medsurg review 3

A patient is admitted to the emergency department with severe abdominal pain with rebound tenderness, anorexia, and chills. The vital signs include 101 temperature, pulse of 130, respirations of 34, and BP of 82/50. Of the following collaborative interventions, which one should the nurse implement first?

Infusion of 1000mL of lactate ringer solution

A patient is receiving heparin therapy for something what will the nurse do

Monitor patient lab values

A total proctocolectomy with a permanent ileostomy is performed for a patient with ulcerative colitis. The patient is very upset and tells the nurse, " I cannot even bare to look at the stoma. I don't think I can manage all these changes." The nurse's best approach to the patient's remarks is to...

ask the patient if a member of an ostomy support group may visit

Which hypertensive medication will the nurse consider for African American with stage 1 hypertension?

calcium channel blocker and diuretics

A nurse is caring for a client diagnosed with esophageal reflux disorder. The nurse instructs the client to...

keep the head of the bed elevated

The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient's peptic ulcer. The nurse will teach the patient to take

-antacids after eating and sucralfate 30 minutes before eating

While obtaining a history with I/BD, the nurse recognizes that the patient may have ulcerative colitis rather than Crohn's disease when the patient is experiencing...

bloody stools

A post op client has orders to start eating following a hiatal hernia repair. Which of the following information should the nurse use to reintroduce solid foods to the patient?

broth, tea, and gelatin

A 42- year-old female is recovering from cholecystectomy t-tube placement. She begins to complain of leg pain dorsiflexion of the foot which feels cool to the touch. The nurse realizes this is...

Forming of thrombus

The nurse is assessing a 22-year-old patient experiencing an onset of symptom of type 1 diabetes. To which question of the nurse is going to anticipate a positive response?

Have you lost weight lately?

. A client with a diagnosis of peptic ulcer disease is scheduled for an endoscopy. He states, "the physician already knows that I have an ulcer, why do I have to take this test?" Which is the best response of the nurse?

the location of the ulcer can be visualized with this test

A client is admitted to the unit with RO appendicitis. The doctor has not seen him and he is complaining of severe pain and is requesting pain medication. The nurse informed him that he cannot have any pain medication until the doctor has seen. The client asked why. What is the appropriate response by the nurse?

the medication may hide the symptoms present that may confirm the diagnosis

Which of these assessment findings are found in a patient with a hiatal hernia who returned from a laparoscopic niss? Funnel application 4 hours ago is most important for the nurse to assess immediately?

the patient has absent breath sounds throughout the left lung

A patient who has an open colectomy and common bile duct exporation 12 hours ago has green drainage from his t-tube. The nurse understands that

this is normal, continue to monitor and record drainage

When discussing risk factor modifications for a client who has a 5cm abdominal aortic aneurysm, the nurse will focus teaching on which patient risk factor?

uncontrolled hypertension

A client has a laparoscopic cholecystectomy complaining of severe pain in the right shoulder. Which instructions should the nurse give the client?

walk for 5 minutes then lies down

Which of the following would be inappropriate to teach a patient with chronic arterial occlusive disease?

wear clean light colored all cotton or all wool socks.

Which diagnostic test would you not use for cholelithiasis and cholecystitis?

Wbc in urine

This patient has been diagnosed with HTN which indicated a need for further therapy..

116/95

A patient receives a daily injection of insulin NPH premixed at 7am. The nurse expects that a hypoglycemic reaction is likely to occur between

11am-5pm

Which BP finding found by the nurse indicates that there is a need for changes in therapy for a 44-year-old patient with newly diagnosed hypertension? Select all that apply.

126/60

A patient comes into clinic, he is 60 something, he had new diagnosed with type 1 hypertension, what blood pressure would he need change in medication? choice would signify that he needs to change in their blood regimen?

126/60 something

Which BP finding by the nurse is indicative that no changes of therapy are needed for a 48-year- old patient who is recently diagnosed with hypertension?

128/92

A client with subtotal gastrostomy is scheduled for discharge. Which instruction should the nurse give the client to reduce the occurrence of dumping syndrome?

avoid drinking fluids with your meal

The client on an intensified insulin regimen consistently has fasting blood glucose between 70 and 80. A post prandial glucose level below 700, hemoglobin of 5.5. What is the nurse's interpretation of these findings?

the client is in good control of blood glucose

The patient is diaphoretic and doubled over in pain. An additional sign indicating perforation of the ulcer for which the nurse should assess

A rigid, boardlike abdomen.

The purpose of the nasogastric tubing question

Collection of drainage and release gas pressure..... what is action

A 50 yr old client with cholecystostomy has Drainage of 150ml over 24 hours. What would you do?

Do nothing and note as normal as signs its not emergency

Which one of the following statements made by the patient indicates the need for further teaching regarding the laparoscopic cholecystectomy?

I may be able to resume activity within a few days

The nurse taught the client with GERD about ways to minimize symptoms. Which client statement requires additional teaching?

I will be sure to drink tea instead of coffee

A diabetic patient has started on intensive insulin therapy. The nurse plans to teach the patient about meal time coverage using blank insulin?

Lispro

A patient with chronic gastritis is associated with the presence of Hyloric Pylor Bacteria is treated with triple drug therapy. The nurse explains to the patient that commonly used drugs for this are...

amoxicillin, Cleraphilmycin, amaprozole

A 16yr old female visits the community clinic complaining of pain in her hands. She says her fingers turn colors. First red then white then blue. She was recently diagnosed of Raynaud's disease. What instructions could the nurse provide her with regarding this condition.

