ATI

Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease? 1. History of side effects experienced from all medications. 2. Use of nonsteroidal anti-inflammatory drugs (NSAIDs). 3. Any known allergies to drugs and environmental factors. 4. Medical histories of at least three (3) generations.

2. Use of nonsteroidal anti-inflammatory drugs (NSAIDs).

The low-pressure alarm sounds on the ventilator. The nurse checks the client and then attempts to determine the cause of the alarm but is unsuccessful. Which initial action should the nurse take? 1. Administer oxygen. 2. Ventilate the client manually. 3. Check the client's vital signs. 4. Start cardiopulmonary resuscitation (CPR).

2. Ventilate the client manually.

Normal Albumin

3.4-5

BUN normal

5-10

when do we use Murphy's sign

ruq- cholelithiasis/gallbladder

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which indicates this occurrence? 1. Sweating and pallor 2. Dry skin and stomach pain 3. Bradycardia and indigestion 4. Double vision and chest pain

1. Early manifestations occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down

A client with ascites is scheduled for a paracentesis. The nurse is assisting the primary health care provider (PHCP) with performing the procedure. Which position should the nurse assist the client into for this procedure? 1. Flat 2. Upright 3. Left side-lying 4. Right side-lying

2. Upright

The public health nurse is discussing hepatitis B with a group in the community. Which health promotion activities should the nurse discuss with the group? Select all that apply. 1. Do not share needles or equipment. 2. Use barrier protection during sex. 3. Get the hepatitis B vaccine. 4. Obtain immune globulin injections. 5. Avoid any type of hepatotoxic medications.

1. Do not share needles or equipment. 2. Use barrier protection during sex. 3. Get the hepatitis B vaccine.

What type of pain is normal after Lap Cole surgery?

R shoulder pain.

Creatanine normal

(0.6-1.3)

A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. Which of the following laboratory findings should the nurse monitor prior to the procedure? A. Prothrombin time B. Serum lipase C. Bilirubin D. Calcium

. Prothrombin time A major complication following a liver biopsy is hemorrhage. Many clients who have liver disease have clotting defects and are at risk for bleeding. Along with the prothrombin time (PT), the activated partial thromboplastin time (aPTT) and the platelet count should be monitored. Liver dysfunction causes the production of blood clotting factors to be reduced, which leads to an increased incidence of bruising, nosebleeds, bleeding from wounds, and gastrointestinal bleeding. This is due to a deficient absorption of vitamin K from the gastrointestinal tract caused by the inability of liver cells to use vitamin K to make prothrombin.

The nurse is teaching a class on diverticulosis. Which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulosis? Select all that apply. 1. Eat a high-fiber diet. 2. Increase fluid intake. 3. Elevate the HOB after eating. 4. Walk 30 minutes a day. 5. Take an antacid every two (2) hours.

1. Eat a high-fiber diet. 2. Increase fluid intake. 4. Walk 30 minutes a day.

The nurse is caring for a client diagnosed with rule-out peptic ulcer disease. Which test confirms this diagnosis? 1. Esophagogastroduodenoscopy. 2. Magnetic resonance imaging (MRI). 3. Occult blood test. 4. Gastric acid stimulation.

1. Esophagogastroduodenoscopy.

475. The nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions should the nurse expect to be prescribed? Select all that apply. 1. Administer antacids, as prescribed. 2. Encourage coughing and deep breathing. 3. Administer anticholinergics, as prescribed. 4. Maintain the client in a supine and flat position. 5. Encourage small, frequent, high-calorie feedings.

1. Administer antacids, as prescribed. 2. Encourage coughing and deep breathing. 3. Administer anticholinergics, as prescribed. The client with acute pancreatitis is normally placed on an NPO status to rest the pancreas and suppress GI secretions. Because abdominal pain is a prominent symptom of pancreatitis, pain medication will be prescribed. Some clients experience lessened pain by assuming positions that flex the trunk and draw the knees up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may also help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted. Antacids and anticholinergics may be prescribed to suppress GI secretions.

Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctuation (tidaling) in the water compartment? 1. Assess the client's bilateral lung sounds. 2. Obtain an order for a STAT chest x-ray. 3. Notify the health-care provider as soon as possible. 4. Document the findings in the client's chart.

1. Assess the client's bilateral lung sounds. then xray

The client diagnosed with ARDS is on a ventilator and the high alarm indicates an increase in the peak airway pressure. Which intervention should the nurse implement first? 1. Check the tubing for any kinks. 2. Suction the airway for secretions. 3. Assess the lip line of the ET tube. 4. Sedate the client with a muscle relaxant.

1. Check the tubing for any kinks.

64. Which signs and symptoms should the nurse report to the health-care provider for the client recovering from an open cholecystectomy? Select all that apply. 1. Clay-colored stools. 2. Yellow-tinted sclera. 3. Amber-colored urine. 4. Wound approximated. 5. Abdominal pain.

1. Clay-colored stools. 2. Yellow-tinted sclera. 5. Abdominal pain.

Normal hemoglobin

12-16

It has been determined that a client with hepatitis has contracted the infection from contaminated food. Which type of hepatitis is this client most likely experiencing? 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D

1. Hepatitis A HAV is transmitted by the fecal-oral route via contaminated food or infected food handlers. HBV, HCV, and HDV are most commonly transmitted via infected blood or body fluids.

The 70-year-old client is admitted to the medical unit diagnosed with acute diverticulitis. Which interventions should the nurse implement? Select all that apply. 1. Tell the client not to eat or drink. 2. Start an intravenous line. 3. Assess the client for abdominal tenderness. 4. Have the dietitian consult for a low-residue diet. 5. Place the client on bedrest with bathroom privileges.

