Adult Health Exam 2

A nurse is caring for a client who received a lower back injury during a fall and describes sharp pain in the back and down the left leg. In which of the following positions should the nurse plan to place the client to attempt to decrease the pain? a. prone without use of pillows b. semi-fowler's with a pillow under the knees c. high-fowler's with the knees flat on the bed d. supine with the head flat

B

A nurse is providing care for a client who had a vertebroplasty of the thoracic spine. Which of the following actions should the nurse take? a. apply heat to the puncture site b. place the client in a supine position c. turn the client every hour d. ambulate the client within the first hour post-procedure

B

A nurse is providing dietary teaching about calcium-rich foods to a client who has osteoporosis. Which of the following foods should the nurse include in the instructions? a. white bread b. kale c. apples d. brown rice

B

A nurse is providing information about capsaicin cream to a client who reports continuous knee pain from osteoarthritis. Which of the following information should the nurse include in the discussion? a. continuous pain relief is provided b. put on gloves before applying the cream to other parts of the body c. leave cream on the hands for 10 min following application d. apply the medication every 2 hr during the day

B

A nurse is admitting an adult client who has suspected osteoporosis. Which of the following findings are risk factors for osteoporosis? (select all that apply) a. history of consuming one glass of wine daily b. loss in height of 2 in (5.1 cm) c. body mass index of 18 d. kyphotic curve at upper thoracic spine e. history of lactose intolerance

B, C, D, E

A nurse is assessing a client's laboratory values before surgery. Which of the following results should the nurse report to the provider? (select all that apply) a. potassium 3.9 mEq/L b. sodium 145 mEq/L c. creatinine 2.8 mg/dL d. blood glucose 235 mg/dL e. WBC 17,850 mm3

C, D, E

A nurse is verifying informed consent for a client who is having a paracentesis. Which of the following actions should the nurse take? (select all that apply) a. explain to the client the purpose of having the procedure b. inform the client of risks to having the procedure c. ensure the client understands information about the procedure d. witness the client signing the informed consent form e. determine if the client is capable of understanding the reason for the procedure

C, D, E

A nurse is caring for a client who arrive in the PACU following a total hip arthroplasty. The client is not responding to verbal stimuli. Which of the following actions should the nurse perform first? a. compare and contrast the peripheral pulses b. apply a warm blanket c. assess dressings d. place the client in a lateral position

D

A preoperative nurse is caring for a client who is having a colon resection. Which of the following actions should the nurse take? a. encourage the client to void after preoperative medication administration b. administer antibiotics 2 hr prior to surgical incision c. remove hair using a manual razor d. remove nail polish on fingers and toes

D

malignant hyperthermia

______________ ______________ is a rare disorder characterized by hyperthermia with rigidity of skeletal muscles that can result in death. It occurs in affected people exposed to certain anesthetic agents.

what should be done first in postop?

assessment (ABCs always first)

patho osteoporosis:

bone is breaking down faster than it can rebuild itself

patho osteoarthritis:

breakdown of the synovial joints

hypovolemic

decrease in urine output (urinary retention) could mean patient is _________________ .

DVT

no scds on affected extremity (will release clot)

30

patient must wait ______ minutes after receiving IV pain meds before going home postop.

slow

when a patient has heart failure, ________ down the rate of IV fluids.

DVT/PE

with _____________ patient's being treated with anticoagulation therapy, avoid normal razors for shaving to prevent blood loss - use electric razor.

neuromuscular checks

- arterial, venous intervention 1. cap refill 2. pedal pulse 3. movement 4. sensation 5. color & temp (if abnormal always call provider second)

PCA pumps

- complication of respiratory depression - ONLY patient can press the button

ensuring rest at night

- pain management - dim lights - quiet entrance - privacy - ask family to leave - cluster cares / group the cares

4 parts of what the nurse does in the OR:

- time out - aseptic technique - positioning and padding the patient appropriately - geriatric patient positioning (arthritis, osteoarthritis, stenosis)

important things to know for preop (7):

1. consent * alert / orientated * understand plan of care * be their own person (child under the age of 18 is not their own person) 2. NPO 3. labs 4. code status 5. allergies 6. baseline vitals 7. pregnancy test !!

