Med surg

A nurse prepares a patient for a colonoscopy scheduled for tomorrow. The patient states, My provider 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 would the nurse respond?

"A negative fecal occult blood test does not rule out the possibility of colon cancer."

You're providing nursing education to a group of nursing students about diverticulosis versus diverticulitis. Which statement by the nursing students demonstrate they understand the education provided?

"Diverticulitis, if not treated, can lead to abscess formation and peritonitis."

After teaching a patient who was hospitalized for Salmonella food poisoning, a nurse assesses the patient's understanding. Which statement made by the patient indicates a need for additional teaching?

"I'll take the ciprofloxacin until the diarrhea has resolved."

You are caring for a patient with a new ileostomy. The patient states, "I have the feeling that my friends will not accept me with this ostomy." How would the you respond?

"Tell me more about your concerns."

In regards to question 5, this patient signs and symptoms are starting to subside. Which of the following food items would be best for the patient to consume?

"The pain seems to be gone now."

A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful?

"Try warm, moist heat packs on your face."

You are teaching a patient who has a new ileostomy; You are about to provide feedback based on the patient's ability to complete the activity: Which statement would you include in this feedback?

"You cleaned the stoma well. Now you need to practice putting on the appliance."

A nurse assesses a patient with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the patient reports constant abdominal pain. Which action would the nurse take next?

Assess the client's bowel sounds.

Which patient is at highest risk for the development of colorectal cancer?

African American

The nurse is caring for a client with peritonitis. What assessment findings would the nurse expect? (Select all that apply.)

Anorexia Distended abdomen

A patient with rheumatoid arthritis has been taking corticosteroids for 11 months. Which nursing action is most likely to detect early signs of infection in this patient?

Ask about fatigue or feelings of malaise.

The nurse is administering finasteride (Proscar) and doxazosin (Cardura) to a 67-year-old client with benign prostatic hyperplasia. What precautions are related to the side effects of these medications? (Select all that apply.)

Assessing for blood pressure changes when lying, sitting, and arising from the bed Immediately reporting any change in the alanine aminotransferase laboratory test Asking the client to report any weakness, light-headedness, or dizziness

A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client?

Assessing vaccination records for booster shot needs

A complete blood count with differential is performed in a patient with chronic sinusitis. Which finding does the nurse expect?

Basophils, 4%

A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions?

Blood cultures Administer IV antibiotics. Sponge patient with cool water. Administer acetaminophen (Tylenol). Sponge patient with cool water Perform wet-to-dry dressing change.

After leaching a patient who has diverticulitis, a nurse assesses the patient's understanding. Which statement made by the patient indicates a need for additional teaching?

Clients who have diverticular disease are prescribed a low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet.

A patient asks what type of testing is performed to assess for diverticulosis. As the nurse, you know that which test below is used to assess for diverticulosis?*

Colonoscopy

Which focus is the nurse most likely to teach for a client with a flaccid bladder?

Crede's maneuver: apply gentle manual pressure to the lower abdomen

A patient is recovering after having an appendectomy. The patient is 48 hours post-opt from surgery and is tolerating full liquids. The Physician orders for the patient to try solid foods. What types of foods should the patient incorporate in their diet?

Foods high in fiber

a male patient BPH to determine the severity of symptoms associated with prostate enlargement. Which finding will prompt you to act.

Foul smelling urine

The nurse is working in a clinical medical area with a cenus of 15. Each patient has a different illness. When planning care, the nurse recognizes which of the following as the most important action to provide protection to each patient from health care-associated infections?

Hand hygiene

A 45-year-old man is admitted to the hospital with cellulitis of the right foot. Three days later, he develops bacterial pneumonia. How is this type of infection classified?

Health care-associated

Your patient who has ulcerative colitis and severe diarrhea. Which assessment would a complete first?

Heart rate and rhythm

The nurse will need to assess the client's performance of clean intermittent self catheterization (CISC) for a client with which urinary diversion?

Kock pouch

The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action?

Leaves the catheter in place and gets a new sterile catheter

The nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.)

Lower gastrointestinal bleeding - Erosion of the bowel wall Abscess formation - Localized pockets of infection develop in the ulcerated bowel lining Nonmechanical bowel obstruction - Paralysis of colon resulting from colorectal cancer

A nurse plans care for a patient with acute pancreatitis Which intervention would the nurse include in this patients plan of care to reduce discomfort?