1235

The nurse is assigned to care for a client after a left pneumonectomy. Which position is contraindicated for this client? 1. Lateral position 2. Low Fowler's position 3. Semi-Fowler's position 4. Head of the bed elevation at 40 degrees

1. Lateral position

The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS? 1. Low arterial oxygen when administering high concentration of oxygen. 2. The client has dyspnea and tachycardia and is feeling anxious. 3. Bilateral breath sounds clear and pulse oximeter reading is 95%. 4. The client has jugular vein distention and frothy sputum

1. Low arterial oxygen when administering high concentration of oxygen.

A client with hiatal hernia chronically experiences heartburn after meals. Which should the nurse teach the client to avoid? 1. Lying recumbent after meals 2. Eating small, frequent, bland meals 3. Raising the head of the bed on 6-inch blocks 4. Taking histamine

1. Lying recumbent after meals Rationale: Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm, where the esophagus usually is positioned. The client generally experiences pain caused by reflux resulting from ingestion of irritating foods, lying flat following meals or at night, and consuming large or fatty meals. Relief is obtained by eating small, frequent, and bland meals; histamine antagonists and antacids; and elevation of the thorax after meals and during sleep.

87. Which intervention should the nurse implement for a male client who has had a left-sided chest tube for six (6) hours and who refuses to take deep breaths because of the pain? 1. Medicate the client and have the client take deep breaths. 2. Encourage the client to take shallow breaths to help with the pain. 3. Explain deep breaths do not have to be taken at this time. 4. Tell the client if he doesn't take deep breaths, he could die.

1. Medicate the client and have the client take deep breaths.

The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment, the nurse finds a hard, rigid abdomen and T 102ÅãF. Which intervention should the nurse implement? 1. Notify the health-care provider. 2. Prepare to administer a Fleet's enema. 3. Administer an antipyretic suppository. 4. Continue to monitor the client closely.

1. Notify the health-care provider. Signs of peritonitis!

Normal platelet

150,000-400,000

23. The circulating nurse assesses tachycardia and hypotension in the client. Which interventions should the nurse implement? 1. Prepare ice packs and mix dantrolene sodium. 2. Request the defibrillator be brought into the OR. 3. Draw a PTT and prepare a heparin drip. 4. Obtain finger stick blood glucose immediately

1. Prepare ice packs and mix dantrolene sodium.

2. The nurse caring for a client diagnosed with GERD writes the client problem of "behavior modification." Which intervention should be included for this problem? 1. Teach the client to sleep with a foam wedge under the head. 2. Encourage the client to decrease the amount of smoking. 3. Instruct the client to take over-the-counter medication for relief of pain. 4. Discuss the need to attend Alcoholics Anonymous to quit drinking.

1. Teach the client to sleep with a foam wedge under the head.

29. The 26-year-old male client in the PACU has a heart rate of 110 and a rising temperature and complains of muscle stiffness. Which interventions should the nurse implement? Select all that apply. 1. Give a back rub to the client to relieve stiffness. 2. Apply ice packs to the axillary and groin areas. 3. Prepare an ice slush for the client to drink. 4. Prepare to administer dantrolene, a smoothmuscle relaxant. 5. Reposition the client on a warming blanket.

2. Apply ice packs to the axillary and groin areas. 4. Prepare to administer dantrolene, a smoothmuscle relaxant.

The postanesthesia care nurse is caring for a client who had abdominal surgery and is complaining of nausea. Which intervention should the nurse implement first? 1. Medicate the client with a narcotic analgesic (IVP). 2. Assess the nasogastric tube for patency. 3. Check the temperature for elevation. 4. Hyperextend the neck to prevent stridor.

2. Assess the nasogastric tube for patency.

The client is admitted to the emergency department with chest trauma. Which signs/ symptoms indicate to the nurse the diagnosis of pneumothorax? 1. Bronchovesicular lung sounds and bradypnea. 2. Unequal lung expansion and dyspnea. 3. Frothy, bloody sputum and consolidation. 4. Barrel chest and polycythemia.

2. Unequal lung expansion and dyspnea.

The unlicensed assistive personnel (UAP) assists the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse? 1. The UAP keeps the chest tube below chest level. 2. The UAP has the chest tube attached to suction. 3. The UAP allowed the client out of the bed. 4. The UAP uses a bedside commode for the client.

2. The UAP has the chest tube attached to suction.

The client diagnosed with liver problems asks the nurse, "Why are my stools clay-colored?" On which scientific rationale should the nurse base the response? 1. There is an increase in serum ammonia level. 2. The liver is unable to excrete bilirubin. 3. The liver is unable to metabolize fatty foods. 4. A damaged liver cannot detoxify vitamins.

2. The liver is unable to excrete bilirubin.

The client with a history of peptic ulcer disease is admitted into the intensive care department with frank gastric bleeding. Which priority intervention should the nurse implement? 1. Maintain a strict record of intake and output. 2. Insert a nasogastric (N/G) tube and begin saline lavage. 3. Assist the client with keeping a detailed calorie count. 4. Provide a quiet environment to promote rest.

2. Insert a nasogastric (N/G) tube and begin saline lavage.

60. The client is admitted to the medical floor with acute diverticulitis. Which collaborative intervention should the nurse anticipate the health-care provider ordering? 1. Administer total parenteral nutrition. 2. Maintain NPO and nasogastric tube. 3. Maintain on a high-fiber diet and increase fluids. 4. Obtain consent for abdominal surgery.

2. Maintain NPO and nasogastric tube.

Which assessment data indicate to the nurse the chest tubes inserted three (3) days ago have been effective in treating the client with a hemothorax? 1. Gentle bubbling in the suction compartment. 2. No fluctuation (tidaling) in the water-seal compartment. 3. The drainage compartment has 250 mL of blood 4. The client is able to deep breathe without any pain.

2. No fluctuation (tidaling) in the water-seal compartment.

35. Which assessment data indicate to the nurse the client's gastric ulcer has perforated? 1. Complaints of sudden, sharp, substernal pain. 2. Rigid, boardlike abdomen with rebound tenderness. 3. Frequent, clay-colored, liquid stool. 4. Complaints of vague abdominal pain in the right upper quadrant.

