MEDSURGE EXAM 3
The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill. Which response by the nurse is most appropriate?
"An immunoglobulin injection will be given to prevent infection or limit symptoms."
The nurse provides discharge instructions for a 64-yr-old woman with ascites and peripheral edema related to cirrhosis. Which patient statement indicates teaching was effective?
"Herbs and other spices should be used to season my foods instead of salt."
After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? "I will replace my nitroglycerin supply every 6 months." "I can take up to five tablets every 3 minutes for relief of my chest pain." "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin." "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain."
"I can take up to five tablets every 3 minutes for relief of my chest pain."
When teaching the patient with acute hepatitis C (HCV), which statement demonstrates understanding of the disease process?
"I will need to be monitored for chronic HCV and other liver problems."
The nurse instructs a 68-yr-old woman with hypercholesterolemia about natural lipid-lowering therapies. The nurse determines further teaching is necessary if the patient makes which statement? "Omega-3 fatty acids are helpful in reducing triglyceride levels." "I should check with my physician before I start taking any herbal products." "Herbal products do not go through as extensive testing as prescription drugs do." "I will take garlic instead of my prescription medication to reduce my cholesterol."
"I will take garlic instead of my prescription medication to reduce my cholesterol."
The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching?
"If I notice a fast heart rate or irregular beats, this is normal for cirrhosis."
In caring for the patient with angina, the patient said, "While I was having a bowel movement, I started having the worst chest pain ever, like before I was admitted. I called for a nurse, then the pain went away." What further assessment data should the nurse obtain from the patient? "What precipitated the pain?" "Has the pain changed this time?" "In what areas did you feel this pain?" "What is your pain level on a 0 to 10 scale?"
"In what areas did you feel this pain?"
The nurse is preparing to administer famotidine to a postoperative patient with a colostomy. The patient states they do not have heartburn. What response by the nurse would be the most appropriate?
"It will reduce the amount of acid in the stomach."
The results of a patient's recent endoscopy indicate the presence of peptic ulcer disease (PUD). Which teaching point should the nurse provide to the patient based on this new diagnosis? "It would be beneficial for you to eliminate drinking alcohol." "You'll need to drink at least two to three glasses of milk daily." "Many people find that a minced or pureed diet eases their symptoms of PUD." "Taking medication will allow you to keep your present diet while minimizing symptoms."
"It would be beneficial for you to eliminate drinking alcohol."
A patient is scheduled for a percutaneous transhepatic cholangiography to restore biliary drainage. The nurse discusses the patient's health history and is most concerned if the patient makes which statement? "I am allergic to bee stings." "My tongue swells when I eat shrimp." "I have had epigastric pain for 2 months." "I have a pacemaker because my heart rate was slow."
"My tongue swells when I eat shrimp."
The nurse teaches senior citizens at a community center how to prevent food poisoning at social events. Which community member statement reflects accurate understanding? "Pasteurized juices and milk are safe to drink." "Alfalfa sprouts are safe if rinsed before eating." "Fresh fruits do not need to be washed before eating." "Ground beef is safe to eat if cooked until it is brown."
"Pasteurized juices and milk are safe to drink."
The nurse instructs a 50-yr-old woman about cholestyramine to reduce pruritus caused by gallbladder disease. Which patient statement indicates understanding of the instructions?
"The medication is a powder and needs to be mixed with milk or juice."
The nurse is preparing to insert a nasogastric (NG) tube into a patient with a suspected small intestinal obstruction that is vomiting. The patient asks the nurse why this procedure is necessary. What response by the nurse is most appropriate?
"The tube will help to drain the stomach contents and prevent further vomiting."
A postoperative patient asks the nurse why the physician ordered daily administration of enoxaparin (Lovenox). Which reply by the nurse is most appropriate? "This medication will help prevent breathing problems after surgery, such as pneumonia." "This medication will help lower your blood pressure to a safer level, which is very important after surgery." "This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal." "This medication is a narcotic pain medication that will help take away any muscle aches caused by positioning on the operating room table."
"This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal."
The nurse is teaching a group of college students how to prevent food poisoning. Which comment shows an understanding of foodborne illness protection? "Eating raw cookie dough from the package is a great snack when you do not have time to bake." "Since we only have one cutting board, we can cut up chicken and salad vegetables at the same time." "To save refrigerator space, leftover food can be kept on the counter if it is in sealed containers." "When the cafeteria gave me a pink hamburger, I sent it back and asked for a new bun and clean plate."
"When the cafeteria gave me a pink hamburger, I sent it back and asked for a new bun and clean plate."
A patient with varicose veins has been prescribed compression stockings. Which nursing instruction would be most appropriate? "Try to keep your stockings on 24 hours a day, as much as possible." "While you're still lying in bed in the morning, put on your stockings." "Dangle your feet at your bedside for 5 minutes before putting on your stockings." "Your stockings will be most effective if you can remove them for a few minutes several times a day."
"While you're still lying in bed in the morning, put on your stockings."
A patient was involved in a motor vehicle crash and reports an inability to have a bowel movement. What is the best response by the nurse? "You are just too nervous to eat or drink, so there is no stool." "Your parasympathetic nervous system is now working to slow the GI tract." "The circulation in the GI system has been increased, so less waste is removed." "Your sympathetic nervous system was activated, so there is slowing of the GI tract".
"Your sympathetic nervous system was activated, so there is slowing of the GI tract".
A patient is given a bisacodyl suppository and asks the nurse how long it will take to work. What is the best response by the nurse?
15-60 minutes
A patient with suspected bowel obstruction had a nasogastric tube inserted at 4:00 AM. The nurse shares in the morning report that the day shift staff should check the tube for patency at what times?
