Exam 4 - Med Surg 2
A female patient has presented to the ED with RUQ pain, the doc has ordered an ultrasound to rule out cholelithiasis. Pt. expresses concern over this test, how should the nurse respond?
Abdominal ultrasound poses no known safety risks of any kind
A nurse is working with a female patient who has developed stress urinary incontinence. Pelvic floor muscle exercises have been prescribed by the PCP. How can the nurse best promote successful treatment?
Arrange for biofeedback when the patient is learning to perform the exercises
A nurse who works in an oncology clinic assessing a patient who comes in for a 2 month check up. Nurse notes the skin is yellow, what blood tests should be done?
CBC to rile out jaundice
From the following profiles of clients, which client would be most likely to undergo the diagnostic test of cholecystography?
Mark, suspected of having stones in the gallbladder
A nurse is caring for a patient with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate?
Orange and foamy urine
A patient is admitted to the hospital with a possible common bile duct obstruction. What clinical manifestations does the nurse understand are indicators of this problem? (Select all that apply.)
Pruritus, Clay-colored feces, Jaundice
A patient admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely the best choice for this patient?
Tofu
A 45 yr old man with diabetic nephropathy has ESKD and is starting dialysis. What should the nurse teach the patient about hemodialysis?
Hemodialysis is a treatment option that is usually required three times a week
A 42 yr old woman comes to the clinic complaining of occasional urinary incontinence when she sneezes. The clinic nurse should recognize what type of incontinence? A. Stress incontinence B Reflex incontinence C Overflow incontinence D functional incontinence
A
A group of nurses has attended an Inservice on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace? A. Disposing of sharps appropriately and not recapping needles B Performing meticulous hand hygiene at the appropriate moments in care C Adhering to the recommended schedule of immunizations D. Wearing an N95 mask when providing care for patients on airborne precautions
A
The nurse has identified the nursing diagnosis of "risk for infection" in a patient who undergoes peritoneal dialysis. What nursing action best addresses this risk? A. Maintain aseptic technique when administering dialysate B. Wash the skin surrounding the catheter site with soap and water prior to each exchange C. Add antibiotics to the dialysate as ordered D Administer prophylactic antibiotics by mouth or IV as ordered
A
A nurse assesses a client with irritable bowel syndrome (IBS). Which questions should the nurse include in this clients assessment? (Select all that apply.)a. Which food types cause an exacerbation of symptoms?b. Where is your pain and what does it feel like?c. Have you lost a significant amount of weight lately?d. Are your stools soft, watery, and black in color?e. Do you experience nausea associated with defecation?
A, B, E
A patient's physician has ordered a "liver panel" in response to the patient's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply A. - Alanine aminotransferase (ALT) B, - C reactive protein (CRP) C. Gamma-glutamyl transferase (GGT) D. Aspartate aminotransferase (AST) E. B-type natriuretic peptide (BNP)
A,C,D
A nurse inserts a nasogastric (NG) tube for an adult client who has a bowel obstruction. Which actions does the nurse perform correctly? (Select all that apply.) a. Performs hand hygiene and positions the client in high-Fowlers position, with pillows behind the head and shoulders b. Instructs the client to extend the neck against the pillow once the NG tube has reached the oropharynx c. Checks for correct placement by checking the pH of the fluid aspirated from the tube d. Secures the NG tube by taping it to the clients nose and pinning the end to the pillowcase e. Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent
A,C,E
A nurse cares for a client who has a nasogastric (NG) tube. Which actions should the nurse take? (Select all that apply.) a. Assess for proper placement of the tube every 4 hours. b. Flush the tube with water every hour to ensure patency. c. Secure the NG tube to the clients upper lip. d. Disconnect suction when auscultating bowel peristalsis. e. Monitor the clients skin around the tube site for irritation.