2. Rigid, boardlike abdomen with rebound tenderness.

A nurse is caring for a client who has a chest tube in place that is attached to a closed-chest drainage system. Which of the following actions should the nurse take if the chest tube becomes dislodged from the closed chest drainage system? 1. Instruct the client to inhale deeply 2. Submerge the end of the chest tube in 1 inch of sterile water 3. Gently milk the chest tube in a proximal-to-distal direction 4. Tape sterile gauze around the open end of the chest tube.

2. Submerge the end of the chest tube in 1 inch of sterile water This action creates a water seal and prevents air from entering the pleural space through the open end of the chest tube when the client inhales.

The nurse reinforces postoperative liver biopsy instructions to a client. Which should the nurse tell the client? 1. Avoid alcohol for 8 hours. 2. Remain NPO for 24 hours. 3. Lie on the right side for 2 hours. 4. Save all stools to be checked for blood.

3 Rationale: To splint the puncture site, the client is kept on the right side for a minimum of 2 hours. It is not necessary to remain NPO for 24 hours. Permission regarding the consumption of alcohol should be obtained from the PHCP.

The nurse is reviewing the primary health care provider's (PHCP'S) prescriptions written for a client admitted with acute pancreatitis. Which PHCP prescription should the nurse verify if noted in the client's chart? 1. NPO status 2. An anticholinergic medication 3. Position the client supine and flat 4. Prepare to insert a nasogastric tube

3. Rationale: The pain associated with acute pancreatitis is aggravated when the client lies in a supine and flat position. Therefore, the nurse would verify this prescription. Options 1, 2, and 4 are appropriate interventions for the client with acute pancreatitis.

The client who smokes two (2) packs of cigarettes a day develops ARDS after a neardrowning. The client asks the nurse, "What is happening to me? Why did I get this?" Which statement by the nurse is most appropriate? 1. "Most people who almost drown end up developing ARDS." 2. "Platelets and fluid enter the alveoli due to permeability instability." 3. "Your lungs are filling up with fluid, causing breathing problems." 4. "Smoking has caused your lungs to become weakened, so you got ARDS."

3. "Your lungs are filling up with fluid, causing breathing problems."

The nurse has been assigned to care for a client diagnosed with peptic ulcer disease. Which assessment data require further intervention? 1. Bowel sounds auscultated 15 times in one (1) minute. 2. Belching after eating a heavy and fatty meal late at night. 3. A decrease in systolic blood pressure (BP) of 20 mm Hg from lying to sitting. 4. A decreased frequency of distress located in the epigastric region.

3. A decrease in systolic blood pressure (BP) of 20 mm Hg from lying to sitting.

The nurse is caring for a client diagnosed with hemorrhaging duodenal ulcer. Which collaborative interventions should the nurse implement? Select all that apply. 1. Perform a complete pain assessment. 2. Assess the client's vital signs frequently. 3. Administer a proton pump inhibitor intravenously. 4. Obtain permission and administer blood products. 5. Monitor the intake of a soft, bland diet.

3. Administer a proton pump inhibitor intravenously. 4. Obtain permission and administer blood products.

The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? 1. Confirm that the ventilator settings are correct. 2. Verify that the ventilator alarms are functioning properly. 3. Assess the respiratory status and pulse oximeter reading. 4. Monitor the client's arterial blood gas results.

3. Assess the respiratory status and pulse oximeter reading.

The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse implement if there is no fluctuation (tidaling) in the water-seal compartment? 1. Obtain an order for a STAT chest x-ray. 2. Increase the amount of wall suction. 3. Check the tubing for kinks or clots. 4. Monitor the client's pulse oximeter reading.

3. Check the tubing for kinks or clots.

52. The nurse is discussing the therapeutic diet for the client diagnosed with diverticulosis. Which meal indicates the client understands the discharge teaching? 1. Fried fish, mashed potatoes, and iced tea. 2. Ham sandwich, applesauce, and whole milk. 3. Chicken salad on whole-wheat bread and water. 4. Lettuce, tomato, and cucumber salad and coffee.

3. Chicken salad on whole-wheat bread and water.

The surgical client's vital signs are T 98˚F, P 106, R 24, and BP 88/40. The client is awake and oriented times three (3) and the skin is pale and damp. Which intervention should the nurse implement first? 1. Call the surgeon and report the vital signs. 2. Start an IV of D5RL with 20 mEq KCl at 125 mL/hr. 3. Elevate the feet and lower the head. 4. Monitor the vital signs every 15 minutes.

3. Elevate the feet and lower the head. Client is hemorrhaging- shunt blood.

67. The client is one (1) hour post-endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse include in the plan of care? 1. Instruct the client to cough forcefully. 2. Encourage early ambulation. 3. Gag reflex return

3. Gag reflex return

The school nurse is discussing methods to prevent an outbreak of hepatitis A with a group of high school teachers. Which action is the most important to teach the high school teachers? 1. Do not allow students to eat or drink after each other. 2. Drink bottled water as much as possible. 3. Encourage protected sexual activity. 4. Sing the happy birthday song while washing hands.

4. Sing the happy birthday song while washing hands.

74. The client has had a liver biopsy. Which postprocedure intervention should the nurse implement? 1. Instruct the client to void immediately. 2. Keep the client NPO for eight (8) hours. 3. Place the client on the right side. 4. Monitor blood urea nitrogen (BUN) and creatinine level.

3. Place the client on the right side. NPO is 2 days after.

51. The client is admitted to the medical unit with a diagnosis of acute diverticulitis. Which healthcare provider's order should the nurse question? 1. Insert a nasogastric tube. 2. Start an IV with D5W at 125 mL/hr. 3. Put the client on a clear liquid diet. 4. Place the client on bedrest with bathroom privileges.