8:00 AM, 12:00 PM, and 4:00 PM
Which patient would be at highest risk for developing oral candidiasis? A 74-yr-old patient who has vitamin B and C deficiencies A 22-yr-old patient who smokes 2 packs of cigarettes per day A 32-yr-old patient who is receiving ciprofloxacin for 3 weeks A 58-yr-old patient who is receiving amphotericin B for 2 days
A 32-yr-old patient who is receiving ciprofloxacin for 3 weeks
The nurse identifies that which patient is at highest risk for developing colon cancer?
A 32-yr-old woman with a 12-year history of ulcerative colitis
A nurse should recognize that nasogastric intubation is indicated to relieve gastric distension for which of the following patients?
A 40 yr old patient with a postoperative bowel obstruction
Which individuals would the nurse identify as having the highest risk for coronary artery disease (CAD)? A 45-yr-old depressed man with a high-stress job A 60-yr-old man with below normal homocysteine levels A 54-yr-old woman vegetarian with elevated high-density lipoprotein (HDL) levels A 62-yr-old woman who has a sedentary lifestyle and body mass index (BMI) of 23 kg/m2
A 45-yr-old depressed man with a high-stress job
Which patient is at greatest risk for sudden cardiac death (SCD)? A 42-yr-old white woman with hypertension and dyslipidemia A 52-yr-old African American man with left ventricular failure A 62-yr-old obese man with diabetes mellitus and high cholesterol A 72-yr-old Native American woman with a family history of heart disease
A 52-yr-old African American man with left ventricular failure
Which person should the nurse identify as having the highest risk for abdominal aortic aneurysm? A 70-yr-old man with high cholesterol and hypertension A 40-yr-old woman with obesity and metabolic syndrome A 60-yr-old man with renal insufficiency who is physically inactive A 65-yr-old woman with hyperhomocysteinemia and substance abuse
A 70-yr-old man with high cholesterol and hypertension
The nurse is caring for a group of patients. Which patient has the highest risk for developing pancreatic cancer?
A 72-yr-old African American man who has smoked cigarettes for 50 years
The nurse is caring for a woman recently diagnosed with viral hepatitis A. Which individual should the nurse refer for an immunoglobulin (IG) injection?
A caregiver who lives in the same household with the patient
When providing discharge teaching for a patient after a laparoscopic cholecystectomy, what information should the nurse include?
A lower-fat diet may be better tolerated for several weeks.
A patient is planned for discharge home today after ostomy surgery for colon cancer. The nurse should assign the patient to which staff member?
A registered nurse with 6 months of experience on the surgical unit
A patient who has bladder cancer tells the nurse that, of the various urinary diversion options the surgeon presented, she prefers one that will allow her to have some control over urinary elimination. The nurse should explain the option that will allow that is
A: A Kock's pouch R: This is a continent ileal bladder conduit that does not require an external drainage collection device because the patient self-catheterizes every 2-4 hours to remove urine. This device will provide the control the patient desires.
A nurse is providing preoperative teaching for a patient who has colon cancer. The surgeon informed the patient his entire large intestine and rectum will be removed. The nurse should explain the type of ostomy he will have is
A: A ileostomy R: After removing the entire large intestine and the rectum, the surgeon will create an ileostomy to divert feces from the small intestine to the abdominal surface and into an ostomy pouch.
A nurse is replacing the ostomy appliance for a patient whose newly created colostomy is functioning. After removing the pouch, which of the following should the nurse do first?
A: Cleanse the stoma and peristomal skin. R: To facilitate the nurse's assessment of the stoma and the peristomal skin, the nursemust remove any effluent adhering to the area.
A nurse is obtaining health history from a young adult patient who has a colostomy. The patient reports frequent episodes of loose stools over the last month, but has no signs of infection or bowel obstruction. He reports that his concerns about leakage have limited his social activities. Which of the following should the nurse recommend?
A: Consume foods that are low in fiber content. Rationale: Foods low in fiber help thicken the stool; examples include rice, noodles, white bread, cream cheese, lean meats, fish, and poultry.
A nurse is teaching a patient with a new ileostomy about incorporating preventive strategies at home. To prevent excoriation and breakdown of the peristomal skin, the nurse should instruct the patient to
A: Empty the pouch when it is no more than half full. R: Waiting until the pouch is more than half full increases the risk of leakage. Ileostomy effluent is irritating to peristomal skin, so patients should replace the pouch when it is one-third to one-half full.
A nurse is teaching a patient how to apply an extended-wear skin barrier. Which of the following strategies should the nurse instruct the patient to use for maximal adherence?
A: Press gently around the barrier for 1 to 2 minute. R: The pressure-sensitive tackifiers and heat-sensitive polymers of the skin barrier require adequate pressure (and warmth from the fingers) to ensure adherence.
While a nurse is teaching a patient how to replace her ostomy pouching system, the patient reports that removing the skin barrier is sometimes painful. Which of the following should the nurse suggest?
A: Push the skin away from the barrier while removing it. R: Pushing the skin away from the barrier helps prevent skin stripping, which can be painful and make the skin sensitive to the adhesive. If the patient is having difficulty with the initial release of the barrier, it may help if she starts in one corner and gently pulls it over the stoma while pushing the ski away from the barrier.
A nurse is providing preoperative teaching for an older patient who has diverticulitis and is scheduled for a creating for a double barrel colostomy in the sigmoid colon. Which of the following instructions should the nurse include in the teaching?
A: Tape a dry gauze pad over the distal stoma to collect drainage. R: The distal stoma (also called a mucous fistula) secretes mucus; it does not drain feces. A dry gauze dressing is usually sufficient.