Tight fitting warm clothing should protect the body from getting cold

The HCP prescribes antacids and sulfocrate for treatment for patient's peptic ulcer. The nurse will teach the patient to...

antacids after eating and sulcrofate 30 minutes before eating

A patient newly diagnosed with Chron's disease asks the nurse what to expect in the future. The best response by the nurse is...

You need to know that there is a probability of lifelong unpredictable periods of remission and reoccurrence

A 56-year-old patient who has no previous history of hypertension or other health problems suddenly develops a BP reading of 198/110. It is important for the nurse to tell the patient that...

a diagnose, treatment and ongoing monitor will be needed

A patient is 24 hours post-surgery with a transverse cholecystectomy. During the initial assessment of the stoma, the nurse finds the stoma to be red and bleeding. The most important intervention of this interpretation of the findings by the nurse is that

a normal blood supply

The nurse is taking care of a client with bleeding ulcer. Which physical finding would be present if the ulcer is perforated?

a rigid built like abdomen

A patient has a large bowel obstruction that occurred as a result of fecal impaction. During the assessment of the patient, the nurse finds that a finding by the nurse is consistent with large bowel obstruction includes...

abdominal distention

A client has a total gastrectomy for cancer. A nurse suspects the client to have...

absorption of colbamin

The nurse is performing an assessment on a 43-yr old female who is diagnosed with cholecystitis and is complaining of upper right quadrant pain, n/v. The nurse observes scratches on the client's arm. This is most likely due to...

accumulation of bile salts

In planning care for a patient with venous stasis ulcer on the right leg. The nurse understands that the most important intervention in promoting healing of the ulcer is...

adequate dietary intake of protein and vitamins

A client's morning glucose reading is 58. Which nursing action should the nurse take based on this reading?

administer half a cup of orange juice

A 36-year-old patient who has a history of Berger's disease is admitted to the hospital on her small right toe. When the nurse is planning expected outcomes for this patient. Which outcome had the highest priority for the patient?

cessation of smoking

After the nurse teaches a patient with GERD dietary modifications, which diet choice does a snack 2 hours before bedtime indicate teaching has been effective?

cherry gelatin or fruit

24 hours following a hernia repair, the nurse notes bloody drainage from the NG tube and 100 mL in suction tube. The nurse should...

contact surgeon

A 26-year-old is diagnosed with Crohn's disease after having frequent diarrhea, weight loss of 10 lbs. over 2 months. The nurse plans to teach the patient about...

corticosteroids

A client is receiving IV heparin for treatment of deep vein thrombosis. Which of the following priority precautions should the nurse incorporate into the client's plan of care as a result of administering heparin intravenously?

establish a separate IV line for other prescribed drugs

Which action should the nurse take after the patient is treated with IM glucagon for hyperglycemia and regains consciousness?

give the patient a snack of peanut butter and crackers

A patient is on warfarin therapy. What kind of diet would be appropriate for this patient.

green leafy vegetable.

The client is admitted to the hospital with ulcerative colitis. The nurse should assess the client for which indication for a sign of the complication of the disease?

hemoglobin of 9.6 and hematocrit of 28

Which clinical manifestation in a client with uncontrolled diabetes should the nurse expect as a result of ketoacids in the blood?

increased rate and depth of respirations

A client has a nasogastric tube in placed for gastric decompression and reports increased nausea. Which action should the nurse take first?

irrigate with 20mL of saline

A nurse prepares to perform an abdominal assessment because the client has abdominal pain. During in examination of the abdomen, the nurse should...

listen to epigastric in all 4 quadrants of the abdomen for 2-5 minutes for bowel sounds

A 44-year old man returns from the post anesthesia unit after having a cholecystectomy. When the nurse plans the care of client, she will put most of the emphasis of prevention of which of the following post-operative complication?

lower hemorrhaging

In establishing a plan of care for a client returning from surgery post cholecystectomy with a T-tube. Which of the following does the nurse plan for maintenance of the T-tube?

monitors the T-tube drainage for color and amount and record records

The nurse obtains the following information from a client recently diagnosed with prehypertension. Which of these findings are most important to address with the patient?

no regular exercise

A patient with type 1 diabetes has an unusual high glucose measurement and the HCP wants to evaluate the possible effect of the Somgyi effect. The nurse will plan to...

obtain the patient's blood glucose at 3 in the morning

The nurse explains to the patient with gastroesophageal reflex disorder that...

often involves relaxation of the lower esophageal sphincter to allow stomach content back into the esophagus

The nurse performs an assessment of the abdomen with possible bowel obstruction of a client. Knowing that manifestations of obstructions high in the intestines is tested is?

persistent, colicky abdominal pain

A patient hospitalized with acute exacerbation of ulcerative colitis is having 14-16 bloody stools a day and crampy abdominal pain due to diarrhea. The nurse plans to

place patient on NPO status

Which assessment finding in a client with diabetes indicates that the disease is damaging the kidneys?

presence of protein in the urine during a random urinalysis

8yr old is admitted for right lower quadrant pain and is suspected of appendicitis. The nurse performs deep palpations of the right lower quadrant and quickly removes hand. This assessment is done to determine...

rebound tenderness

While obtaining a nursing history from a 55-yr old patient scheduled for a colonostomy, the nurse will be most concerned about?

recent blood in stools

A 50-yr old client with a T-tube in place following a cholecystectomy, she calls the clinic to report that she's experiencing nausea after meals. The nurse teaching should have included...

report to the clinic to have the t-tube removed

A patient with type 2 diabetes that is controlled with diet and metformin also has arthritis. During acute exacerbation of the patient's arthritis, the HCP prescribes prednisone to control inflammation. The nurse will anticipate that the client may

require an administration if insulin while taking predinose