3. Put the client on a clear liquid diet. NPO!!!

The nurse is presenting a class on chest tubes. Which statement best describes a tension pneumothorax? 1. A tension pneumothorax develops when an airfilled bleb on the surface of the lung ruptures. 2. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere. 3. The injury allows air into the pleural space but prevents it from escaping from the pleural space. 4. A tension pneumothorax results from a puncture of the pleura

3. The injury allows air into the pleural space but prevents it from escaping from the pleural space.

An ultrasound of the gallbladder is scheduled for the client with a suspected diagnosis of cholecystitis. Which should the nurse explain to the client about this test? 1. The test is uncomfortable. 2. The test requires that the client be NPO. 3. The test requires the client to lie still for short intervals. 4. The test is preceded by the administration of oral tablets.

3. The test requires the client to lie still for short intervals.

The client is four (4) hours postoperative open cholecystectomy. Which data warrant immediate intervention by the nurse? 1. Absent bowel sounds in all four (4) quadrants. 2. The T-tube has 60 mL of green drainage. 3. Urine output of 100 mL in the past three (3) hours. 4. Refusal to turn, deep breathe, and cough.

4.

The nurse is preparing a client diagnosed with GERD for discharge following an esophagogastroduodenoscopy (EGD). Which statement indicates the client understands the discharge instructions? 1. "I should not eat for at least one (1) day following this procedure." 2. "I can lie down whenever I want after a meal. It won't make a difference." 3. "The stomach contents won't bother my esophagus but will make me nauseous." 4. "I should avoid orange juice and eating tomatoes until my esophagus heals."

4. "I should avoid orange juice and eating tomatoes until my esophagus heals."

7. The nurse is administering morning medications at 0730. Which medication should have priority? 1. A proton pump inhibitor. 2. A nonnarcotic analgesic. 3. A histamine receptor antagonist. 4. A mucosal barrier agent.

4. A mucosal barrier agent.

Which assessment data supports the client's diagnosis of gastric ulcer to the nurse? 1. Presence of blood in the client's stool for the past month. 2. Reports of a burning sensation moving like a wave. 3. Sharp pain in the upper abdomen after eating a heavy meal. 4. Complaints of epigastric pain 30 to 60 minutes after ingesting food.

4. Complaints of epigastric pain 30 to 60 minutes after ingesting food.

A nurse is caring for a client who is 6 hours post operative and has a chest tube in place that is attached to a closed-chest water-seal drainage system. The nurse should identify that which of the following is an indication of a problem in the drainage system? 1. Constant bubbling in the suction-control chamber. 2. Fluctuations in the fluid level in the water seal chamber 3. Occasional bubbling in the water seal chamber. 4. Continuous bubbling in the water-seal chamber

4. Continuous bubbling in the water-seal chamber Excessive and continuous bubbling in the water-seal chamber indicates an air leak in the drainage system. The nurse should use rubber-tipped clamps to try to locate the leak by clamping the tube momentarily near the site of the chest tube insertion.

50. The nurse is teaching the client diagnosed with diverticulosis. Which instruction should the nurse include in the teaching session? 1. Discuss the importance of drinking 1,000 mL of water daily. 2. Instruct the client to exercise at least three (3) times a week. 3. Teach the client about eating a low-residue diet. 4. Explain the need to have daily bowel movements.

4. Explain the need to have daily bowel movements. water is good- but need 3000 ml exercise should be daily.

The nurse is caring for a client with a rightsided chest tube that is accidentally pulled out of the pleural space. Which action should the nurse implement first? 1. Notify the health-care provider to have chest tubes reinserted STAT. 2. Instruct the client to take slow shallow breaths until the tube is reinserted. 3. Take no action and assess the client's respiratory status every 15 minutes. 4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.

4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.

The client developed a paralytic ileus after abdominal surgery. Which intervention should the nurse include in the plan of care? 1. Administer a laxative of choice. 2. Encourage the client to increase oral fluids. 3. Encourage the client to take deep breaths. 4. Maintain a patent nasogastric tube.

4. Maintain a patent nasogastric tube

Which problems should the nurse include in the plan of care for the client diagnosed with peptic ulcer disease to observe for physiological complications? 1. Alteration in bowel elimination patterns. 2. Knowledge deficit in the causes of ulcers. 3. Inability to cope with changing family roles. 4. Potential for alteration in gastric emptying.

4. Potential for alteration in gastric emptying.

The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication? 1. Restrict sodium intake to 2 g/day. 2. Limit oral fluids to 1,500 mL/day. 3. Decrease the daily fat intake. 4. Reduce protein intake to 60 to 80 g/day.

4. Reduce protein intake to 60 to 80 g/day.

71. Which problem is highest priority for the nurse to identify in the client who had an open cholecystectomy surgery? 1. Alteration in nutrition. 2. Alteration in skin integrity. 3. Alteration in urinary pattern. 4. Alteration in comfort

4. pain worsening is a bad sign-

A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome (ARDS)? (Select all that apply) A. A client who experienced a near-drowning incident B. A client following coronary artery bypass graft surgery C. A client who has a hemoglobin of 15.1 mg/dL D. A client who has dysphagia E. drug overdose

ABDE

Normal WBC

5-10,000

Normal ca

8.6-10

Normal INR

9.8-11.8

nurse is caring for four clients. Which of the following clients is at greatest risk for pulmonary embolism?

A client who is 48 hr postoperative following a total hip arthroplasty The nurse should identify that a client who has undergone a total hip arthroplasty surgery is at greatest risk for a pulmonary embolus because of decreased mobility of the affected extremity and an increased amount of blood clots forming in the veins of the thigh following hip surgery. Deep-vein thromboses are most likely to occur 48 to 72 hr following the arthroplasty. The nurse should intervene to reduce the risk by applying sequential compression devices or antiembolic stockings and by administering anticoagulant medications.