A,D,E
A nurse cares for a middle-aged male client who has irritable bowel syndrome (IBS). The client states, I have changed my diet and take bulk-forming laxatives, but my symptoms have not gotten better. I heard about a drug called Amitiza. Do you think it might help? How should the nurse respond? a. This drug is still in the research phase and is not available for public use yet. b. Unfortunately, lubiprostone is approved only for use in women. c. Lubiprostone works well. I will recommend this prescription to your provider. d. This drug should not be used with bulk-forming laxatives.
B
A patient with a history of injection drug use has been diagnosed with hepatitis C. When collaborating with the care team to plan this patient's treatment, the nurse should anticipate what intervention? A. Administration of immune globulins B. A regimen of antiviral medications C. Rest and watchful waiting D Administration of fresh-frozen plasma
B
A female patient has been experienced recurrent UTIs. What health education should the nurse provide to the patient? A Bathe daily and keep the perineal region clean B Avoid voiding immediately after sex C Drink liberal amounts of fluid D Void at least every 6 to 8 hrs
C
A nurse cares for a client with colon cancer who has a new colostomy. The client states, I think it would be helpful to talk with someone who has had a similar experience. How should the nurse respond? a. I have a good friend with a colostomy who would be willing to talk with you. b. The enterostomal therapist will be able to answer all of your questions. c. I will make a referral to the United Ostomy Associations of America. d. You'll find that most people with colostomies don't want to talk about them.
C
A nurse has entered the room of a patient with cirrhosis and found the patient on the floor. The patient states that she fell when transferring to the commode. The patient's vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurse's most appropriate action? A. remove the patient's commode and supply a bedpan B. Complete an incident report and submit it to the unit supervisor C. Have the patient assessed by the physician due to the risk of internal bleeding D. Perform a focused abdominal in order to rule out injury
C
A nurse is caring for a patient with hepatic encephalopathy. The nurse's assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4
C
A nurse is caring for a patient with severe hemolytic jaundice. Laboratory tests show freee bilirubin to 24 mg/dL. For what complication is this patient at risk? A. Chronic jaundice B Pigment stones in portal circulation C Central nervous system damage D Hepatomegaly
C
A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patient's liver?A. Place hand under the right lower abdominal quadrant and press down lightly with the other hand B. Place the left hand over the abdomen and behind the left side at the 11th rib. C. Place hand under right lower rib cage and press down lightly with the other hand D. Hold hand 90 degrees to right side of the abdomen and push down firmly.
C
A patient has a glomerular filtration rate (GFR) of 43 mL/min/1.73 m2. Based on this GFR, the nurse interprets that the patient's chronic kidney disease is at what stage? A. Stage 1 B Stage 2 C Stage 3 D Stage 4
C
A nurse is amending a patient's plan of care in light of the fact that the patient has recently developed ascites. What should the nurse include in this patient's care? A. Mobilization with assistance at least 4 times daily B. Administration of beta-adrenergic blockers as ordered C Vitamin B 12 injections as ordered D Administration of diuretics
D
A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at this restaurant and have never received the hepatitis A vaccine? A. The hepatitis A vaccine B. Albumin infusion C. The hepatitis A and B vaccines D. An immune globulin injection
D
A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patient's increased risk of bleeding. The nurse recognizes that this risk is related to the patient's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? A. Alterations in glucose metabolism B. Retention of bile salts C. Inadequate production of albumin by hepatocytes D. Inability of the liver to use Vitamin K
D
A patient admitted with nephrotic syndrome is being cared for on the medical unit. When writing this patient's care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include? A Constipation related to immobility B Risk for injury related to altered thought processes C Hyperthermia related to the inflammatory process D Excess fluid volume related to generalized edema
D
A patient being treated in the hospital has been experiencing occasional urinary retention. What nursing action should the nurse take to encourage a patient who is having a difficult time voiding? A Use a slipper bedpan B Apply a cold compress to the perineum C Have the patient lie in a supine position D provide privacy for the patient
D
A patient with ESKD is scheduled to begin hemodialysis. The nurse is working with the patient to adapt the patient's diet to maximize the therapeutic effect and minimize the risk of complications. The patient's diet should include which of the following modifications? Select all
Decreased protein intake Decreased sodium intake Fluid restriction
A client is given a diagnosis of hepatic cirrhosis. The client asks the nurse what findings led to this determination. Which of the following clinical manifestations would the nurse correctly identify? Select all that apply.
