PrepU Questions: Final Review NURS 111

To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction?

"Avoid coffee and alcoholic beverages." To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client need not limit fluid intake with meals as long as the fluids aren't gastric irritants.

Health teaching for a patient with GERD is directed toward decreasing lower esophageal sphincter pressure and irritation. The nurse instructs the patient to do which of the following? Select all that apply.

Avoid beer, especially in the evening. Elevate the head of the bed on 6- to 8-inch blocks. Elevate the upper body on pillows. Milk should be avoided, as should eating before bed. Advise the patient not to eat or drink 2 hours before bedtime.

Which of the following is the most common complication associated with peptic ulcer?

Hemorrhage Hemorrhage, the most common complication, occurs in 28% to 59% of patients with peptic ulcers. Vomiting, elevated temperature, and abdominal pain are not the most common complications of a peptic ulcer.

The nurse is conducting a community education program on peptic ulcer disease prevention. The nurse includes that the most common cause of peptic ulcers is:

gram-negative bacteria. The nurse should include that the most common cause of peptic ulcers is gram-negative bacteria (Helicobacter pylori).

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect:

left calf circumference 1" (2.5 cm) larger than the right. Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased pulse, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT.

Which term refers to the symptom of gastroesophageal reflux disease (GERD), which is characterized by a burning sensation in the esophagus?

Pyrosis Pyrosis refers to a burning sensation in the esophagus and indicates GERD. Indigestion is termed dyspepsia. Difficulty swallowing is termed dysphagia. Pain on swallowing is termed odynophagia.

A client admitted to the medical-surgical unit with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The client asks the nurse why two medications are needed. Which response by the nurse is accurate?

"The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect." Oral anticoagulants such as warfarin are monitored by the prothrombin time (PT) or the international normalized ratio (INR). Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0).

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?

A client with a nasogastric tube Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.

The nurse is assessing a patient with suspected acute venous insufficiency. What clinical manifestations would indicate this condition to the nurse? (Select all that apply.)

Cool and cyanotic skin Sharp pain that may be relieved by the elevation of the extremity Full superficial veins Postthrombotic syndrome is characterized by chronic venous stasis, resulting in edema, altered pigmentation, pain, and stasis dermatitis. The patient may notice the symptoms less in the morning and more in the evening. Obstruction or poor calf muscle pumping in addition to valvular reflux must be present for the development of severe postthrombotic syndrome and stasis ulcers. Superficial veins may be dilated.

A nurse who provides care in a busy postsurgical unit recognizes that patients are at particular risk of thromboembolism during their immediate postoperative recovery. Which of the following interventions best facilitates venous blood flow and the prevention of thrombosis?

Early ambulation Early ambulation is most effective in preventing venous stasis. Stockings and compression devices are clinically useful interventions for patients who are unable to ambulate, but early mobilization is preferred. Warfarin is not used for the general prevention of DVT in postsurgical patients.

The nurse is caring for a client who has just returned from the PACU after surgery for peptic ulcer disease. For what potential complications does the nurse know to monitor? Select all that apply.

Hemorrhage Perforation Penetration Pyloric obstruction Potential complications may include hemorrhage, perforation, penetration, and pyloric obstruction. A client who has had surgery for peptic ulcer disease may have a decreased appetite in the immediate postoperative stage, but it is not something the nurse would monitor for and would not cause cachexia. Inability to clear secretions is generally not a complication of peptic ulcer surgery.

While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first?

Prepare to administer protamine sulfate. Frank hematuria indicates excessive anticoagulation and bleeding — and heparin overdose. The nurse should discontinue the heparin infusion immediately and prepare to administer protamine sulfate, the antidote for heparin. Decreasing the heparin infusion rate wouldn't prevent further bleeding. Although the nurse should continue to monitor PTT, this action should occur later. An I.V. infusion of D5W may be administered, but only after protamine has been given.

A nurse is monitoring a client with peptic ulcer disease. Which assessment findings would most likely indicate perforation of the ulcer? Select all that apply.