A nurse is caring for a patient with a diagnosis of deep venous thrombosis (DVT). The patient has an order to receive 30 mg enoxaparin (Lovenox). Which injection site should the nurse use to administer this medication safely? Buttock, upper outer quadrant Abdomen, anterior-lateral aspect Back of the arm, 2 inches away from a mole Anterolateral thigh, with no scar tissue nearby
Abdomen, anterior-lateral aspect
When caring for the patient with heart failure, the nurse knows that which gastrointestinal process is most dependent on cardiac output and may affect the patient's nutritional status? Ingestion Digestion Absorption Elimination
Absorption
The nurse is reviewing the home medication list for a patient admitted with suspected hepatic failure. Which medication reviewed by the nurse could cause hepatotoxicity? Digoxin Nitroglycerin Ciprofloxacin Acetaminophen
Acetaminophen
A 39-yr-old woman with a history of smoking and oral contraceptive use is admitted with a venous thromboembolism (VTE) and prescribed unfractionated heparin. What laboratory test should the nurse review to evaluate the expected effect of the heparin? Platelet count Activated clotting time (ACT) International normalized ratio (INR) Activated partial thromboplastin time (APTT)
Activated partial thromboplastin time (APTT)
A patient with cholelithiasis is being prepared for surgery. Which patient assessment represents a contraindication for a cholecystectomy?
Activated partial thromboplastin time (aPTT) of 54 seconds
The patient is being dismissed from the hospital after acute coronary syndrome and will be attending rehabilitation. What information would be taught in the early recovery phase of rehabilitation? Therapeutic lifestyle changes should become lifelong habits. Physical activity is always started in the hospital and continued at home. Attention will focus on management of chest pain, anxiety, dysrhythmias, and other complications. Activity level is gradually increased under cardiac rehabilitation team supervision and with electrocardiographic (ECG) monitoring.
Activity level is gradually increased under cardiac rehabilitation team supervision and with electrocardiographic (ECG) monitoring.
For which problem is percutaneous coronary intervention (PCI) most clearly indicated? Chronic stable angina Left-sided heart failure Coronary artery disease Acute myocardial infarction
Acute myocardial infarction
The nurse is reviewing the laboratory test results for a 68-yr-old patient whose warfarin (Coumadin) therapy was terminated during the preoperative period. On postoperative day 2, the international normalized ratio (INR) result is 2.7. Which action by the nurse is most appropriate? Hold the daily dose of warfarin. Administer the daily dose of warfarin. Teach the patient signs and symptoms of bleeding. Call the physician to request an increased dose of warfarin.
Administer the daily dose of warfarin.
The patient with chronic gastritis is being put on a combination of medications to eradicate Helicobacter pylori. Which drugs does the nurse know will probably be used? Antibiotic(s), antacid, and corticosteroid Antibiotic(s), aspirin, and antiulcer/protectant Antibiotic(s), proton pump inhibitor, and bismuth Antibiotic(s) and nonsteroidal antiinflammatory drugs (NSAIDs)
Antibiotic(s), proton pump inhibitor, and bismuth
The nurse is caring for a postoperative patient who has just vomited yellow green liquid and reports nausea. Which action would be an appropriate nursing intervention? Offer the patient an herbal supplement such as ginseng. Apply a cool washcloth to the forehead and provide mouth care. Take the patient for a walk in the hallway to promote peristalsis. Discontinue any medications that may cause nausea or vomiting.
Apply a cool washcloth to the forehead and provide mouth care.
The nurse would assess a patient with complaints of chest pain for which clinical manifestations associated with a myocardial infarction (MI) (select all that apply.)? Flushing Ashen skin Diaphoresis Nausea and vomiting S3 or S4 heart sounds
Ashen skin Diaphoresis Nausea and vomiting S3 or S4 heart sounds
A patient with critical limb ischemia had peripheral artery bypass surgery to improve circulation. What nursing care should be provided on postoperative day 1? Keep patient on bed rest. Assist patient to walk several times. Have patient sit in the chair several times. Place patient on their side with knees flexed
Assist patient to walk several times.
Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery includes monitoring for which common complication? Dehydration Paralytic ileus Atrial dysrhythmias Acute respiratory distress syndrome
Atrial dysrhythmias
The nurse is performing an abdominal assessment for a patient. Which assessment technique by the nurse is most accurate? Palpate the abdomen before auscultation. Percuss the abdomen before auscultation. Auscultate the abdomen before palpation. Perform deep palpation before light palpation.
Auscultate the abdomen before palpation.
A patient was admitted for possible ruptured aortic aneurysm. No back pain was reported. Ten minutes later, the nurse notes sinus tachycardia 138 beats/min, blood pressure is palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret the findings? Tamponade will soon occur. The renal arteries are involved. Perfusion to the legs is impaired. Bleeding into the abdomen is likely.
Bleeding into the abdomen is likely.
The patient with suspected pancreatic cancer is having many diagnostic studies done. Which one can be used to establish the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment?
Cancer-associated antigen 19-9
Inspection of an older patient's mouth reveals the presence of white, curd-like lesions on the patient's tongue. What does the nurse recognize is the most likely etiology for this abnormal assessment finding? Herpesvirus Candida albicans Vitamin deficiency Irritation from ill-fitting dentures
Candida albicans
When evaluating a patient's knowledge regarding a low-sodium, low-fat cardiac diet, the nurse recognizes additional teaching is needed when the patient selects which food? Baked flounder Angel food cake Baked potato with margarine Canned chicken noodle soup
Canned chicken noodle soup
A patient admitted to the emergency department 24 hours ago with complaints of chest pain was diagnosed with a ST-segment-elevation myocardial infarction (STEMI). What complication of myocardial infarction should the nurse anticipate? Unstable angina Cardiac tamponade Sudden cardiac death Cardiac dysrhythmias
Cardiac dysrhythmias
The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed? Decreased cardiac output Increased blood pressure Cerebral or pulmonary emboli Excessive bleeding from incision or IV sites
Cerebral or pulmonary emboli
The nurse is preparing to administer a scheduled dose of docusate sodium when the patient reports an episode of loose stool and does not want to take the medication. What is the appropriate action by the nurse?
