Therapeutics Test 2

A nurse is administering an enema medicated with sodium polystrene sulfonate (Kayexalate) to an older adult patient who has hyperkalemia. The nurse should insert the tip of the rectal tube

7.5 cm to 10 cm (3-4 in)

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 Kock's pouch

A nurse is receiving evening shift report on four clients who returned from the PACU this morning. The nurse should assess which of the following clients first?

A client who is postoperative following a thoractomy and has a chest tube with 150mL of bright-red blood in the collection chamber from the last hour.

A nurse is providing teaching to a client who is scheduled to undergo moderate sedation for a bronchoscopy. The nurse should verify that the client understands the procedure. Which of the following actions should the nurse take if the client develops manifestations of malignant hyperthermia?

Administer dantrolene

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following nursing interventions should the nurse perform to prevent respiratory complications

Advise the client to splint the surgical incision when coughing and deep breathing

A nurse is providing preoperative teaching for a patient who has colon cancer. The surgeon informed the patient that his entire large intestine and rectum will be removed. The nurse should explain the type of ostomy he will have is

An ileostomy

A nurse is caring for a client who is preoperative and is asking multiple questions about risk of the procedure. Which of the following actions should the nurse take.

Ask the surgeon to speak to the client for clarification.

A nurse is preparing to administer an oil-retention enema to a patient who has constipation. The nurse explains that the patient should try to retain the oil for

At least 30 minutes, but preferably as long as he can.

A nurse is planning care for a client who is postoperative and has a closed-wound drainage system in place. Which of the following interventions should the nurse plan to include?

Cleanse the drain plug with alcohol after emptying

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?

Cleanse the stoma and the peristomal skin

A nurse is reviewing the medication administration record for a client who is scheduled for surgery the next day. The nurse should identify that which of the following medications places the client at risk for complications during surgery and should be reported to the provider?

Clopidogrel

A nurse inserting a nasogastric tube asks the patient to flex her head toward her chest after the tube passes through the nasopharynx. This action facilitates proper insertion of the tube by

Closing off the glottis

A nurse is caring for a patient who has a tracheostomy tube in place. During tracheostomy care, which of the following should the nurse place underneath the flanges of the outer cannula?

Commercially prepared fenestrated dressing A commercially prepared tracheostomy dressing is made of material that doesn't unravel and has a fenestration (slit) designed to fit around the tracheostomy tube under the flanges

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 nor bowel obstruction. He reports that his concerns about leakage have limited his social activities. Which of the following should the nurse recommend?

Consume foods that are low in fiber content

A nurse is providing teaching for a client who is in the immediate postoperative period and has a PCA pump. Which of the following statements should the nurse include in the teaching?

Do not allow your family to push the PCA button while you are sleeping

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

A nurse is assessing a client who is 2 days postoperative following a total prostatectomy. The nurse notes that the client's right calf is red, edematous, and warm to the touch. Which of the following actions should the nurse take?

Elevate the clients right extremity

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

Empty the pouch when it is no more than half full

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 to other patients.

A nurse is caring for a client who has bradycardia following a surgical procedure using spinal anesthesia. The nurse should plan to administer which of the following medications to the client

Epinephrine

A nurse is caring for a client who is receiving moderate sedation with midazolam. The clients respiratory rate decreases from 16/min to 6/min, and the oxygen saturation decreases from 92% to 85%. Which of the following medications should the nurse administer?`

Flumazenil

A nurse is caring for a patient who has a tracheostomy tube with an inner cannula in place. Which of the following supplies should the nurse use to dry the inner cannula of the tube after cleaning it?

Folded pipe cleaners Pipe cleaners remain intact without leaving any particulate matter the patient could aspirate

A nurse is caring for a client who s 12 hours post operative from a gastrectomy and has an NG tube set to continuous low suction. Which of the following findings requires intervention by the nurse?

Gastric distention

A nurse is preparing to perform endotracheal (ET) tube care and plans to use tape to secure the tube. Which of the following is an appropriate preparatory action for this procedure?

Have tincture of benzoin ready to apply to the patients face Tincture of benzoin or a liquid adhesive not only protects the patients skin, but it also prepares the skin around the nose or mouth and on the face for better adherence of the tape

A nurse is providing preoperative teaching to a client who is scheduled to have a mastectomy with reconstructive surgery. Which of the following statement by the client indicates an understanding of the teaching

I will be able to shower after the doctor removes the drain

A nurse is providing discharge instructions for a client who is postoperative following abdominal surgery. Which of the following client statements indicates an understanding of the teaching?

I will eat foods that are high in protein and vitamin C during my recovery

A circulating nurse is monitoring the temperature in a surgical suite. The nurse should identify that cool temperatures reduce a clients risk for which of the following potential complications of surgery?

Infection

A nurse is caring for a client who is 2 days postoperative following a cholecystectomy. The client has been vomiting for the past 24 hours and reports a pain level of 8 on a scale from 0 to 10. The nurse notes a hard, distended abdomen and absent bowel sounds. After conferring with the provider, which of the following actions should the nurse take first?

Insert an NG tube

Nasogastric tube feedings are an appropriate choice for a patient who

Is postoperative following a laryngectomy

A nurse is preparing an older patient for an enema. The nurse should assist the patient to which of the following positions?

Left lateral with the right leg flexed

To prevent a common complication of continuous enteral tube feedings, a nurse should

Limit the time the formula hangs to 4 hours

A nurse is assessing a client who is preoperative. The nurse should identify that which of the following factors reported by the client increases the risk for a postoperative wound infection?