Tachycardia Hypotension A rigid, board-like abdomen Signs and symptoms of perforation include sudden, severe upper abdominal pain (persisting and increasing in intensity); pain, which may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm; vomiting; collapse (fainting); extremely tender and rigid (board-like) abdomen; and hypotension and tachycardia, indicating shock. Perforation is a surgical emergency.

After assessing a client with peptic ulcer disease, the nurse notifies the health care provider because the nurse suspects that the client may be experiencing perforation. Which assessment finding would support the nurse's suspicion? Select all that apply.

severe upper abdominal pain vomiting board-like abdomen Signs and symptoms of perforation include sudden, severe upper abdominal pain (persisting and increasing in intensity); pain that may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm; vomiting; collapse (fainting); extremely tender and rigid (board-like) abdomen; and hypotension and tachycardia, which indicate shock.

The nurse is developing a plan of care for a patient with peptic ulcer disease. What nursing interventions should be included in the care plan? Select all that apply.

Frequently monitoring hemoglobin and hematocrit levels Observing stools and vomitus for color, consistency, and volume Checking the blood pressure and pulse rate every 15 to 20 minutes The nurse assesses the patient for faintness or dizziness and nausea, which may precede or accompany bleeding. The nurse must monitor vital signs frequently and evaluate the patient for tachycardia, hypotension, and tachypnea. Other nursing interventions include monitoring the hemoglobin and hematocrit, testing the stool for gross or occult blood, and recording hourly urinary output to detect anuria or oliguria (absence of or decreased urine production).

A patient describes a burning sensation in the esophagus, pain when swallowing, and frequent indigestion. What does the nurse suspect that these clinical manifestations indicate?

Gastroesophageal reflux disease Symptoms may include pyrosis (burning sensation in the esophagus), dyspepsia (indigestion), regurgitation, dysphagia or odynophagia (pain on swallowing), hypersalivation, and esophagitis.

A nurse understands that the target international normalized ratio (INR) for a patient taking Coumadin will depend on the patient's condition. A normal INR is 1.0. However, this value is increased depending on the medical condition. Select the condition that would warrant achieving an INR target value of 3.0 with anticoagulation.

Prevention of recurrent deep vein thrombosis An INR goal of 2.5 can be used for deep vein thrombosis. However, when the occurrence happens more often, the value needs to increase to 3.0.

The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment?

Tachypnea Symptoms of PE depend on the size of the thrombus and the area of the pulmonary artery occluded by the thrombus; they may be nonspecific. Dyspnea is the most frequent symptom; the duration and intensity of the dyspnea depend on the extent of embolization. Chest pain is common and is usually sudden and pleuritic in origin. It may be substernal and may mimic angina pectoris or a myocardial infarction. Other symptoms include anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope. The most frequent sign is tachypnea (very rapid respiratory rate).

Influenza, an annual epidemic in the U.S., creates a significant increase in hospitalizations and an rise in the death rates from pneumonia and cardiovascular disease. Besides death, what is the most serious complication of influenza?

staphylococcal pneumonia Complications include tracheobronchitis, bacterial pneumonia, and cardiovascular disease, however staphylococcal pneumonia is the most serious complication.

A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. What would be the first activity performed by the nurse?

Assess lung sounds bilaterally. All these activities are things the nurse may do for a client with a foreign body in the esophagus. This client is at risk for esophageal perforation, and thus pneumothorax. By auscultating lung sounds the nurse will be able to assess if a pneumothorax is present. The client has little saliva in the oral cavity and does not need to be suctioned. A client may also report pain with a foreign body. However, ABCs (airway, breathing, circulation) take priority. The consent for the esophagogastroscopy may be obtained after the nurse has completed the client assessment.

The nurse is educating a patient with chronic venous insufficiency about prevention of complications related to the disorder. What should the nurse include in the information given to the patient? (Select all that apply.)

Avoid constricting garments. Elevate the legs above the heart level for 30 minutes every 2 hours. Sleep with the foot of the bed elevated about 6 inches. Elevating the legs decreases edema, promotes venous return, and provides symptomatic relief. The legs should be elevated frequently throughout the day (at least 15 to 20 minutes four times daily). At night, the patient should sleep with the foot of the bed elevated about 15 cm (6 inches). Prolonged sitting or standing in one position is detrimental; walking should be encouraged. When sitting, the patient should avoid placing pressure on the popliteal spaces, as occurs when crossing the legs or sitting with the legs dangling over the side of the bed. Constricting garments, especially socks that are too tight at the top or that leave marks on the skin, should be avoided.