Enlarged Liver size, Ascites, Hemorrhoids
A parent has been experiencing disconcering GI symptoms that have been worsening in severity. Following medical assessment, the patient has been diagnosed with lactose intolerance. The nurse should recognize an increased need for what form of health promotion?
Frequent screening for osteoporosis
A mother brings her teenage son to the clinic, where tests show that he has hepatitis A virus (HAV). They ask the nurse how this could have happened. Which of the following explanations would the nurse correctly identify as possible causes? Select all that apply.
Infection at school Sexual activity Suboptimal sanitary habits Consumption of sewage-contaminated water or shellfish
A patient with ESKD receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurse's most appropriate action?
Inform the physician and assess the patient for signs of infection
A nurse is caring for a client with mild acute pancreatitis. Which health care provider prescriptions will the nurse question as it relates to evidence based practices in the treatment of acute pancreatitis? Select all that apply.
Initiate parenteral feedings first and advance to enteral feedings as tolerated. Full liquid diet as tolerated. Nasogastric tube to intermittent wall suction for removal of gastric secretions.
A client is admitted to the hospital with acute hemorrhage from esophageal varices. What medication should the nurse anticipate administering that will reduce pressure in the portal venous system and control esophageal bleeding?
Octreotide
A patient with diagnosis of Respiratory acidosis is experiencing renal compensation. What function does the kidney perform to restore the acid-base balance?
Returning bicarbonate to the bodys circulation
An older adult has experienced a new onset of urinary incontinence and family members identify this problem as being unprecedented. When assessing the patient for factors that may have contributed to incontinence, the nurse should prioritize what assessment?
Reviewing the patient's medication administration record for recent changes
A patient admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely the best choice for this patient?
TOFU
A patient who has recently undergone ESWL for the treatment of renal calculi has phoned urology where he was treated telling the nurse that he has a temp of 101.1 F. How should the nurse best respond to the patient?
Tell the patient to report to the ED for further assessment
A patient with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the complication of this diagnostic test, what nursing intervention should the nurse perform? A. Keep the patient NPO until the results of the test are known B. Keep the patient NPO until the patient's gag reflex returns C Administer analgesia until post-procedure tenderness is relieved D Give the patient a cold beverage to promote swallowing ability
B
The nurse is caring for a patient who underwent percutaneous lithotripsy earlier in the day. What instruction should the nurse give to the patient? A limit oral fluid intake for 1 to 2 days B. report the presence of fine, sand like particles through the nephrostomy tube C Notify the physician about cloudy or foul smelling urine D Report any pink-tinged urine within 24 hrs after the procedure
C
The nurse is caring for a patient with an indwelling catheter. The nurse is aware that what nursing action helps prevent infection? A vigorously clean the meatus area daily B Apply powder to the perineal area 2 x daily C Empty the drainage bag at least every 8hr D Irrigate the catheter every 8 hrs with NS
C
A patient with a history of incontinence will undergo urodynamic testing in the physician's office. Because voiding in the presence of others can cause situational anxiety, the nurse should perform what action? A administer diuretics as ordered B Push fluids for several hours prior to the test C Discuss possible test results as the patient voids D Help the patient to relax before and during the test
D
A patient with esophageal varices is being cared for in the ICU. The varices have begun to bleed and the patient is at risk for hypovolemia. The patient has Lactated Ringer's at 150cc/hr infusing. What else might the nurse expect to have ordered to maintain volume for this patient? A. Arterial line B. Diuretics C. Foley Catheter D Volume expanders
D
A nurse is caring for a female patient whose urinary retention has not responded to conservative treatment. When educating this patient about self-catheterization, the nurse should encourage what practice? A Assuming a supine position B Using clean technique at home to catheterize C Inserting the catheter 1 to 2 inches into the urethra D Self-catheterizing every 2 hours at home