Chart the dose as not given on the medical record and explain in the nursing progress notes.
A patient returns after cardiac catheterization. Which nursing care would the registered nurse delegate to the licensed practical nurse? Monitor the electrocardiogram for dysrhythmias Check for bleeding at the catheter insertion site Prepare discharge teaching related to complications Take vital signs and report abnormal values
Check for bleeding at the catheter insertion site
A patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After a comprehensive evaluation, which finding may be a contraindication for liver transplantation?
Chest x-ray showed another lung cancer lesion
A patient with abdominal pain is being prepared for surgery to make an incision into the common bile duct to remove stones. What procedure will the nurse prepare the patient for? Colectomy Cholecystectomy Choledocholithotomy Choledochojejunostomy
Choledocholithotomy
Which assessment findings of the left lower extremity will the nurse identify as consistent with arterial occlusion (select all that apply.)? Edematous Cold and mottled Complaints of paresthesia Pulse not palpable with Doppler Capillary refill less than three seconds Erythema and warmer than right lower extremity
Cold and mottled Complaints of paresthesia Pulse not palpable with Doppler
The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What is the nurse's priority?
Control abdominal pain.
The nurse requests a patient scheduled for colectomy to sign the operative permit as directed in the physician's preoperative orders. The patient states that the physician has not really explained very well what is involved in the surgical procedure. What is the most appropriate action by the nurse?
Delay the patient's signature on the consent and notify the physician about the conversation with the patient.
The nurse should recognize that the liver performs which functions (select all that apply.)? Bile storage Detoxification Protein metabolism Steroid metabolism Red blood cell (RBC) destruction
Detoxification Protein metabolism Steroid metabolism Red blood cell (RBC) destruction
The nurse is providing teaching to a patient recovering from a myocardial infarction. How should resumption of sexual activity be discussed? Delegated to the primary care provider Discussed along with other physical activities Avoided because it is embarrassing to the patient I Accomplished by providing the patient with written material
Discussed along with other physical activities
The nurse is admitting a patient with severe dehydration and frequent watery diarrhea. A 10-day outpatient course of antibiotic therapy for bacterial pneumonia has just been completed. What is the most important for the nurse to take which action?
Don gloves and gown before entering the patient's room
When teaching the patient about the diet for diverticular disease, which foods should the nurse recommend?
Dried beans, All Bran (100%) cereal, and raspberries
After administering a dose of promethazine to a patient with nausea and vomiting, what medication side effect does the nurse explain is common and expected? Tinnitus Drowsiness Reduced hearing Sensation of falling
Drowsiness
The nurse is caring for a patient treated with IV fluid therapy for severe vomiting. As the patient recovers and begins to tolerate oral intake, which food choice would be most appropriate? Iced tea Dry toast Hot coffee Plain yogurt
Dry toast
A patient who had a gastroduodenostomy (Billroth I operation) for stomach cancer reports generalized weakness, sweating, palpitations, and dizziness 15 to 30 minutes after eating. What long-term complication does the nurse suspect is occurring? Malnutrition Bile reflux gastritis Dumping syndrome Postprandial hypoglycemia
Dumping syndrome
When the patient is being examined for venous thromboembolism (VTE) in the calf, what diagnostic test should the nurse expect to teach the patient about first? Duplex ultrasound Contrast venography Magnetic resonance venography Computed tomography venography
Duplex ultrasound
A patient is scheduled for surgery with general anesthesia in 1 hour and is observed with a moist but empty water glass in his hand. Which assessment finding may indicate that the patient drank a glass of water? Easily heard, loud gurgling in abdomen High-pitched, hollow sounds in abdomen Tenderness in left upper quadrant upon palpation Flat abdomen without movement upon inspection
Easily heard, loud gurgling in abdomen
Which of the following formulas is appropriate to administer to a patient who has a dysfunctional gastrointestinal tract?
Elemental (elemental formulas contain predigested nutrients that are easy for a partially functional gastrointestinal tract to absorb.)
The nurse prepares a discharge teaching plan for a 44-yr-old male patient who has recently been diagnosed with coronary artery disease (CAD). Which risk factor should the nurse plan to focus on during the teaching session? Type A personality Elevated serum lipids Family cardiac history Hyperhomocysteinemia
Elevated serum lipids
An older adult patient in a long-term care facility is receiving intermittent enteral feedings in his room. His affect is flat, and the nurse suspects that he is feeling isolated. Which of the following interventions is appropriate for this patient?
Encourage him to go to the dining room at meal times to talk with other patients.
After an exploratory laparotomy, a patient on a clear liquid diet reports severe gas pains and abdominal distention. Which action by the nurse is most appropriate?
Encourage the patient to ambulate as ordered
A patient is seeking emergency care after choking on a piece of steak. The nursing assessment reveals a history of alcoholism, cigarette smoking, and hemoptysis. Which diagnostic study is most likely to be performed on this patient? Barium swallow Endoscopic biopsy Capsule endoscopy Endoscopic ultrasonography
Endoscopic biopsy
The nurse is preparing a patient for a capsule endoscopy. What should the nurse ensure is included in the preparation? Ensure the patient understands the required bowel preparation. Have the patient return to the procedure room for removal of the capsule. Teach the patient to maintain a clear liquid diet throughout the procedure. Explain to the patient that conscious sedation will be used during capsule placement.