The nurse is planning the care for a client at risk of developing pulmonary embolism. What nursing interventions should be included in the care plan? Select all that apply.

Encouraging a liberal fluid intake Instructing the client to move the legs in a "pumping" exercise Using elastic stockings, especially when decreased mobility would promote venous stasis Applying a sequential compression device The use of anti-embolism stockings or intermittent pneumatic leg compression devices reduces venous stasis. These measures compress the superficial veins and increase the velocity of blood in the deep veins by redirecting the blood through the deep veins. Having the client move the legs in a "pumping" exercise helps increase venous flow. Legs should not be dangled or feet placed in a dependent position while the client sits on the edge of the bed; instead, feet should rest on the floor or on a chair.

A patient with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett's esophagus and has been admitted to a medical unit. The nurse is writing a care plan for this patient. What information is essential to include?

He will need to undergo an upper endoscopy every 6 months to detect malignant changes. In the patient with Barrett's esophagus, the cells lining the lower esophagus have undergone change and are no longer squamous cells. The altered cells are considered precancerous and are a precursor to esophageal cancer. To facilitate early detection of malignant cells, upper endoscopies may be performed every 6 to 12 months. H2 receptor antagonists are commonly prescribed for patients with GERD; however, monitoring of liver enzymes is not routine. Stools that contain evidence of frank bleeding or which are tarry are not expected and should be reported immediately. When antacids are prescribed for patients with GERD, they should be taken as ordered whether or not the patient is symptomatic.

A critical care nurse is closely monitoring a patient who has recently undergone surgical repair of a bleeding peptic ulcer. The nurse should prioritize assessments of which of the following signs and symptoms of a recurrence of hemorrhage?

Hypotension and tachycardia Rebleeding has multiple manifestations. However, an increase in heart rate and decrease in blood pressure are key signs of a hemorrhage that are present in nearly all patients who are experiencing rebleeding.

The client with a lower respiratory airway infection is presenting with the following symptoms: fever, chills, dry hacking cough, and wheezing. Which nursing diagnosis best supports the assessment by the nurse?

Ineffective Airway Clearance The symptom of wheezing indicates a narrowing or partial obstruction of the airway from inflammation or secretions. Risk for Infection is a real potential because the client is already exhibiting symptoms of infection (fever with chills). Impaired Gas Exchange may occur, but no symptom listed supports poor exchange of gases. No documentation of respiratory rate or abnormalities is listed to justify this nursing diagnosis.

A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be:

Ineffective airway clearance. Ineffective airway clearance is the priority nursing diagnosis for this client. Pneumonia involves excess secretions in the respiratory tract and inhibits air flow to the capillary bed. A client with pneumonia may not have an Ineffective breathing pattern, such as tachypnea, bradypnea, or Cheyne-Stokes respirations. Risk for falls and Impaired tissue integrity aren't priority diagnoses for this client.

Rebleeding may occur from a peptic ulcer and often warrants surgical interventions. Signs of bleeding include which of the following?

Mental confusion Signs of bleeding include tachycardia, tachypnea, hypotension, mental confusion, thirst, and oliguria.

A client receives tube feedings after an oral surgery. The nurse manages tube feedings to minimize the risk of aspiration. Which measure should the nurse include in the care plan to reduce the risk of aspiration?

Use semi-Fowler position during, and 60 minutes after, an intermittent feeding. To minimize the risk of aspiration, it is important to place the client in a semi-Fowler position during, and 60 minutes after, an intermittent feeding because proper positioning prevents regurgitation. Checking tube placement and gastric residual prior to feedings is another important measure because it prevents improper infusion and vomiting. If aspiration is suspected, feeding should be stopped as cessation prevents further problems and allows for treatment of the immediate problem. Changing tube feeding container and tubing, monitoring weight daily, and administering 15 to 30 mL of water before and after medications and feedings are measures to maintain tube function.