A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes. Which of the following findings should the nurse identify as manifestations of fluid volume deficit? (select all that apply) A. Decreased skin turgor B. Concentrated urine C. Bradycardia D. Low-grade fever E. Tachypnea

A, B, D, E

A nurse is caring for several clients. Which of the following clients are at risk for having a pulmonary embolism? (Select all that apply) A. A client who has a BMI of 30 B. A female client who has postmenopausal C. A client who has a fractured femurD . A client who is a marathon runner E. A client who has chronic atrial fibrillation

A, C, E Obesity, a long bone fracture, and turbulent blood flow in the heart increase the risk for a blood clot

A nurse is providing discharge teaching for a client who has peptic ulcer disease and a new famotidine. Which of the following statements by the client indicates an understanding of the teaching?A. "I should take this medication at bedtime." B. "I should expect this medication to discolor my stools." C. "I will drink iced tea with my meals and snacks." D. "I will monitor my blood glucose level regularly while taking this medication."

A. "I should take this medication at bedtime."The nurse should instruct the client to take the medication at bedtime to inhibit the action of histamine at the H2-receptor site in the stomach.

A nurse is providing discharge teaching for a client who has GERD. Which of the following statements by the client indicates an understanding of the teaching? A. "I will decrease the amount of carbonated beverages I drink." B. "I will avoid drinking liquids for 30 minutes after taking a chewable antacid tablet." C. "I will eat a snack before going to bed." D. "I will lie down for at least 30 minutes after eating each meal."

A. "I will decrease the amount of carbonated beverages I drink." The nurse should instruct the client to limit or eliminate fatty foods, coffee, cola, tea, carbonated beverages, and chocolate from his diet because they irritate the lining of the stomach.

A nurse is monitoring a client who received succinylcholine during a surgical procedure. Which of the following actions should the nurse take if the client develops manifestations of malignant hyperthermia? A. Administer dantrolene B. Institute seizure precautions C. Remove endotracheal tube D. Give IV atropine

A. Administer dantrolene

A community health nurse is planning an educational program about hepatitis A. When preparing the materials, the nurse should identify that which of the following groups is most at risk for developing hepatitis A? A. Children B. Older adults C. Women who are pregnant D. Middle-aged men

A. Children The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The hepatitis A virus can be contracted from the feces, bile, and blood of infected clients. The usual mode of transmission is the fecal-oral route. Children and young adults are the two groups most often affected by the hepatitis A virus. Typically, a child or young adult acquires the infection at school, through poor hygiene, hand-to-mouth contact, or another form of close contact.

A nurse is caring for a client who is to receive fibrinolytic thrombolytic therapy. Which of the following should the nurse recognize as a contraindication to the therapy? A. Hip arthroplasty 2 weeks ago B. Elevated sedimentation rate C. Incident of exercise-induced asthma 1 week ago D. Elevated platelet count

A. Clients who have undergone a major surgical procedure within the last 3 weeks should not receive thrombolytic therapy because of the risk of hemorrhage from the surgical site.

A nurse is caring for a client who is 4 hr postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? A. Right shoulder pain B. Urine output 20 mL/hr C. Temperature 38.4° C (101.1° F) D. Oxygen saturation 92%

A. Right shoulder pain The client can experience pain in the right upper shoulder due to gas (carbon dioxide) injected into the abdominal cavity during the laparoscopic procedure, which can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1 to 2 days. Mild analgesics and a recumbent position can help with client comfort.

a nurse is providing discharge teaching for a client who has a new prescription for medications to treat peptic ulcer disease. The nurse should identify that which of the gollowing medications inhibits gastric acid secretion? A. Calcium carbonate B. Famotidine C. Aluminum hydroxide D. Sucralfate

B. Famotidine The nurse should inform the client that famotidine is an H2-receptor antagonist that is prescribed for the treatment of peptic ulcer disease to inhibit the secretion of gastric acid.

A nurse is reviewing the laboratory results of a client who has acute pancreatitis. Which of the following findings should the nurse expect? A. Blood glucose 110 mg/dL B. Increased serum amylase C. WBC 9,000/mm3 D. Decreased bilirubin

B. Increased serum amylase

A nurse is teaching a client who has Barrett's esophagus and is scheduled to undergo an esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in the teaching? A. "This procedure is performed to measure the presence of acid in your esophagus." B. "This procedure can determine how well the lower part of your esophagus works." C. "This procedure is performed while you are under general anesthesia." D. "This procedure can determine if you have colon cancer."

B. "This procedure can determine how well the lower part of your esophagus works."An EGD is useful in determining the function of the esophageal lining and the extent of inflammation, potential scarring, and strictures.

A nurse is caring for a client who has pulmonary embolism which of the following interventions is a priority

Administer heparin via continuous IV infusion.

The nurse in the emergency department is caring for a client who is experiencing pulmonary embolism which of the following actions should the nurse take first

Apply supplemental oxygen

A nurse is caring for a client in an acute respiratory failure who is receiving mechanical ventilation which of the following assessments is the best method for the nurse to use to determine effectiveness of the current treatment regimen

Arterial blood gases

A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect? A. Jaundice B. Anorexia C. Dark urine D. Pale feces

B. Anorexia Anorexia is an early manifestation of hepatitis A and is often severe. It is thought to result from the release of a toxin by the damaged liver or by the failure of the damaged liver cells to detoxify an abnormal product. THE REST ARE LATE STAGES.

A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect? A. Bloody diarrhea B. Board-like abdomen C. Periumbilical cyanosis D. Increased bowel sounds

B. Board-like abdomen

A nurse is providing discharge teachinf for a pt postop from lap cholecystectomt. What should the nurse teach? A. bathe don;t shower B. resume a diet of choice C. Cleanse puncture site soap and water D. Remove adhesive strips in 24hr E. Report N/V

B, C, E

A nurse is assessing a client who has a pulmonary embolism. Which of the clinical manifestations should the nurse expect to find? (Select all that apply) A. Bradypnea B. Pleural friction rub C. Hypertension D. Petechiae E. Tachycardia

B, D, E

A nurse is preparing a community education program about hepatitis B. Which of the following statements should the nurse include in the teaching? A. "A hepatitis B immunization is recommended for those who travel, especially military personnel." B. "A hepatitis B immunization is given to infants and children." C. "Hepatitis B is acquired by eating foods that are contaminated during handling." D. "Hepatitis B can be prevented by using good personal hygiene habits and proper sanitation."

