressure, and voiding reflexes. Radiography is a diagnostic test for clients with disorders of kidney and urinary system to screen for the presence of two kidneys, to measure kidney size, and to detect gross obstruction in kidneys or urinary tract. Renal arteriography is a diagnostic study used to determine renal blood vessel size and abnormalities. Electromyography (EMG) is an urodynamic study used to test the strength of perineal muscles in voiding.

A client had a gastric bypass procedure to treat morbid obesity. After surgery the client reports weakness, sweating, palpitations, and dizziness after eating. What should the nurse encourage the client to do? Reduce the intake of protein-rich foods Drink 8 ounces of water with meals Divide the daily caloric intake into six smaller meals Remain in an upright position for one hour after eating

Divide the daily caloric intake into six smaller meals The client's clinical manifestations are related to the dumping syndrome from the gastric bypass procedure. Smaller meals along with other interventions will help minimize this response. After gastric bypass, a bolus of hypertonic fluid enters the intestines before carbohydrates and electrolytes are diluted. Extracellular fluid is drawn into the bowel lumen; this causes a decrease in plasma volume, distention of the bowel lumen, and rapid intestinal transit. Protein intake should be increased, not decreased, to meet energy needs and promote healing. Fluids should be avoided at mealtimes because they increase the volume in the stomach and decrease the transit time of gastric contents moving from the stomach to the intestine, which contributes to dumping syndrome. An upright position decreases the transit time of gastric contents moving from the stomach to the intestines via gravity, which contributes to the dumping syndrome; clients may lie flat after eating for a short time.

Which type of biopsy would the nurse identify as required for removal of entire lesions on the skin? Punch biopsy Shave biopsy Incisional biopsy Excisional biopsy

Excisional biopsy An excisional biopsy is required to remove entire lesions on the skin. A punch biopsy provides full thickness skin for diagnostic purposes. A shave biopsy provides a thin specimen for diagnostic purposes. An incisional biopsy is used along with shave and punch biopsies.

Which hormone is released from the posterior pituitary gland? Oxytocin Prolactin Growth hormone Luteinizing hormone

Oxytocin Oxytocin is released from the posterior pituitary gland, which acts on the uterus and mammary glands. Prolactin, growth hormone, and luteinizing hormone are produced by the anterior pituitary gland.

Which hormone is released in response to low serum levels of calcium? Renin Erythropoetin Parathyroid hormone Atrial natriuretic peptide

Parathyroid hormone

A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? Select all that apply. Rye Oats Rice Corn Wheat

Rye Oats Wheat Rye, oats, and wheat should be avoided because they are irritating to the gastrointestinal mucosa. Gluten is not found in rice or corn; therefore, these items do not have to be avoided.

Which cells are affected in DiGeorge syndrome? T-cells B-cells Monocytes Polymorphonuclear cells

T-cells DiGeorge syndrome is a primary immune deficiency disorder in which T-cells are affected. The B-cells are affected in Bruton's X-linked agammaglobulinemia; common variable hypogammaglobulinemia; and selective IgA, IgM, and IgG deficiency. Monocytes and polymorphonuclear cells are affected in chronic granulomatous disease and Job syndrome.

A client who just returned from a cardiac catheterization reports to the nurse that the pressure bandage on the right groin is tight. What action should the nurse take? Loosen the dressing slightly Notify the primary healthcare provider Assess the pulses distal to the dressing Have the client flex the joints of the right leg

Assess the pulses distal to the dressing Assessing the circulatory status of the extremity will determine whether the dressing is too tight. Loosening the dressing slightly may result in bleeding from the catheter insertion site and is contraindicated. Notifying the primary healthcare provider is premature; the primary healthcare provider should be notified if circulation to the leg is compromised. Having the client flex the joints of the right leg may result in bleeding from the catheter insertion site and is contraindicated. The leg should remain extended for several hours.

A client is admitted to the hospital for an emergency cardiac catheterization. What adaptation is the client most likely to complain of after this procedure? Fear of dying Skipped heartbeats Pain at the insertion site Anxiety in response to intensive monitoring

Pain at the insertion site Pain at the arterial puncture site is attributable to entry and cannulation of the artery and is a common complaint after a cardiac catheterization. Fear of dying might occur during the precatheterization period. Although skipped heartbeats may occur during the procedure because of trauma to the conduction system, usually it does not continue after the procedure. Although some clients may be anxious, many feel safe when receiving ongoing monitoring.

Which condition results in elevated serum adrenocorticotropic hormone (ACTH) and urine cortisol levels? Diabetes insipidus Adrenal Cushing's syndrome Pituitary Cushing's syndrome Syndrome of inappropriate antidiuretic hormone

Pituitary Cushing's syndrome In pituitary Cushing's syndrome, urine cortisol and serum adrenocorticotropic hormone levels are raised. Diabetes insipidus is the result of decreased levels of antidiuretic hormone and is not associated with cortisol and ACTH levels. Adrenal Cushing's syndrome is caused by chronic steroid use, so the client will have increased urine cortisol and decreased ACTH levels. Syndrome of inappropriate antidiuretic hormone is the result of elevated levels of antidiuretic hormone and is not related with the ACTH and cortisol levels.