Maintain nothing by mouth (NPO) and administer intravenous fluids

A patient is experiencing an acute episode of diverticulitis. The patient is having abdominal pain, temperature 102.6 F, and elevated WBC's. As the nurse, you know it is important to

Monitor the patient for peritonitis

A patient with an open leg wound has a white blood cell (WBC) count of 13, 500/µL and a band count of 11%. What action should the nurse take first?

Obtain wound cultures

The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate?

Obtain wound cultures

During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply.

Perineal skin irritation Fluid intake of less than 1,500 mL/d History of UTI A fecal impaction

A patient is scheduled for appendectomy at noon. While performing your morning assessment, you note that the patient has a fever of 103.8 F and rates abdominal pain 9 on 1-10. In addition, the abdomen is distended and the patient states, " was feeling better last night but it seems the pain has become worst." The patient is having tachycardia and tachypnea. Based on the scenario, what do you suspect the patient is experiencing?

Peritonitis

Which of the following behaviors indicates that the client on a bladder training program has met the expected outcomes?

Practices slow, deep breathing until the urge decreases Performs pelvic muscle exercises

Patient's laboratory results from the patient's urine analysis is considered normal if ?

Presence of Ketone bodies

The nurse is caring for a client with a bowel obstruction. Which assessment findings indicate the possible onset of peritonitis? Select all that apply. One, some, or all responses may be correct.

Rebound tenderness Diminished bowel sounds Rigid, boardlike abdomen

The nurse is caring for a client with probable colorectal cancer (CRC). What assessment findings would...

Rectal bleeding Anemia Change in stool shape Abdominal discomfort

A female client has a urinary tract infection (UTI). Which teaching points by the nurse would be helpful to the client? Select all that apply.

Review symptoms of UTI with the client Wear cotton underclothes

Your patient has Crohn's disease and a draining fistula bloody in color. Which documentation would alert you to urgently contact the provider stat?

Serum potassium of 2.6 mEq/L

An 80 year old man was admitted with Acute Kidney Injury has a blood pressure of 79/56 mm Hg. The healthcare provider had ordered 1000mL of normal saline bolus, and a continuous Ringers lactate at the rate of 125ml/hr. During your morning assessment you observed crackles and saturation in the upper 80's. What possible interventions are necessary? Select all that apply?

Stop the infusion Raise the head of the bed Check the vital signs Notify the provider

The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem?

Suppressor T cells

A patient with a history of diverticulosis is admitted with abdominal pain. The physician suspects diverticulitis. What other findings would correlate with diverticulitis?

Unrelenting cramping type pain Blood in stool Fever Reports of constipation Abdominal bloating

You are teaching a patient with hepatitis who is prescribed cabarin (Copegus). Which statement would you include in the discharge education?

Use a pill organizer to ensure you take this medication as prescribed

A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ?

Bone marrow

After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client's understanding. Which menu selection indicates that the client correctly understands the dietary teaching?

Broiled chicken with brown rice, steamed broccoli, glass of apple juice

Which statement indicates a need for further teaching of the home care client with a long-term indwelling catheter?

Check the penis for adequate circulation 30 min after applying

The nursing instructor is discussing the chain of infection to a group of student nurses. What is the most important information about identifying the chain of infection for the health care provider?

Determination of points at which the infection can be stopped or prevented can be made by identifying the chain of infection

The nurse is caring for a client who is diagnosed with a complete small bowel obstruction. For what priority problem is this client most likely at risk?

Electrolyte imbalance

The physician orders a urine culture on your patient in room 5505 with a urinary tract infection. In addition, the patient is ordered to start IV Bactim (Sulfamethoxazole/Trimethoprim). How will you proceed with following this order?*

First, collect the urine culture, and then hang the antibiotic

A client is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best?

Teach the client to sneeze in the upper sleeve.

The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following?

The amount of urine retained after voiding increases

Which statement accurately explains otitis media?

The inflammatory response is triggered by the invasion of foreign organisms.

Your patient is 4 days post-opt from an appendectomy. Which assessment finding requires further evaluation?

The patient reports their last bowel movement was the day before surgery

The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)?

The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer

A 24-year-old is admitted to a medical unit with the diagnosis of hepatitis A and placed in contact precautions. What is the primary goal of this action?

To prevent transmission of infectious microorganisms

A nurse teaches a patient who is recovering from a colon resection. Which statement would the nurse include in this patient's plan of care?

Take a stool softener to promote softer stools for ease of defecation.