B
A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. Which assessment should the nurse prioritize in this patient's plan of care? A. Measurement of abdominal girth and body weight B. Assessment for variceal bleeding C. Assessment for signs and symptoms of jaundice D. Monitoring of results of liver function testing
B
A nurse is caring for a patient with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate? A. Watery, blood streaked diarrhea B. Orange and foamy urine C. Increased abdominal girth D. Decreased cognition
B
A patient's most recent laboratory findings indicate a glomerular filtration rate (GFR) of 58/mL/min. The nurse should recognize what implication of this diagnostic finding? A. The patient is likely to have a decreased level of blood urea nitrogen (BUN) B. The patient is at risk for hypokalemia C The patient is likely to have irregular voiding patterns D The patient is likely to have increased serum creatinine levels
D
A patient with recurrent UTI has just undergone a cystoscopy and complains of slight hematuria during the first void after the procedure, what is the nurse's most appropriate action? A. Administer a STAT dose of vitamin K, as ordered B Reassure the patient that this is not unexpected and then monitor the patient for further bleeding. C. Promptly inform the physician of this assessment finding D. Position the patient supine and insert a Foley catheter, as order
B
A patient with renal failure secondary to diabetic nephropathy has been admitted to the medical unit. What is the most life threatening effect of renal failure for which the nurse should monitor the patient? A Accumulation of wastes B Retention of potassium C Depletion of calcium D Lack of BP control
B
A nurse cares for a client who states, My husband is repulsed by my colostomy and refuses to be intimate with me. How should the nurse respond? a. Lets talk to the ostomy nurse to help you and your husband work through this. b. You could try to wear longer lingerie that will better hide the ostomy appliance. c. You should empty the pouch first so it will be less noticeable for your husband. d. If you are not careful, you can hurt the stoma if you engage in sexual activity.
A
A nurse is caring for a 73 yo patient with a urethral obstruction related to prostatic enlargement. When planning this patient's care, the nurse should be aware of the consequent risk of what complication? A. UTI B. Enuresis C Polyuria D. Proteinuria
A
A nurse is caring for a patient admitted with symptoms of an anorectal infection; cultures indicate that the patient has a viral infection. The nurse should anticipate the administration of what drug? A) Acyclovir (Zovirax) B) Doxycycline (Vibramycin) C) Penicillin (penicillin D) Metronidazole (Flagyl)
A
A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patient's stools will have what characteristics? A. Watery with blood and mucus B. Hard and black or tarry C. Dry and streaked with blood D. Loose with visible fatty streaks
A
A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patient's current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacological intervention? A. Two to 3 soft bowel movements daily B. Significant increase in appetite and food intake C. Absence of nausea and vomiting D. Absence of blood or mucus in stool
A
A patient with elevated BUN and creatinine levels has been referred by her primary physician for further evaluation. The nurse should anticipate the use of what initial diagnostic test? A. ultrasound B X-ray C Computed tomography (CT) D. Nuclear scan
A
A patient with kidney stones is scheduled for extracorporeal shock wave lithotripsy. What should the nurse include in the patient post procedure teaching? A Strain the patient's urine following the procedure B Administer a bolus of 500 mL NS following the procedure C Monitor the patient for fluid overload following the procedure D Insert a urinary catheter for 24 to 48 hrs
A
A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the patient's cognition and behavior. What is the nurse's most appropriate response? A. Ensure that the patient's sodium intake does not exceed recommended levels B. Report this finding to the primary care provider due to the possibility of hepatic encephalopathy C. Inform the primary care provider that the patient should be assessed for alcoholic hepatitis D. Implement interventions aimed at ensuring a calm and therapeutic care environment
B