A nurse is caring for a client who is scheduled for an exploratory laparotomy. The client's temperature is 39 C (102.2 F) orally. Which of the following actions should the nurse take? a. inform the surgeon of the elevated temperature b. transfer the client to the preoperative unit c. apply ice packs to the groin d. encourage the client to increase intake of clear liquids

A

A nurse is caring for a client who reports nausea and vomiting 2 days postoperative following hysterectomy. Which of the following actions should the nurse perform first? a. assess bowel sounds b. administer antiemetic medication c. restart prescribed IV fluids d. insert a prescribed nasogastric tube

A

A nurse is caring for a client who manifests indications of hypovolemia whole in the PACU. Which of the following findings requires action by the nurse? (select all that apply) a. urine output less than 25 mL/hr b. hematocrit 53% c. BUN 24 mg/dL d. tenting of skin over the sternum e. apical pulse rate 62/min

A, B, C, D

A nurse is reviewing the medical records of several clients in the postanesthesia care unit (PACU) to identify risk factors that can lead to postoperative complications. Which of the following clients are at risk for complications? (select all that apply) a. a client who has a WBC of 22,500 b. a client who uses an insulin pump c. a client who takes warfarin daily d. a client who has heart failure e. a client who has a BMI of 26

A, B, C, D

A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care? (select all that apply) a. encourage use of the incentive spirometer every 2 hr b. instruct the client to splint the incision when coughing and deep breathing c. reposition the client every 2 hr d. administer antibiotic therapy e. assist with early ambulation

A, B, C, E

A nurse is planning discharge teaching on home safety for an adult client who has osteoporosis. Which of the following information should the nurse include in the teaching? (select all that apply) a. remove throw rugs in walkways b. use prescribed assistive devices c. remove clutter from the environment d. wear soft-bottomed shoes e. maintain lighting of doorway areas

A, B, C, E

A nurse is providing preoperative teaching to a client who is to have abdominal surgery. Which of the following statements should the nurse make? (select all that apply) a. "Take your heart medication with a sip of water before surgery" b. "Splint the abdominal incision with a pillow when coughing and deep breathing" c. "Bed rest is recommended for the first 48 hours" d. "Anti-embolism stockings are applied before surgery" e. "You can eat solid foods up to 4 hours before surgery"

A, B, D

A nurse is performing health screenings at a health fair. Which of the following clients have a risk factor for osteoporosis? (select all that apply) a. a 40 year-old client who has been taking prednisone for 4 months b. a 30 year-old client who jogs 3 miles daily c. a 45 year-old client who takes phenytoin for seizures d. a 65 year-old client who has a sedentary lifestyle e. a 70 year-old client who has smoked for 50 years

A, C, D, E

A nurse is providing information to a client who has osteoarthritis of the hip and knee. Which of the following information should the nurse include in the information? (select all that apply) a. apply heat to joints to alleviate pain b. ice inflamed joints for 30 min following activity c. reduce the amount of exercise done on days with increased pain d. prop the knees with a pillow while in bed e. active range of motion is more effective than passive

A, C, E

A nurse is assessing a client who has osteoarthritis of the knees and fingers. Which of the following manifestations should the nurse expect to find? (select all that apply) a. Heberden's nodes b. swelling of all joints c. small body frame d. enlarged joint size e. limp when walking

A, D, E

A nurse is providing teaching for a client who has a history of low back injury. Which of the following instructions should the nurse give the client to prevent future problems with low back pain? a. engage in regular exercise including walking b. sit for up to 10 hr each day to rest the back c. maintain weight within 25% of ideal body weight d. create a smoking cessation plan e. wear low-heeled shoes

A, D, E