Long-term use of corticosteroids

A nurse who is administering a return-flow enema to a patient shoudl instill 100 mL of enema fluid and then

Lower the container to allow the solution to flow back out

While the nurse is administering a cleansing enema, the patient reports abdominal cramping. Which of the following is the appropriate intervention?

Lower the enema fluid container

A patient with a gastric ileus postoperatively requires nutritional support for approxmately 2 weeks. Which of the following types of feeding tubes is appropriate for this patient?

Nasointestinal tube

A client had an open transverse colectomy 5 days ago. The nurse enters the clients room and recognizes that the wound has eviscerated. After covering the wound with a sterile, saline-soaked dressing, which of the following actions would the nurse take?

Obtain vital signs to assess for shock

The most reliable method for verifying initial placement of a small-bore feeding tube is by

Obtaining abdominal xray

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

To prevent aspiration during the administration of an enteral tube feeding, a nurse should

Place the patient in Fowler's position

A nurse is preparing to adminsiter a cleansing enema to a patient who is prone to fetal incontinence due to poor sphincter control and is unlikely to retain the enema solution. Which of the following interventions is appropriate for this patient?

Place the patient in a dorsal recumbent position on a bedpan

A nurse in the PACU is assessing a client who is postoperative. Which of the following findings should the nurse report to the provider?

Presence of inspiratory stridor

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?

Press gently around the barrier for 1-2 minutes

A nurse is providing preoperative teaching to a client who is scheduled for a gastrectomy in 1 week. The client is anxious about the upcoming surgery. Which of the following actions should the nurse take?

Provide concise, factual information

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

Push the skin away from the barrier while removing it

A nurse is caring for a patient who has a cuffed endotracheal (ET) tube in place. Which of the following is an appropriate component of ET tube care for this patient?

Repositioning the ET tube in the patient's mouth every 12 hours Moving the ET tube to the other side of the patient's mouth every 12 hours helps to prevent irritation of the oral mucous membranes

A patient who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should anticipate receiving an order from the provider for which of the following types of enemas?

Return-flow

A nurse is suctioning a patient's airway using in-line suctioning. When using this method, it is appropriate for the nurse to

Reuse the catheter repeatedly With in line suctioning, the catheter attaches to the ventilator tubing and does not have to be replaced until the system is replaced. It can be used repeatedly.

A nurse is reviewing the medical record of a client who is to undergo eneral anesthesia for surgery. The nurse should report which of the following findings to the provider?

Serun potassium 2.8 mEq/L

A nurse is providing preoperative teaching for an older adult patient who has diverticulitis and is scheduled for a creation of a double-barrel colostomy in the sigmoid colon. Which of the following instructions should the nurse include in the teaching?

Tape a dry gauze pad over the distal stoma to collect drainage

A surgical nurse enters a surgical suite to ensure surgical asepsis is maintained. Which of the following findings requires intervention by the nurse?

The scrub technologist is wearing a watch under his scrubs

A nurse is assessing a client's recovery from spinal anesthesia. Which of the following sensations should the nurse expect to return to the client first?

Touch

A nurse is caring for a patient who sustained trauma to his head and neck and will require long-term airway support. Which of the following devices will be required for home health care for this patient?

Tracheostomy tube

A nurse is providing discharge teaching for a client who is postoperative following a rhinoplasty using general anesthesia. Which of the following instructions should the nurse include?

Une cool compresses on your eyes, nose, and face.

A nurse is assessing a client who is 2 hr postoperative following an appendectomy. Which of the following findings should the nurse report to the provider

Urine output of 20 mL/hr

A client is transferred from the surgical suite to the PACU following oral surgery. While monitoring the client's vital signs, the nurse finds that the clients tongue has become swollen and is obstructing the airway. Which of the following actions should the nurse take first

Use the head-tilt, chin-lift method to open the airway

A nurse is caring for a client who has a surgical wound with a Penrose drain in place. Which of the following interventions should the nurse plan to perform

Use the sterile technique when performing dressing changes

A nurse is performing chest physiotherapy for a patient who needs help mobilizing and expectorating thick pulmonary secretions. To increase the turbulence of the air as the patient exhales, the nurse should use which of the following techniques?

Vibration

A nurse is reviewing the medical record of a client who is scheduled for an elective surgery. Which of the following medications should the nurse expect the provider to discontinue prior to surgery to minimize the risk of complications?

Warfarin

A nurse is preparing to administer the first two large-volume, cleansing enemas prescribed for a patient in preparation for a diagnostic procedure. Which of the following is an appropriate step in the procedure?

Warm the enema solution prior to instillation

To determine how much of the length of a nasoenteric tube to insert, a nurse should measure the distance from the tip of the patients nose to the earlobe and from the earlobe to the

Xiphoid process plus 20-30 cm more

A nurse is preparing to suction secretions from the mouth of a patient who has dysphagia. Which of the following is the appropriate suction device or method for the nurse to use?

Yankauer catheter A yakauer (tonsil tip) suction catheter helps clear secretions from the mouth. This is the appropriate device for patients who can cough effectively but cannot swallow or expectorate secretions

A nurse is providing preoperative teaching for a client who is about to have a below-the-knee amputation. Which of the following instructions should the nurse include?

Your surgeon may prescribe an antibiotic before surgery