Ensure the patient understands the required bowel preparation.
The nurse determines a patient has experienced the beneficial effects of therapy with famotidine when which symptom is relieved? Nausea Belching Epigastric pain Difficulty swallowing
Epigastric pain
Which antilipemic medications should the nurse question for a patient with cirrhosis of the liver (select all that apply.)? Niacin Cholestyramine Ezetimibe (Zetia) Gemfibrozil (Lopid) Atorvastatin (Lipitor)
Ezetimibe (Zetia) Gemfibrozil (Lopid) Atorvastatin (Lipitor)
Which factor should be considered when caring for a woman with suspected coronary artery disease? Fatigue may be the first symptom. Classic signs and symptoms are expected. Increased risk is present before menopause. Women are more likely to develop collateral circulation.
Fatigue may be the first symptom.
A patient after a stroke who primarily uses a wheelchair for mobility has developed diarrhea with fecal incontinence. What is a priority assessment by the nurse?
Fecal impaction
A patient with a family history of adenomatous polyposis had a colonoscopy with removal of multiple polyps. Which signs and symptoms should the nurse teach the patient to report immediately? Fever and abdominal pain Flatulence and liquid stool Loudly audible bowel sounds Sleepiness and abdominal cramps
Fever and abdominal pain
A patient is admitted to the emergency department after a motor vehicle crash with suspected abdominal trauma. What assessment finding by the nurse is of highest priority?
Firmly distended abdomen
A patient had a gastric resection for stomach cancer. The nurse plans to teach the patient about decreased secretion of which hormone? Gastrin Secretin Cholecystokinin Gastric inhibitory peptide
Gastrin
A patient has a sliding hiatal hernia. What nursing intervention will reduce the symptoms of heartburn and dyspepsia? Keeping the patient NPO Putting the bed in the Trendelenburg position Having the patient eat 4 to 6 smaller meals each day Giving various antacids to determine which one works for the patient
Having the patient eat 4 to 6 smaller meals each day
The patient who is admitted with a diagnosis of diverticulitis and a history of irritable bowel disease and gastroesophageal reflux disease (GERD) has received a dose of Mylanta 30 mL PO. The nurse will determine the medication was effective when which symptom has been resolved? Diarrhe Heartburn Constipation Lower abdominal pain
Heartburn
The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would help determine if the patient has developed liver cancer?
Hepatic structure ultrasound
The nurse is caring for a patient admitted with a suspected bowel obstruction. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture?
High-pitched and hyperactive above the area of obstruction
The nurse is assessing a patient admitted with a possible bowel obstruction. Which assessment finding would be expected in this patient? Tympany to abdominal percussion Aortic pulsation visible in epigastric region High-pitched sounds on abdominal auscultation Liver border palpable 1 cm below the right costal margin
High-pitched sounds on abdominal auscultation
A 73-yr-old man with dementia has a venous ulcer related to chronic venous insufficiency. The nurse should provide teaching on which type of diet for this patient and his caregiver? Low-fat diet High-protein diet Calorie-restricted diet High-carbohydrate diet
High-protein diet
The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT) who is scheduled for an emergency appendectomy. Vitamin K is ordered for immediate administration. The international normalized ratio (INR) value is 1.0. Which nursing action is most appropriate? Administer the medication as ordered. Hold the medication and record in the electronic medical record. Hold the medication until the lab result is repeated to verify results. Administer the medication and seek an increased dose from the health care provider.
Hold the medication and record in the electronic medical record.
What information would have the highest priority for the nurse to include in preoperative teaching for a patient scheduled for a colectomy?
How to deep breathe and cough
A patient with hepatitis B surface antigen (HBsAg) present in the serum is being discharged with pain medication after knee surgery. Which medication order should the nurse question?
Hydrocodone with acetaminophen
When using chilled normal saline solution during gastric lavage, the nurse should watch for which of the following complications?
Hypothermia(Iced normal saline can cause a raid loss of electrolytes)>
A patient experienced sudden cardiac death (SCD) and survived. Which preventive treatment should the nurse expect to be implemented? External pacemaker An electrophysiologic study (EPS) Medications to prevent dysrhythmias Implantable cardioverter-defibrillator (ICD)
Implantable cardioverter-defibrillator (ICD)
A 32-yr-old woman is prescribed diltiazem (Cardizem) for Raynaud's phenomenon. To evaluate the effectiveness of the medication, which assessment will the nurse perform? Improved skin turgor Decreased cardiac rate Improved finger perfusion Decreased mean arterial pressure
Improved finger perfusion
When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis?
Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume
A hospitalized patient has just been diagnosed with diarrhea due to Clostridium difficile. Which nursing interventions should be included in the patient's plan of care (select all that apply.)?
Initiate contact isolation precautions. Disinfect the room with 10% bleach solution. Teach any visitors to wear gloves and gowns.
A patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. Which intervention should the nurse include in the patient's plan of care?
Insert an NG and maintain NPO status to allow pancreas to rest.
A nurse is performing a nasogastric intubation. Which of the following actions should the nurse take immediately after inserting the tube to the predetermined length?
Inspect the oropharynx with a penlight and a tongue blade.
A female patient who has type 1 diabetes mellitus has chronic stable angina that is controlled with rest. She states that over the past few months, she has required increasing amounts of insulin. What goal should the nurse use to plan care that should help prevent cardiovascular disease progression? Exercise almost every day. Avoid saturated fat intake. Limit calories to daily limit. Keep Hgb A1C (A1C) less than 7%.
Keep Hgb A1C (A1C) less than 7%.
The nurse is caring for a 55-yr-old man patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect?