B. "A hepatitis B immunization is given to infants and children."Hepatitis B immune globulin is given as part of the standard childhood immunizations. It can be administered as early as birth, especially in infants born to hepatitis B surface antigen (HBsAg) negative mothers. These infants should receive the second dose between 1 and 4 months of age.

A nurse is providing discharge teaching for a client who has chronic hepatitis C. Which of the following statements indicates an understanding of the teaching? A. "I will avoid alcohol until I'm no longer contagious." B. "I will avoid medications that contain acetaminophen." C. "I will decrease my intake of calories." D. "I will need treatment for 3 months."

B. "I will avoid medications that contain acetaminophen."A client who has hepatitis C should avoid medications that contain acetaminophen, which can cause additional liver damage.

A nurse is providing teaching for a client who has cirrhosis and a new prescription for lactulose. THe nurse should include which of the following instructions in the teaching. A. Notify provider if bloating occurs B. Expect to have 2-3 soft stools per day C. Restrict carbohydrates in the diet D. Limit oral fluid intake to 1000 mL per day of clear fluids

B. Expect ot have 2-3 soft stools per dayThe purpose of administering lactulose is to promote excretion of ammonia in stool. the nurse should instruct the client to take he medication every day and inform the client that 2-3 bowel movements everyday is the treatment goal.

A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse? A. I am allergic to morphine B. I take antacids several times a day C. I had a blood clot in my leg several years ago D. It hurts to take a deep breath

B. The greatest risk to this client is the possibility of bleeding from a peptic ulcer. Further assessment should be completed and the nurse should notify the provider of the finding

A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy (EGD). The nurse should identify that this procedure is used to do which of the following? A. To visualize polyps in the colon B. To detect an ulceration in the stomach C. To identify an obstruction in the biliary tract D. To determine the presence of free air in the abdomen

B. To detect an ulceration in the stomachAn EGD is used to visualize the esophagus, stomach, and duodenum with a lighted tube to detect a tumor, ulceration, or obstruction.

A nurse is caring for a client who is 2 days postoperative following a cholecystectomy. The client has been vomiting for the past 24 hr and reports a pain level of 8 on a 0 to 10 scale. 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? a. draw the client's blood for electrolytes b. insert an NG tube c. administer pain medication d. initiate intake and output

B. insert an NG tube. this will decompress the bowel bc the build up of fluids and gas is an issue! Think paralytic ileus. Early ambulation could have prevented this. Priority action is an NG tube.

What lab value may be elevated with cholelithias?

Billrubin

A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, hear rate 124/min, respiratory rate 38/min, temperature 38.6C (101/4F), and SaO2 92% on room air. Which of the following actions should the nurse take first? A. obtain chest xray B. Prepare for chest tube insertion C. Administer oxygen via a high flow mask. D. Initiate IV acess

C. Administer oxygen via a high flow mask.

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? A. Instruct the client to exhale into the incentive spirometer every 1-2 hr B. Minimize the amount of pain meds the client receives to prevent sedation C. Advise the client to splint the surgical incision when coughing and deep breathing D. Reposition the client every 8 hours for the first 48 hours

C. Advise the client to splint the surgical incision when coughing and deep breathing --> Not A bc you inhale deeply with the incentive spiromter to expand the lungs.

A nurse is assessing a client who has cirrhosis. Which of the following findings is a priority for the nurse to report to the provider? A. Spider angiomas B. Peripheral edema C. Bloody stools D. Jaundice

C. Bloody stools The greatest risk to the client who has cirrhosis of the liver is hemorrhagic shock due to bleeding in the esophageal varices. Therefore, bloody stools is the priority finding to report to the provider.

A nurse is providing dietary teaching to a client who has diverticulitis about preventing acute attacks. Which of the following foods should the nurse recommend? A. Foods high in vitamin C B. Foods low in fat C. Foods high in fiber D. Foods low in calories

C. Foods high in fiberThe result of long-term, low-fiber eating habits along with increased intracolonic pressure lead to straining during bowel movements, causing the development of diverticula. High-fiber foods help strengthen and maintain active motility of the gastrointestinal tract.

A nurse is assessing a client who has upper GI bleeding. Which of the following findings should the nurse expect? A. Bradycardia B. Bounding peripheral pulses C. Hypotension D. Increased hematocrit levels

C. Hypotension

A nurse is admitting a client who has acute pancreatitis. Which of the following actions should the nurse take first? A. Insert a nasogastric tube for the client. B. Administer ceftazidime to the client. C. Identify the client's current level of pain. D. Instruct the client to remain NPO.

C. Identify the client's current level of pain.The first action the nurse should take when using the nursing process is to assess the client. Clients who have acute pancreatitis often have severe abdominal pain. By assessing the client's level of pain, the nurse can identify the need for and implement interventions to alleviate the client's pain.

A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states that she is anxious because she feels that she cannot get enough air. Vital signs are: HR 117/min, RR 38/min, temp 38.4 (101.2), BP 100/54. Which of the following actions is the priority action at this time? A. Notify the provider B. Administer heparin via IV infusion C. Administer oxygen therapy D. Obtain a spiral CT scan

C. Meeting the oxygenation needs first is the priority action according to ABCs

A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings should indicate to the nurse that a possible bowel perforation has occurred? A. Elevated blood pressure B. Bowel sounds increased in frequency and pitch C. Rigid abdomen D. Emesis of undigested food

C. Rigid abdomen (BP goes down, and bowel sounds are silent)

A nurse in the emergency department is caring for a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications? A. Famotidine B. Esomeprazole C. Vasopressin D. Omeprazole

C. Vasopressin

Respiratory failure=

Can't get ride of CO2- CO2 rises. PH decreases bc of the co2. P02 is big indicator

Observing constant bubbling in the water seal chamber column. The nurse should?

