Med Surg GI GU Nutrition

Which assessment is important for the nurse to monitor in a client receiving TPN?

Blood glucose

After a preschooler undergoes craniotomy for the removal of a brain tumor, the nurse identifies an area of serosanguineous drainage about the size of a quarter on the child's dressing. Which action would be the immediate response by the nurse?

Circling the area with non-absorbable ink

Which factor increases the risk for one dehiscence in a client who had major abdominal surgery one day ago?

Client being overweight

For which response for the nurse critically assess the client with a nasogastric tube inserted who is attached to section?

Dehydration

Which action with the nurse take when observing that a post surgical client has a urine output of 800 ML total in the first 24 hours after surgery?

Document the normal finding

When would the nurse remove the abductor pillow splint for a client who had surgery in which a hip prosthesis was inserted?

During the clients skin care and physical therapy

Which purpose is served by obtaining informed consent?

Enabling the client to make knowledgeable decisions

Which intervention by the nurse promotes perfusion and healing of the surgical wound in an older adult?

Keeping the client adequately hydrated

Which type of incontinence would be documented by the nurse caring for a client who has an involuntary loss of small amounts of urine from an over distended bladder?

Overflow

A client is receiving TPN. Which finding with the nurse determines is caused by hyperglycemia due to the TPN?

Polyuria

A client who had a choledochostomy is returned to the surgical unit with a T tube in place. Which intervention is the priority when caring for this client?

Protecting the abdominal skin from bile drainage

A healthcare provider prescribes daily docusate sodium for a client. Which action does docusate sodium have in the G.I. tract?

Softens the stool

Which statement made by the nurse is correct regarding TPN?

TPN must be administered through a central IV catheter

Which action with a nurse recommend be taken by a client the day before a scheduled IVP?

Take a laxative before going to bed

When the nurse is caring for several clients on a medical/surgical floor, which task is appropriate to delegate to the UAP?

Turn a bedbound client to prevent pressure injuries

How would the nurse respond to a client who is total cholesterol level is found to be 210 mg/DL at a community health screening session and who asked the nurse what to do in light of this result?

Your level is elevated slightly, and a diet low in saturated fats should be followed

A client it's a meal that contains 13 g of fat, 31 g of carbohydrates, and 5 g of protein. Calculate the clients total caloric intake for this meal. Record your answer using a whole number.

261

Which food selected by an athletic teenager indicates understanding of the nurse's teaching about nutrients that provide the quickest source of energy?

A glass of orange juice

Which circumstance would legally prevent a client scheduled for surgery from giving consent?

A sedative type of medication has been given recently

Which action with the nurse take when caring for a client whose urine output has progressively diminished and is less than 40 ML's per hour over the past three hours despite receiving 2900 ML's intake for two days?

Assess breathing sounds and take VS

Which factor is most related to why cholesterol is important in the human body in normal levels?

Cellular membranes

Which is the primary purpose that pre-operative antibiotics are prescribed for a client who is scheduled for a surgical resection of the colon and creation of a colostomy?

Decrease bacteria in the intestines

Which factor with a nurse reference when teaching a client about the differences between the terms saturated fat and unsaturated fat?

Density

Which intervention would the nurse recommend for a client who is receiving total parenteral nutrition and is experiencing dumping syndrome after consulting the dietitian?

Drink fluid along with meals

A nurse is caring for a client who just had a gastrectomy. Which client teaching with the nurse emphasize when discussing how to avoid dumping syndrome?

Eat small meals with low-carb and Moderate fat content

Which measure with the nurse take to prevent aspiration when caring for a client receiving enteral feedings?

Elevate head of bed 30-45 degrees

During the insertion of an NG tube, which response indicates that the tube may be in the airway?

Inability to speak

Which classification describes an infection that a surgical client developed in the wound during hospitalization?

Nosocomial

Which action will the nurse take first for a post surgical client who is still intubated but becoming restless, with an increased pulse rate and blood pressure, when it has been four hours since the last dose of pain medication?

Notify HCP

A nurse is teaching menu planning tweak client who has a high triglyceride level. Which food avoided by the client indicates the teaching about foods that are high in saturated fat was understood?

Red meat

Which action will the nurse take a specimen for a routine urinalysis cannot be sent immediately to the laboratory?

Refrigerate the specimen

Which intervention is generally used to reduce discomfort after a rubber band ligation of internal hemorrhoids?

Sitz bath

Because of its role in wound healing, which vitamin with the nurse expect the healthcare provider to prescribe for a client with a large surgical incision?