L upper abd pain
The nurse is caring for a newly admitted patient with vascular insufficiency. The patient has a new order for enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to correctly administer this medication? Spread the skin before inserting the needle. Leave the air bubble in the prefilled syringe. Use the back of the arm as the preferred site. Sit the patient at a 30-degree angle before administration.
Leave the air bubble in the prefilled syringe.
The patient is having an esophagoenterostomy with anastomosis of a segment of the colon to replace the resected portion. What initial postoperative care should the nurse expect when this patient returns to the nursing unit? Turn, deep breathe, cough, and use spirometer every 4 hours. Maintain an upright position for at least 2 hours after eating. NG will have bloody drainage and it should not be repositioned. Keep in a supine position to prevent movement of the anastomosis.
NG will have bloody drainage and it should not be repositioned.
A patient with a gastric ileus postoperatively requires nutritional support for approximately 2 weeks. Which of the following types of feeding tubes is appropriate for this patient?
Nasointestinal tube (A lack of motility in the stomach (gastric ileus) would prevent the digestion of enteral formula placed in the stomach.)
A 74-yr-old man with a history of prostate cancer and hypertension is admitted to the emergency department with substernal chest pain. Which action will the nurse complete before administering sublingual nitroglycerin? Administer morphine sulfate IV. Auscultate heart and lung sounds. Obtain a 12-lead electrocardiogram (ECG). Assess for coronary artery disease risk factors
Obtain a 12-lead electrocardiogram (ECG).
A 74-yr-old female patient with osteoporosis is diagnosed with gastroesophageal reflux disease (GERD). Which over-the-counter medication to treat GERD should be used with caution? Sucralfate Cimetidine Omeprazole Metoclopramide
Omeprazole
The patient receiving chemotherapy rings the call bell and reports the onset of nausea. The nurse should prepare an as-needed dose of which medication? Zolpidem Ondansetron Dexamethasone Morphine sulfate
Ondansetron
A patient with cirrhosis has increased abdominal girth from ascites. Which items identify the pathophysiology related to ascites (select all that apply.)?
Osmoreceptors in the hypothalamus stimulate thirst Portal hypertension causes leaking of protein and water into the peritoneal cavity. Aldosterone is released to stabilize intravascular volume by saving salt and water. Inability of the liver to synthesize albumin reducing intravascular oncotic pressure.
When planning emergent care for a patient with a suspected myocardial infarction (MI), what should the nurse anticipate administrating? Oxygen, nitroglycerin, aspirin, and morphine Aspirin, nitroprusside, dopamine, and oxygen Oxygen, furosemide (Lasix), nitroglycerin, and meperidine Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin)
Oxygen, nitroglycerin, aspirin, and morphine
Which assessment finding would alert the nurse that a postoperative patient is not receiving the beneficial effects of enoxaparin (Lovenox)? Crackles bilaterally in the lung bases Pain and swelling in a lower extremity Absence of arterial pulse in a lower extremity Abdominal pain with decreased bowel sounds
Pain and swelling in a lower extremity
The nurse is caring for a patient who complains of abdominal pain and hematemesis. Which new assessment finding(s) would indicate the patient is experiencing a decline in condition? Pallor and diaphoresis Ecchymotic peripheral IV site Guaiac-positive diarrhea stools Heart rate 90, respiratory rate 20, BP 110/60
Pallor and diaphoresis
A patient was just diagnosed with acute arterial ischemia in the left leg secondary to atrial fibrillation. Which early clinical manifestation must be reported to the physician immediately to save the patient's limb? Paralysis Paresthesia Cramping Referred pain
Paresthesia
The nurse is examining the electrocardiogram (ECG) of a patient just admitted with a suspected MI. Which ECG change is most indicative of prolonged or complete coronary occlusion? Sinus tachycardia Pathologic Q wave Fibrillatory P waves Prolonged PR interval
Pathologic Q wave
A 67-yr-old man with peripheral artery disease is seen in the primary care clinic. Which symptom reported by the patient would indicate to the nurse that the patient is experiencing intermittent claudication? Patient complains of chest pain with strenuous activity. Patient says muscle leg pain occurs with continued exercise. Patient has numbness and tingling of all his toes and both feet. Patient states the feet become red if he puts them in a dependent position.
Patient says muscle leg pain occurs with continued exercise.
A nurse is caring for a patient who has a nasogastric tube connected to suction. Which of the following should indicate to the nurse that the tube has become occluded?
Patient's report of nausea (Tubes connected to suction decompress the GI tract. This is needed when peristalsis is absent. If gastric secretions are unable to move through the GI tract and if the nasogastric tube is unable to evacuate the stomach due to an occlusion, nausea and vomiting will result.)
A patient reports severe pain when the nurse assesses for rebound tenderness. What may this assessment finding indicate? Hepatic cirrhosis Hypersplenomegaly Gallbladder distention Peritoneal inflammation
Peritoneal inflammation
A nurse is providing teaching to a patient who is receiving intermittent nasogastric feedings. Which of the following should the nurse instruct the patient to report immediately?
Persistent coughing (This could indicate that the distal end of the nasogastric tube has moved into the respiratory tract. Immediate assessment is needed, because the patient might be at risk for aspiration.)
The nurse is preparing to administer a scheduled dose of enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to administer this medication correctly? Remove the air bubble in the prefilled syringe. Aspirate before injection to prevent IV administration. Rub the injection site after administration to enhance absorption. Pinch the skin between the thumb and forefinger before inserting the needle.
Pinch the skin between the thumb and forefinger before inserting the needle.
