advanced nursing final Keiser University

most common sign of colorectal cancer

#1 change of bowel habits #2 blood in stool

A client with a Q information of diverticulitis should maintain a what diet?

A diet very low in fiber the client can consume low fiber foods like white bread low fat milk yogurt with active cultures poached eggs canned soft fruit

Lactulose is what?

A laxative that decreases ammonia levels

Sigmoid: resection with colonostomy

After surgery the client quickly return to a regular diet and there are no food restrictions.

A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect?

Anorexia is a early manifestation of hepatitis A and is often severe.

Chronic pancreatitis or pancreatic cancer you should expect to find what?

Ascites-Abdominal swelling caused by accumulation of fluid, most often related to liver disease.

A nurse is assessing a client with meningitis possibly flexing neck and bringing legs up what sign is this?

Bruzinski's sign

The number one post operative with a client who had a CHOLECYSTECTOMY

COUGHING AND DEEP BREATHING EXERCSES TO PROMOTE LUNG EXPANSION

A patient with diverticulitis needs to be on a low fiber diet what food item should the nurse remove the patients meal tray

Call Saul contains raw cabbage which is high in fiber clients who are following a low fiber diet should avoid most raw vegetables.

Esophageal cancer early prevention?

Early treatment of gastric reflux disease

Interventions for intercranial pressure.

Elevate the head of the bed 20°

Respiratory alkalosis

Elevated pH and decrease PAC02

Hyper glycemia patient will exhibit what?

Excessive thirst

A client being discharged after ineffective endocarditis discharge teaching

Finish antibiotics until complete.

Boiled hamburger is an appropriate low fiber food for a client who is following a low fiber diet.

Fish and poultry are low fiber options.

To prevent an acute diverticulitis attack what foods to the nurse recommend

Foods high in fiber. The pressure leading to a stranger in bowel movements causing the development of diverticula high-fiber foods help strengthen and maintain active mobility IN GI TRACT

A client with a diagnosis of colon cancer is two days post op following a reception and Anastomosis. The nurse plans what should the nurse prioritize?

Frequent abdominal auscultation

Management of happy includes?

Frequent rest periods throughout the day.

What laboratory test would you use to determine the possibility of recent excessive alcohol use?

GGT gamma glutamyl transfers

Pain above umbilicus when assessing the client the nurse notices sister Mary St. Joseph's Najwa what health problems does this patient present with?

Gastro intestinal malignancy

Prevention of have a transmission is?

Good hand hygiene.

Complete intestinal obstruction what should the nurse expect?

Hyper active bowel sounds around the obstruction

End stage liver failure what to expect?

Increase pro thrombin time related to the in adequate supply of clotting factors in an increased or prolong thrombin time

A community health nurse is preparing an initial visit to a client that is being discharged following a total Gastroectomy from gastric cancer . what should they anticipate the plan of care to include?

Injections of B 12

Undergoing testing of a tumor of ace the small intestines what symptoms promoted the client to seek medical attention?

Intermittent pain and bloody stools

A client who is MPL and has a nasal drip gastric tube to suction. When the client reports nausea which of the following actions should the nurse take?

Irrigate the tube with normal saline

A patient with dumping syndrome should

It's small and frequent meals and do not have liquids at meal times.

Late manifestations of hepatitis A

Jaundice dark urine pale feces

The nurse should expect to find a positive KEHRS sign in a client who has what type of trauma?

Liver trauma

Postulation of pleurisy is what type of breath sound?

Loud scratching sound rubbing

Canned fruit is an appropriate diet choice for which of the following diets

Low fiber

Dumping syndrome following a gastric bypass surgery four days ago which of the following recommendations should the nurse include in the teaching

Maintain a supine position after meals to slow the rapid emptying of food into the small intestine.

A nurse in a community health clinic is caring for a client with a headache and stiff neck what should she evaluate?

Neurological status

What are the following is a late sign of ICP

Nonreactive dilated pupils

Cirrhosis

Obtain the clients PT and INR measurements admin lactose 30 mL four times a day and abdominal girth measurements daily multivitamin

What medication would you administer for intercranial pressure?

Osmotic diuretics such as mannitol to reduce the edema of the brain

The nurse should expect a phone Gastro intestinal bleeding in a client who has what type of cancer?

Pancreatic cancer

A nurse is caring for a client in late stage esophageal cancer what assessments are characterics of this disease?

Perforation of the mediastinum erosion great vessels obstruction obstruction of esophagus

Play Pasa with a peg tube is receiving intermittent feedings. Prior to initiating the feeding which of the following actions should the nurse take first?

Place the client in semi Fowler's position.

A nurse is caring for a client who is a quadriplegic who has severe headache and a blood pressure of 210/108 and suspects autonomic dysreflexia what should the nurse do?

Please client high Fowlers

A nurse is caring for a client who had a gastric resection to treat adenocarcinoma of the stomach. The client tells the nurse in the PACU that he does not remember why the surgeon said he had to have a tube in his nose. The nurse should explain that the NG tube service which of the following purposes?

Prevents excessive pressure on suture lines

a nurse is caring for a patient following treatment for supraventorial brain tumor which of the following interventions should the nurse do?

Raise the head of the bed 30°

Kehr's sign

Referred pain down the left shoulder; indicative of a ruptured spleen.

What manifestations of Gerd sure the nurse expect?