Vitamin C (ascorbic acid)

When encouraging a client a cough and deep breathe after a bilateral mastectomy, the client says, "Leave me alone! Don't you know I'm in pain?" Which response with the nurse give?

What's your pain level right now?

Which item included on a list of foods to avoid by a client with hypercholesterolemia supports the nurses conclusion that teaching has been effective?

Whole milk & hard cheeses

Which teaching with the nurse provide to help prevent future bleeding episodes for a client who has recent recurrent episodes of bleeding hemorrhoids?

Consume a high fiber diet and drink adequate water

A client is being prepared for surgery to have placement of a percutaneous endoscopic gastrostomy. The client asks why the PEG tube is preferred over the existing NG tube that is being used for feedings. Which explanation would the nurse give?

There is less chance of aspiration

A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery?

Assess patency of the airway

An unconscious toddler requires intermittent nasogastric feeding. When would the nurse check placement of the tube?

Before each feeding

What action by the client using an incentive spirometer indicates the need for further instruction?

Blowing vigorously into the mouthpiece

A client with a known history of opioid addiction is treated for multiple stab wounds to the abdomen. After surgical repair the nurse notes that the clients pain is not relieved by the prescribed morphine injections. Which phenomenon is the client most likely experiencing?

Tolerance

When assessing an obese client, the nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse place is the client in the low fowler position with the knees slightly bent and encourage the client to lie still. Which nursing action with the nurse take next?

Cover the wound with a sterile gauze moistened with NS

Which nursing action is the priority if after surgery in the inguinal area the client is reporting pain on the right side of the chest, becomes dyspneic, and begins to cough violently?

Elevate head of bed

Which action would the nurse take with a client scheduled for a surgical procedure who is morning blood glucose reading was a 140?

Hold the dose and notify healthcare provider

Which response for the nurse use when a client expresses concern about the surgical consent the client signed?

Inform the HCP of the clients concern

Which action by the client demonstrates effective teaching about use of an incentive spirometer post operatively?

Inhales deeply through device, holds breath for 5 seconds, then exhales

Which action will the nurse complete in a client who just had a thoracic surgery and complains of pain at the incision site when coughing or deep breathing?

Instruct the client to splint the wound when coughing

During the administration of TPN, in assessment of the client reveals a bounding pulses, distended jugular veins, dyspnea, and cough. Which nursing intervention is the priority at this time?

Interrupt the clients infusion and notify the healthcare provider

Which action related to the drainage tube would the nurse include in the plan of care for a client with a T-tube after an open cholecystectomy?

Monitor the color of the stool

Which clinical finding indicates that a post operative client who has an NG tube attached to low continuous suction may be experiencing hypokalemia?

Muscle weakness and cardiac dysrhythmia

Which intervention is the priority in a client with two portable drainage catheter's after a radical neck dissection and 6 hours after the nurse empties 180 ML of serosanguineous drainage from one of the drainage catheters?

Notify HCP immediately

Which intervention with the LPN prioritize with the RN for a client receiving parenteral nutrition who develops a headache and has a bounding pulses, lung crackles on auscultation, in the blood pressure of 160/95?

Obtaining a prescription to slow or stop the IV infusion

Which medication will the nurse administer to specifically lower the clients elevated triglyceride level?

Omega-3 fatty acids

The nurse monitors the three day post operative client who underwent abdominal surgery vital signs are temperature 102°F pulse 104 bpm respirations 22 breaths per minute blood pressure 128/74 oxygen saturation is 93% on room air. The client feels tired and has a productive cough. Fine crackles are audible in the bases of the lungs posteriorly. The nurse consider the client has developed which post operative problem?

PNA

Which term with the nurse use after being informed on rounds by the surgical team that a client is to undergo surgery to relieve pain associated with malignant tumor?

Palliative

A client sustained a complex comminuted fracture of the tibia with soft tissue injuries after being hit by a car while riding a bicycle. Surgical placement of an external fixator is performed to maintain the bone in alignment. Which action is essential for the nurse to perform post operatively?

Perform a neurovascular assessment of both lower extremities

Which recommendation by the physical therapist for the nurse follow to prevent displacement of the surgical prosthesis when positioning a client properly in bed after total hip replacement?

Placed the abductor splint while the client is in bed

Which intervention would the nurse expect to prevent the most common post surgical complication after an open reduction and internal fixation of a fractured hip?

Sequential compression stockings (SCD)

Which clinical finding supports the nurses conclusion that the client is experiencing wound dehiscence five days after abdominal surgery?

Serosanguineous drainage

The nurse is counseling a client with diabetes about foods low in carbohydrates. Which food choice made by the client indicates the teaching has been successful?

Skim milk