Check the connections between the chest and drainage tube and where the tube connects to the drainage unit.

The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the healthcare provider is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first? 1. Gather the needed supplies for the procedure. 2. Obtain a signed informed consent form. 3. Assist the client into a side-lying position. 4. Discuss the procedure with the client.

Consent

A nurse is caring for a client who has a chest tube following a lobectomy which of the following items should the nurse keep easily accessible for the client

Container of sterile water (you don't need an extra drainage, don't need nonadherent pads nearby)

A nurse is assessing a client who has a chest tube in place following thoracic surgery. for which of the following findings should the nurse notify the provider

Continuous bubbling in the water seal chamber

High pressure alarms

Coughing Biting Secretions 1st thing: SUCTION. Check for secretion, check lung sounds.

A nurse is providing dietary teaching for a client who has chronic pancreatitis. Which of the following food selections by the client indicates an understanding of the teaching? A. 8 oz whole milk B. One slice of beef bologna C. 1 oz cheddar cheese D. 1 cup sliced banana

D. 1 cup sliced bananaFoods that are high in fat can cause diarrhea for clients who have pancreatitis. One cup of sliced banana, which contains 0.49 g of fat, is a low-fat food option. Clients who have pancreatitis should consume a high-protein and low-fat diet with an adequate amount of carbohydrates and calories.

A nurse is reviewing the laboratory results of a client who has hepatic cirrhosis. Which of the following laboratory findings should the nurse report to the provider? A. Albumin 4.0 g/dL B. INR 1.0 C. Direct bilirubin 0.5 mg/dL D. Ammonia 180 mcg/dL

D. Ammonia 180 mcg/dL Ammonia=hepatic encepolopathy

A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of the following manifestations should the nurse expect? A. Increased blood pressure B. Decreased heart rate C. Yellowing of the skin D. Boardlike abdomen

D. Boardlike abdomenThe nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of a boardlike abdomen and severe pain in the abdomen or back that radiates to the right shoulder. Vomiting of blood and shock can occur if the perforation causes hemorrhaging. HYPotension too. bc bleeding

A nurse is assessing a client immediately following a paracentesis for the treatment of ascites. Which of the following findings indicates the procedure was effective? A. Presence of a fluid wave B. Increased heart rate C. Equal pre and postprocedure weights D. Decreased SOB

D. Decreased SOBIncreased abdominal fluid can limit the expansion of the diaphragm and prevent the client from taking a deep breath. Once excess peritoneal fluid is removed, the diaphragm will expand more freely. The nurse should identify this finding as an indicator the procedure was effective.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? A. Hypertension B. Excessive thirst C. Fever D. Diaphoresis

D. DiaphoresisThe nurse should recognize that the client has the potential for the development of hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis, other potential manifestations of hypoglycemia can include weakness, anxiety, confusion, and hunger.

A nurse is assessing a client who is dehydrated for fluid volume deficit. Which of the following findings should the nurse expect in the client? A. Moist skin B. Distended neck veins C. Increased urinary output D. Tachycardia

D. Tachycardia

A nurse is assessing a client who has a duodenal ulcer. Which of the following findings should the nurse expect? A. The client states that the pain is in the upper epigastrium. B. The client is malnourished. C. The client states that ingesting food intensifies the pain. D. The client reports that pain occurs during the night.

D. The client reports that pain occurs during the night.Pain associated with a duodenal ulcer occurs when the stomach is empty, which is typically 1.5 to 3 hr after meals and during the night.

Low Pressure alarms

Disconection in circuit Pt not breathing Self extubated 1st thing: MANUAL VENTILATE can't find issue? HELP IN RM. Assess pt - are they blue and cyanotic diff breathing?

The public health nurse is teaching day-care workers. Which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person? 1. Hepatitis A. 2. Hepatitis B. 3. Hepatitis C. 4. Hepatitis D.

Hep a

A nurse is assessing a client who is postoperative following a gastrectomy. The nurse should identify which of the following findings as an indication of abdominal distention? A. Hiccups B. Hypertension C. Bradycardia D. Chest pain

Hiccups Following surgery, hiccups can be caused by irritation of the phrenic nerve due to abdominal distension. If the hiccups are intractable, the nurse should anticipate a prescription for chlorpromazine because persistent hiccups are distressful to the client and can lead to complications, such as vomiting.

duodenal vs gastric ulcers

In a client diagnosed with a gastric ulcer, pain usually occurs 30 to 60 minutes after eating but not at night. In contrast, a client with a duodenal ulcer has pain during the night often relieved by eating food. Pain occurs one (1) to three (3) hours after meals.

A nurse is caring for a client who has acute respiratory distress syndrome which of the following findings should the nurse report to the provider

Intercostal reactions

The nurse is reinforcing discharge instructions to a client after a gastrectomy. Which measure should the nurse include during client teaching to help prevent dumping syndrome? 1. Ambulate after a meal. 2. Eat high-carbohydrate foods. 3. Limit the fluids taken with meals. 4. Sit in a high Fowler's position during meals.

Limit the fluids taken with meals. The client should be instructed to decrease the amount of fluid taken at meals. The client should also be instructed to avoid high-carbohydrate foods, including fluids such as fruit nectars; assume a low-Fowler's position during meals; lie down for 30 minutes after eating to delay gastric emptying; and take antispasmodics as prescribed.

A nurse is caring for a client who is in respiratory distress which of the following low flow delivery devices should the nurse used to provide the client with the highest level of oxygen

Non rebreather mask

What should be done if the chest tube is disconnected?

Submerge the end of the tube in a bottle of sterile water

A nurse is caring for a client who is 1 hr postoperative following a thoracentesis which of the following is a priority assessment finding

Persistent cough (could be a tension pneumothorax) Temp (99.1), insertion site pain, and pallor are all important but the cough is more alarming.