A nurse is caring for a client with a below-the-knee amputation. What should the nurse encourage the client to do to prepare the residual limb for a prosthesis? Abduct the residual limb when ambulating Dangle the residual limb off the bed frequently Soak the residual limb in warm water twice a day Press the end of the residual limb against a pillow periodically

Press the end of the residual limb against a pillow periodically The client usually is instructed to press the end of the residual limb against a pillow to toughen the limb for weight bearing; this process is begun by pushing the residual limb against increasingly harder surfaces. Abduction of the residual limb does not maintain functional alignment and should be avoided; it does not prepare the end of the residual limb for a prosthesis. Dangling the residual limb does not help prepare it for a prosthesis and may impede venous return, which prolongs healing. Soaking the residual limb in warm water twice a day may macerate the residual limb and hinder the use of a prosthesis.

A client with multiple sclerosis is informed that it is a chronic progressive neurologic condition. The client asks the nurse, "Will I experience pain?" What is the nurse's best response? "Tell me about your fears regarding pain." "Analgesics will be prescribed to control the pain." "Pain is not a characteristic symptom of this condition." "Let's make a list of the things you need to ask your primary healthcare provider."

"Pain is not a characteristic symptom of this condition." The response "Pain is not a characteristic symptom of this condition" is a truthful answer that provides hope for the client. The response "Tell me about your fears regarding pain" avoids the client's question and can increase anxiety. Analgesics commonly are not prescribed unless pain results from some other condition. The response "Let's make a list of the things you need to ask your primary healthcare provider" avoids the client's question; the nurse should respond directly.

A client who is considering sclerotherapy asks the nurse to explain what causes varicose veins. Which response by the nurse is best? "The cause is abnormal configurations of the veins." "The cause is incompetent valves of superficial veins." "The cause is decreased pressure within the deep veins." "The cause is atherosclerotic plaque formation in the veins."

"The cause is incompetent valves of superficial veins." Incompetent valves result in retrograde venous flow and subsequent dilation of veins. Abnormal configurations of the veins are considered a result of, rather than a cause of, varicose veins. Pressure within the deep veins is increased, not decreased. Plaque formation is considered an arterial, rather than a venous, problem and is associated with atherosclerosis.

A client admitted to the hospital with an acute episode of rheumatoid arthritis (RA) asks why physical therapy has not been prescribed. What is the most appropriate nursing response? "Your primary healthcare provider must have forgotten to prescribe it." "Your condition is not severe enough to have physical therapy approved." "Your joints are still inflamed, and physical therapy can be harmful." "Physical therapy is not helpful for persons who suffer from RA."

"Your joints are still inflamed, and physical therapy can be harmful." Rest is required during active inflammation of the joints to prevent injury; once active inflammation has receded, an activity and exercise regimen can begin. Physical therapy is not prescribed during a period of exacerbation because it can traumatize already inflamed joints. The extent of the arthritis is not the determinant; whether the process is in exacerbation or remission is the deciding factor. Physical therapy is helpful, but it is not performed during an acute exacerbation of the arthritis.

What does the presence of ketones in the urine of a client with renal dysfunction indicate? Cystitis Heart failure Urinary calculi Anorexia nervosa

Anorexia nervosa The body of a client with anorexia nervosa produces ketones as an alternate source of fuel for muscles and organs. Increased red blood cells (RBCs) in the urine indicate cystitis. Increased specific gravity of the urine indicates heart failure. The presence of casts in the urine indicates urinary calculi.

A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first? Feel for a pulse Begin chest compressions Leave to call for assistance Perform the abdominal thrust maneuver

Begin chest compressions According to the American Heart Association and Heart and Stroke Foundation of Canada for CPR, the first step is to feel for a pulse after unresponsiveness is established. In this case, it has been established the client has no pulse (cardiopulmonary arrest); therefore chest compressions are initiated. Do not leave the client to call for assistance. The abdominal thrust (Heimlich) maneuver is used to relieve airway obstruction and is not appropriate in this instance.

What should be used to clean needles and syringes between intravenous drug users (IDUs)? Bleach Hot water Ammonia Rubbing alcohol

Bleach Intravenous drug users (IDUs) should be instructed to fill syringes with household bleach and shake the syringe for 30 to 60 seconds. Hot water, ammonia, or rubbing alcohol are not used to disinfect used syringes.