A 52-yr-old male patient has received a bolus dose and an infusion of alteplase (Activase) for an ST-segment elevation myocardial infarction (STEMI). Which patient assessment would determine the effectiveness of the medication? Presence of chest pain Blood in the urine or stool Tachycardia with hypotension Decreased level of consciousness
Presence of chest pain
The nurse is caring for a preoperative patient who has an order for vitamin K by subcutaneous injection. The nurse should verify that which laboratory study is abnormal before administering the dose? Hematocrit (Hct) Hemoglobin (Hgb) Prothrombin time (PT) Partial thromboplastin time (PTT)
Prothrombin time (PT)
A patient recovering from gastric surgery remains NPO and has a nasogastric tube connected to suction. which of the following actions should the nurse take to prevent dry mucous membranes?
Provide frequent mouth care
A patient with a history of peptic ulcer disease has presented to the emergency department with severe abdominal pain and a rigid, boardlike abdomen. The health care provider suspects a perforated ulcer. Which interventions should the nurse anticipate? Providing IV fluids and inserting a nasogastric (NG) tube Administering oral bicarbonate and testing the patient's gastric pH level Performing a fecal occult blood test and administering IV calcium gluconate Starting parenteral nutrition and placing the patient in a high-Fowler's position
Providing IV fluids and inserting a nasogastric (NG) tube
What medications should the nurse expect to include in the teaching plan to decrease the risk of cardiovascular events and death for PAD patients (select all that apply.)? Ramipril (Altace) Cilostazol (Pletal) Simvastatin (Zocor Clopidogrel (Plavix) Warfarin (Coumadin) Aspirin (acetylsalicylic acid)
Ramipril (Altace) Simvastatin (Zocor) Aspirin (acetylsalicylic acid)
After administration of a dose of metoclopramide, which patient assessment finding would show the medication was effective? Decreased blood pressure Absence of muscle tremors Relief of nausea and vomiting No further episodes of diarrhea
Relief of nausea and vomiting
Assessment of a patient's peripheral IV site reveals that phlebitis has developed over the past several hours. Which intervention should the nurse implement first? Remove the patient's IV catheter. Apply an ice pack to the affected area. Decrease the IV rate to 20 to 30 mL/hr. Administer prophylactic anticoagulants.
Remove the patient's IV catheter.
A patient with an intestinal obstruction has a nasogastric (NG) tube to suction but complains of nausea and abdominal distention. The nurse irrigates the tube as necessary as ordered, but the irrigating fluid does not return. What should be the priority action by the nurse?
Reposition the tube and check for placement.
The patient has chronic venous insufficiency and a venous ulcer. The unlicensed assistive personnel (UAP) decides to apply compression stockings because that is what patients 'always' have ordered. Which assessment finding would indicate the application of compression stockings could harm the patient? Rest pain High blood pressure Elevated blood sugar Dry, itchy, flaky skin
Rest pain
The nurse is performing a focused abdominal assessment of a patient who has been recently admitted. In order to palpate the patient's liver, where should the nurse palpate the patient's abdomen? Left lower quadrant Left upper quadrant Right lower quadrant Right upper quadrant
Right upper quadrant
A patient was admitted with epigastric pain because of a gastric ulcer. Which patient assessment warrants an urgent change in the nursing plan of care? Back pain 3 or 4 hours after eating a meal Chest pain relieved with eating or drinking water Burning epigastric pain 90 minutes after breakfast Rigid abdomen and vomiting following indigestion
Rigid abdomen and vomiting following indigestion
During report, a nurse is informed that a patient has a nasogastric tube connected to continuous suction. The nurse should recognize that this patient must have which of the following types of tube?
Salem sump (A salem sump is the only type of tube that allows for continuous suction. The tube has two lumens; one removes gastric contents and the other serves as an air vent. The vent allows air to enter the stomach, allowing the tube to float freely and preventing damage to the gastric mucosa.)
A patient is suspected of having acute pancreatitis after presenting to the emergency department with severe abdominal pain. Which laboratory result would best indicate the presence of acute pancreatitis? Gastric pH of 1.4 Blood glucose of 104 Serum amylase of 420 U/L Serum potassium of 3.5 mEq/L
Serum amylase of 420 U/L
A 62-yr-old Hispanic male patient with diabetes mellitus has been diagnosed with peripheral artery disease (PAD). The patient is a smoker with a history of gout. To prevent complications, which factor is priority in patient teaching? Gender Smoking Ethnicity Comorbidities
Smoking
The nurse is preparing to administer a daily dose of docusate sodium to a patient that will continue taking it after discharge. What information should the nurse provide to the patient to optimize the outcome of the medication?
Take each dose with a full glass of water or other liquid
The nurse is aware of potential complications related to cirrhosis. Which interventions would be included in a safe plan of care (select all that apply.)?
Teach the patient to use soft-bristle toothbrush and electric razor. Teach the patient to avoid vigorous blowing of nose and coughing. use the smallest gauge needle possible when giving injections or drawing blood. Instruct the patient to avoid aspirin and nonsteroidal antiinflammatory (NSAIDs).
What is a priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI)? Application of topical antibiotics to venous ulcers Maintaining the patient's legs in a dependent position Administration of oral and/or subcutaneous anticoagulants Teaching the patient the correct use of compression stockings
Teaching the patient the correct use of compression stockings
A male patient who has coronary artery disease (CAD) has serum lipid values of low-density lipoprotein (LDL) cholesterol of 98 mg/dL and high-density lipoprotein (HDL) cholesterol of 47 mg/dL. What should the nurse include in patient teaching? Consume a diet low in fats. Reduce total caloric intake. Increase intake of olive oil. The lipid levels are normal.
The lipid levels are normal.