What ABG would someone have if a flail chest or pneumothorax?

Resp. acidosis HYPOventilation Inadequate mechanical ventilation Alveolar capillary blockage (from a PE, ARDS etc)

What blood pressure changes does the nurse report Postop?

Shift 25% above or below baseline. Inspiratory stridor is important to report too bc it can be from tracheal edema. Requires intervention.

Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator? 1. The client's urine output is 100 mL in four (4) hours. 2. The pulse oximeter reading is greater than 95%. 3. The client has asymmetrical chest expansion. 4. The telemetry reading shows sinus tachycardia.

The client has asymmetrical chest expansion.

A nurse is providing dietary teaching for a client who is postoperative following a gastrectomy. Which of the following foods should the nurse encourage the client to include in her diet to prevent dumping syndrome? A. Ice cream B. Eggs C. Grape juice D. Honey

The nurse should instruct the client to increase intake of protein-containing foods, such as eggs, to decrease the risk for manifestations of dumping syndrome. The client should eat some form of protein at each meal

A nurse is working in the emergency department is caring for a client following an acute chest trauma which of the following findings indicate to the nurse the client is possibly experiencing a tension pneumothorax

Tracheal deviation to the UNaffected side

Hallmark treatment of active bleeding esophogeal varicies?

VASOPRESSIN IV. Your esophagus is a vase.

A nurse is receiving evening shift report on four clients who returned from the PACu that morning. Which of the following clients should the nurse assess first? a. a client who is post-op following a thoracotomy and has a chest tube with 150 mL of bright red blood in the collection chamber in the past 1 hour b. a client who is postoperative following a small bowel resection and has a temporary colostomy along with absent bowel sounds in all four quadrants c. a client who is post-op following a tonsillectomy and has had one coffee emesis. d. a client who is postoperative following a total knee arthroplasty and is reporting a pain level of 7

a. a client who is post-op following a thoracotomy and has a chest tube with 150 mL of bright red blood in the collection chamber in the past 1 hour Remember not more than 100 ml/hr

A nurse in the emergency department is assessing a client for a closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for Which of the following manifestations of pneumothorax? a. absence of breath sounds b. expiratory wheezing c. inspiratory stridor d. rhonchi

a. absence of breath sounds

A nurse is caring for a client who is 12 hr postoperative from a gastrectomy and has an NG tube set to continuous low suction. Which of the following findings requires intervention by the nurse?a. gastric distention b. absent bowel sounds c. urine output of 150 mL over the last 4 hr d. yellow drainage in the NG tube

a. gastric distention Gastric distention is a sign the nG tube is not patent check for kinks Absent bowel sounds are expected in the first 24 hrs.

A surgical nurse enters a surgical suite to ensure surgical asepsis is maintained. For which of the following findings should the nurse intervene? a. the scrub technologist is wearing a watch under their scrubs b. the circulating nurse opens dressing packages before applying sterile gloves c. the surgeon has their hands folded 5 cm (2 in) above their waist d. the holding area nurse is performing client education

a. the scrub technologist is wearing a watch under their scrubs --> you can open packages just don;t touch them inside....the outside does not need to be sterile.

When do we use McBurney's point?

appendicitis, rlq, point of pain.

A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by nonrebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome? a. tympanic temp 38 C (100.4 F) b. PaO2 50 mmHg c. rhonchi d. hypopnea

b. PaO2 50 mmHg

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? a. apply an ice pack to the client's right calf b. elevate the client's right extremity c. administer testosterone to the client d. gently massage the client's right calf

b. elevate the client's right extremity venous return.

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? a. frequent use of ecchinacae b. long-term use of corticosteroids c. history of osteoperosis d. diet high in vitamin C

b. long-term use of corticosteroids

The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that the client is at risk for which vitamin deficiency? 1. Vitamin A 2. Vitamin C 3. Vitamin E 4. Vitamin B12

b12 Deterioration and atrophy of the lining of the stomach lead to the loss of function of the parietal cells. When the acid secretion decreases, the source of the intrinsic factor is lost, which results in the inability to absorb vitamin B12. This leads to the development of pernicious anemia.

A nurse is teaching a client who is in the immediate postoperative period about the use of a PCA pump. Which of the following statements should the nurse include in the teaching? a. "You will receive a dose of medication every time you push the button." b. "Do not allow visitors to push the PCA button if you are sleeping." c. "You cannot receive too much medication by pushing the button." d. "Do not push the PCA button until your pain reaches a severe level."

c. "You cannot receive too much medication by pushing the button." --> remember patients can only press their button and everyone will react differently to the PCA. Still explain s/s of too many opioids.

A nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care? a. clamp the chest tube if there is continuous bubbling in the water seal chamber b. keep the chest tube drainage system at the level of the right atrium c. tape all connections between the chest tube and drainage system d. empty the collection chamber and record the amount of drainage every 8 hrs.

c. tape all connections between the chest tube and drainage system.

A nurse is preparing a client for a thoracentesis. In which of the following positions should the nurse place the client? a. lying flat on the affected side b. prone with the arms raised over the head c. supine with the head of the bed elevated d. sitting while leaning forward over the bedside table

d. sitting while leaning forward over the bedside table

Respiratory alkalosis: decreased co2, hyperventilating, can't keep co2 in.

decreased co2, hyperventilating, can't keep co2 in.

How often should we reposition the ET tube?

every 12 hrs to prevent skin breakdown in mouth.

Hallmark sign of flail chest

paradoxical chest movement

T tube care for a choleosetomy

report absence of drainage- could be obstructed. inspect for leakage monitor color and and amount of drainage. assess stool color- gray until biliary flow restored. Monitor for peritonitis (pain, fever, jaundice) Tube removed 1-3 weeks.

ETIOLOGY OF pneumothorax vs. tension pneumothroax

tension- air can enter but can't leave. PRESSURE. the organs shift to opposite side, causes the trachea to deviate to the unaffected side.