A nurse assesses a client with the diagnosis of an intestinal obstruction in the descending colon. When auscultating the midabdomen, what should the nurse expect to hear? Tympany Borborygmi Abdominal bruit Pleural friction rub

Borborygmi Borborygmi are rapid, high-pitched bowel sounds that are indicative of the hyperperistalsis that occurs behind an intestinal obstruction. Tympany is not auscultated but percussed, and it is described as high pitched or musical because of the presence of gas. An aortic bruit is auscultated above the umbilicus; a renal bruit is heard laterally above the umbilicus. Neither bruit can be auscultated at the midabdomen, and neither is related to an intestinal obstruction. A pleural friction rub is heard in the chest; it is associated with inflamed lung pleura.

The nurse is aware that the Cowper gland is also often referred to by which other term? Skene gland Prostate gland Bartholin gland Bulbourethral gland

Bulbourethral gland Cowper glands are accessory glands of the male reproductive system; they are also referred to as the bulbourethral glands. Skene glands are a part of the female reproductive system. The prostate gland is also a gland of the male reproductive system. Bartholin glands are part of the female reproductive system.

During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take? Take the client's vital signs Inform the healthcare provider Turn the client to the unaffected side Check the tube to ensure that it is not kinked

Check the tube to ensure that it is not kinked Once the drainage tube is patent, the fluctuation in the water column will resume; a lack of fluctuation because of lung reexpansion is unlikely 36 hours after a traumatic open chest injury. Taking the client's vital signs may be done eventually but is not the priority at this time. Informing the healthcare provider is unnecessary at this time; the chest tube is occluded, and nursing interventions should be attempted first. Turning the client to the unaffected side will compromise aeration of the unaffected lung.

A nurse in the postanesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the primary healthcare provider? Client pushes the airway out Client has snoring respirations Client's respirations are 16 breaths per minute and unlabored Client's systolic blood pressure drops from 130 to 90 mm Hg

Client's systolic blood pressure drops from 130 to 90 mm Hg A drop in blood pressure; rapid pulse rate; cold, clammy skin; and oliguria are signs of decreased blood volume and shock, which if not treated promptly can lead to death. The client pushing the airway out is an expected response; the client will push out the airway as the effects of anesthesia subside. Respirations of 16 breaths per minute is a common response postoperatively. If the client is experiencing a depressant effect of anesthesia, the nurse will assess shallow and slow respirations.

A client is instructed to avoid straining on defecation postoperatively. Which food item chosen by the client indicates successful learning? Ripe bananas Milk products Green vegetables Creamed potatoes

Green vegetables Green vegetables contain fiber, which promotes defecation. Bananas, milk products, and creamed potatoes have a constipating effect, which results in straining at stool.

A client who had a transurethral resection of the prostate is transferred to the postanesthesia care unit with an intravenous (IV) line and a urinary retention catheter. For which major complication is it most important for the nurse to assess during the immediate postoperative period? Sepsis Phlebitis Hemorrhage Leakage around the IV catheter

Hemorrhage After transurethral surgery[1][2], hemorrhage is common because of venous oozing and bleeding from many small arteries in the area. Sepsis is unusual, and if it occurs it will manifest later in the postoperative course. Phlebitis is assessed for, but it is not the most important complication. Hemorrhage is more important than phlebitis. Leaking around the IV catheter is not a major complication.

A nurse is providing postoperative teaching to a client who is scheduled to have an above-the-knee amputation. The client will use crutches during the postoperative period. Which activity will prepare the client for crutch walking? Lifting weights Changing bed positions Caring for the residual limb Performing phantom limb exercises

Lifting weights Preparation for crutch walking includes exercises to strengthen arm and shoulder muscles. Position changes help prevent hip flexion contractures but do not prepare the client for crutch walking. Caring for the residual limb promotes healing and helps prepare the limb for the prosthesis; it does not prepare the client for crutch walking. The phantom limb sensation includes a feeling that the absent limb is present; there are no specific exercises for this phenomenon.

The nurse at a health fair has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated. The nurse records the two blood pressures of 172/104 mm Hg and 164/98 mm Hg. What is the appropriate nursing action in response to these readings? Refer the client to a nutritionist after providing health teaching about a low-sodium diet. Place the client in a recumbent position and call the paramedics for transport to the hospital. Talk with the client to assess whether there is stress in the client's life and refer to a counseling service. Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible.

Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible. According to the United States Department of Health and Human Services (Canada: Canadian Heart and Lung Association), both of these readings indicate hypertension and thus require further evaluation by a healthcare provider; having a baseline for both arms can assist the healthcare provider with the medical diagnosis. Teaching about a low-sodium diet is an inadequate intervention. An appointment with a healthcare provider, not a nutritionist, should be scheduled as soon as possible. There are insufficient data to support this emergency intervention (calling the paramedics). The client's elevated blood pressure needs to be evaluated by a healthcare provider and then medical therapy implemented. Although emotional stress can precipitate hypertension, physical causes should be ruled out first.