When providing nutritional counseling for patients at risk for coronary artery disease (CAD), which foods would the nurse encourage patients to include in their diet (select all that apply.)? Tofu Walnuts Tuna fish Whole milk Incorrect Orange juice
Tofu Walnuts Tuna fish
A patient complaining of nausea receives a dose of metoclopramide. Which potential adverse effect should the nurse tell the patient to report? Tremors Constipation Double vision Numbness in fingers and toes
Tremors
The patient had aortic aneurysm repair 6 hours ago. What priority nursing action will maintain graft patency? Assess output for renal dysfunction. Use IV fluids to maintain adequate BP. Use oral antihypertensives to maintain cardiac output. Maintain a low BP to prevent pressure on surgical site.
Use IV fluids to maintain adequate BP.
The patient reports tenderness when she touches her leg over a vein. The nurse assesses warmth and a palpable cord in the area. The nurse knows the patient needs treatment to prevent which sequela? Pulmonary embolism Pulmonary hypertension Post-thrombotic syndrome Venous thromboembolism
Venous thromboembolism
The nurse is admitting a 68-yr-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which medication? Vitamin K Cobalamin Heparin sodium Protamine sulfate
Vitamin K
A patient with oral cancer is not eating. A small-bore feeding tube was inserted and the patient started on enteral feedings. Which patient goal would indicate improvement? Weight gain of 1 kg in 1 week Administer tube feeding at 25 mL/hr. Consume 50% of clear liquid tray this shift. Monitor for tube for placement and gastrointestinal residual.
Weight gain of 1 kg in 1 week
A nurse is caring for a patient who has a newly inserted nasogastric tube. Which of the following methods is appropriate for verifying the initial placement?
X-ray examination of the chest and abdomen.
An older adult patient is seen in the primary care provider's office for a well check complains of difficulty swallowing. What common effect of aging should the nurse assess for as a possible cause? Anosmia Xerostomia Hypochlorhydria Salivary gland tumor
Xerostomia
An older adult patient reports difficulty swallowing. Which age-related change does the nurse teach the patient about? Xerostomia Esophageal cancer Decreased taste buds Thinner abdominal wall
Xerostomia
A colectomy is scheduled for a patient with ulcerative colitis. The nurse should plan to include which prescribed measure in the preoperative preparation of this patient?
administration of a cleansing enema
When checking for nasogatric tube placement, the nurse should conduct which of the following procedures?
aspirate stomach contents and check the pH
Which clinical manifestations of inflammatory bowel disease does the nurse determine are common to both patients with ulcerative colitis (UC) and Crohn's disease (select all that apply.)?
bloody, diarrhea stools cramping abd pain
A nurse inserting a nasogastric tube asks the pt to flex her head toward her check after the tube passes through the nasopharynx. The action facilitates proper insertion of the tube by
closing off the glottis
The health care provider orders lactulose for a patient with hepatic encephalopathy. Which finding indicates the medication has been effective?
decreased ammonia levels
The nurse is developing a plan of care for a patient with an abdominal mass and suspected bowel obstruction. Which factor in the patient's history does the nurse recognize as increasing the patient's risk for colorectal cancer?
history of colorectal polyps
When evaluating the patient's understanding about the care of the ileostomy, which statement by the patient indicates the patient needs more teaching
i will be able to regulate when i have stools
Two days after a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result what event?
impaired peristalsis
The nurse assesses the right femoral artery puncture site as soon as the patient arrives after having a stent inserted into a coronary artery. The insertion site is not bleeding or discolored. What should the nurse do next to ensure the femoral artery is intact? Palpate the insertion site for induration. Assess peripheral pulses in the right leg. Inspect the patient's right side and back. Compare the color of the left and right legs.
inspect the patient's right side and back.
Nasogastric tube feedings are an appropriate choice for a patient who
is postoperative following laryngectomy. (immediately following removal of the larynx, patients typically receive IV fluids or parenteral nutrition until the gastrointestinal tract recovers from anesthesia. Then, a nasogastric tube is inserted and left in place for about 7 to 10 days to provide enteral feedings until swallowing is safe and adequate.)
The nurse is preparing to administer a dose of bisacodyl to a patient with constipation and the patient asks how it will work. What is the best response by the nurse?
it will increase peristalsis by stimulating nerves in the colon wall
To prevent a common complication of continuous enteral tube feedings, a nurse should
limit the time the formula hangs to 4 hours
The nurse is administering a cathartic agent to a patient with renal insufficiency. Which order will the nurse question?
magnesium hydroxide
The nurse is conducting discharge teaching for a patient with metastatic lung cancer who was admitted with a bowel impaction. Which instructions would be most helpful to prevent further episodes of constipation?
maintain a high intake of fluid and fiber in the diet
A patient with type 2 diabetes and cirrhosis asks the nurse if it would be acceptable to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge?
milk thistle may affect liver enzymes and thus alter drug metabolism
The nurse should administer an as-needed dose of magnesium hydroxide after noting what information when reviewing a patient's medical record?
no bowel movement for 3 days
The most reliable method for verifying initial placement of a small-bore feeding tube is by
obtaining an abdominal x-ray
A 54-yr-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. Which diagnosis does the nurse expect?
pancreatitis
To prevent aspiration during the administration of an enteral tube feeding, a nurse should
place the patient in Fowler's position (or elevate the bed at 30 degrees)
The wound, ostomy, and continence nurse (WOCN) selects the site where the ostomy will be placed. What should be included in site consideration?
the patient must be able to see the site
When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements (select all that apply.)?
vitamin A vitamin D vitamin E vitamin K
To determine how much of the length of a nasoenteric tube to insert, a nurse should measure the distance from the tip of the patient's nose to the earlobe and from the earlobe to the
xiphoid process plus 20-30 cm more. (Measure from the tip of the nose to the earlobe to the xiphoid process approximates the distance from the nose to the stomach for 98% of patients. For duodenal or jejunal placement, an additional 20-30 cm is required.)