A patient has been diagnosed with advanced stage breast cancer and will soon begin aggressive treatment. What assessment findings would most strongly suggest that the patient may have developed liver metastases? A. Persistent fever and cognitive changes B. Abdominal pain and hepatomegaly C. Peripheral edema unresponsive to diuresis D Spontaneous bleeding and jaundice
B
A patient has had an ileostomy created for treatment of irritable bowel disease and the patient is now preparing for discharge. What should the patient be taught about changing this device in the home setting? A. Apply antibiotic ointment as ordered after cleaning the stoma B. Apply a skin barrier to the peristomal skin prior to applying the pouch C. Dispose of the clamp with each bag change D. Cleanse the area surrounding the stoma with alcohol or chlorhexidine
B
A patient with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the patient's abdomen is increasing in girth. What is the nurse's most appropriate action? A. Advance the catheter 2 to 4 cm further into the peritoneal cavity B Reposition the patient to facilitate drainage C Aspirate from the catheter using a 60 mL syringe D Infuse 50 ML of additional dialysate
B
After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the clients understanding. Which menu selection indicates that the client correctly understands the dietary teaching? a. Ham sandwich on white bread, cup of applesauce, glass of diet cola b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice c. Grilled cheese sandwich, small banana, cup of hot tea with lemon d. Baked tilapia, fresh green beans, cup of coffee with low-fat milk
B
The clinic nurse is preparing a plan of care for a patient who has a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach? A Provide medication teaching related to pseudoephedrine sulfate B Teach the patient to perform pelvic floor muscle exercises C Prepare the patient for an anterior vaginal repair D Provide information on periurethral bulking
B
The nurse coming on shift on the medical unit is taking a report on four patients. What patient does the nurse know is at greatest risk for developing ESKD? A. A patient with a history of polycystic kidney disease B A patient with diabetes mellitus and poorly controlled hypertension C A patient who is morbidly obese with a history of vascular disorders D A patient with severe COPD
B
The nurse is caring for a patient who describes changes in his voiding patterns. The patient states, "I feel the urge to empty my bladder several times an hour and when the urge hits me I have to get to the restroom quickly. But when I empty my bladder there doesn't seem to be a great deal of urine flow." What would the nurse expect this patient's physical assessment to reveal? A. Hematuria B. Urine retention C Dehydration D. Renal Failure
B
A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, My doctor told me that the fecal occult blood test was negative for colon cancer. I don't think I need the colonoscopy and would like to cancel it. How should the nurse respond? a. Your doctor should not have given you that information prior to the colonoscopy. b. The colonoscopy is required due to the high percentage of false negatives with the blood test. c. A negative fecal occult blood test does not rule out the possibility of colon cancer. d. I will contact your doctor so that you can discuss your concerns about the procedure.
C
A patient who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize? A. The patient will obtain measurement of drainage from the T-tube B. The patient will exercise three times a week C. The patient will take immunosuppressive agents as required D. The patient will monitor for signs of liver dysfunction
C
A patient with liver disease has developed jaundice, the nurse is collaborating with the patient to develop a nutritional plan. The nurse should prioritize which of the following in the patient's plan? A Increased potassium intake B Fluid restriction to 2 L per day C Reduction in sodium intake D High protein, low fat diet
C
A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem? A. Assessment of blood pressure and assessment for headaches and visual changes B. Assessments for signs and symptoms of venous thromboembolism C. Daily weights and abdominal girth measurement D. Blood glucose monitoring q4h
C
A nursing instructor is explaining the pathophysiology and clinical manifestations of pancreatitis to a group of nursing students. The instructor evaluates the teaching as effective when a student correctly identifies which symptom as that most commonly reported by clients with pancreatitis?
Sever, radiating abdominal pain
A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required a hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patients stool will have what chrteristics?
Watery with blood and mucus