Regurgitation nausea belching heartburn

A nurse is assessing a client with a head injury in a brief level of consciousness which of the following should the nurse report?

Small drop of clear fluid in left ear.

HYPOXIA

TACHYCARDIA

A client with an infection will have an increased what?

Temperature

A nurse is caring for a client who has a Trumatic brain injury which of the following findings for indications of ICP?

The greatest risk to this client is injury from increased intracranial pressure. Therefore, the nurse's priority action is to maintain the PaCO2 at approximately 35 mm Hg to prevent hypercarbia and subsequent vasodilation effects that lead to increase in intracranial pressure.

A client with continuous tube feeding through a pump at 75 mL per hour. When the nurse assesses a client at 8:00 AM following find findings requires intervention?

The head of the bed is elevated at 20°. The head of the bed should be Élevage at least 30° semi Fowler's position while the two fitting is administered this position is a scrubby to help the feeding move through the digestive system unless there's a possibility of regurgitation

What happens if you turn total prenatal nutrition TPN therapy off?

The patient will have diaphoresis and the potential to develop hypo glycemia due to the sudden withdrawal of TPN solution. In addition to diaphoresis other potential manifestations of hyperglycemia I can include weakness anxiety confusion and hunger

A patient is having a tonic clonic seizure what action should the nurse take?

Turn the clients head to the side. Lower the patient from sitting position to the ground Remove all restrictive clothing Remove hard objects away from the patient place pillow under patients head assess air ways patency

A nurse is caring for a client who has acute diverticulitis. While the client has active information the nurse should instruct the client to include which of the following foods in her diet?

White bread and plain yogurt

White bread is an appropriate low fiber food for a client who is following a low fiber diet.

Whole grain bread contains more fiber.

A nurse is planning care for a client with cirrhosis of the liver to prevent ascites diet?

a low sodium diet administration of furosemide or spilactrone - diuretics measurements of abdominal girth daily

Irregular palpitations dizziness rapid and irregular ousels deficit . what will nurse find on EKG?

a-fib

pulmonary embolism `

admin O2

ARDS (acute respiratory distress syndrome)

admin vecuronium to facilitate ventilation

aspirin

anti platelet drug

Early signs of Gastric cancer

are not alarming or unusual

Abdominal swelling caused by accumulation of fluid, most often related to liver disease.

ascities

lacerated spleen osculate decrease breath sounds in lower lobes

atelectasis

cardiac enzymes

blood test to determine the level of enzymes specific to heart muscles in the blood

Cholecystitis findings `

blumbergs sign

Admitted with pheochromocytoma after adrenalectomy. assessment that is most concerning

bp 169/98, tumors on adrenal gland increases blood pressure

1 day post op trantonoidal hyposisectomy with clear drainage coming from nose what is nurses action?

check drainage for glucose

no bubbling in chest tube chamber

check for suction leaks 1

cardiac Cath on left AC

check left radial pulse cardiac

alcohol use and frequent bruises and nose bleeds are caused by what?

cirrhosis

close chest tube water seal suction check for

continuous bubbling in seal chamber

lactate dehydrogenase

converts pyruvate to lactate

the albumin levels with end stage liver failure

decrease 4-36 u/L---normal levels

cardiac emzymes

degree of damage to heart tissue

dumping syndrome

eat small meals frequently at same intervals

tonsillectomy

gag reflex excessive swallowing = hemorrhage

post operative care

get up and ambulate ASAP use incentive spirometer SCD's leg exercises passive and active range motion

Caring for a patient with questions on treatment options for new diagnosis of basal carcinoma what treatment should be included?

gyro therapy electrotherapy radiation micrographic surgery

laryngeal cancer

hoarseness

post op to prevent pulmonary embolism

incentive spirometry

Atelectasis/Post -op complication

increased dyspnea

end stage liver failure ammonia levels

increased with ESLF

lactate dehydrogenase in end stage liver failure

indicative of

A nurse in the ER has a patient with myasthenia gravis patient in crisis which of the following causes of crisis?

infection

Cholecystitis

inflammation of the gallbladder

Tumor of small intestine

intermittent pain and bloody stool

patient with colorectal cancer are prescribed cephalexin (kelfex) to reduce what

intestinal bacterial levels `

mona b

morphine oxygen nitro aspirin beta blockers

mi manifestations

nausea tachycardia diaphoresis

atrial fibrillation

occurs when the normal rhythmic contractions of the atria are replaced by rapid irregular twitching of the muscular heart wall

esophageal cancer late stage

perforation of the mediastinum erosion great vessels obstruction of esophagus

cath interventions

peripheral pulses in hip and leg extended remain in bed for 6hoursz keep affected leg straight and extended

The nurse finds a patient on the floor following a clonic phase of clinic type seizure what action should the nurse take?

place pillow under her head

liver failure

prothrombin prolonged

atrial fibrillation

rapid, random, ineffective contractions of the atrium

blumbergs sign for cholecystitis

rebound tenderness

Cephalexin (Keflex)

reduces intestinal bacterial levels

Kehr sign is defined as:

referred pain to the shoulder following injury to the liver or spleen.

ARDS (acute respiratory distress syndrome)

respiratory insufficiency marked by progressive hypoxia

pleurisy

scratch sound in lungs

Troponin 1

specific to heart

Always keep the chest tube below the level of what body part

waist