Med Surg 1.1
Which statement by a client scheduled for bariatric surgery indicates to the nurse that further preoperative teaching is necessary? "I need to eat more high-protein foods." "I'm going to have a figure like a model in about a year." "I'm going to be out of bed and sitting in a chair the first day after surgery." "I will be limiting my intake to 600 to 800 calories a day once I start eating again."
"I'm going to have a figure like a model in about a year." Clients need to be prepared emotionally for the body image changes that occur after bariatric surgery. After weight stabilizes clients generally experience excessive abdominal skin folds, which may require a panniculectomy. Body image disturbance often occurs in response to incorrectly estimating one's size; it is not uncommon for the client to still feel fat no matter how much weight is lost. The client needs to increase protein intake and avoid foods high in sugar and fat; alcohol and sweetened fluids should be avoided. Barring complications, clients are ambulated and transferred to a chair within eight hours of surgery. Six small feedings for a total calorie intake of 600 to 800 calories in 24 hours, plus fluids to prevent dehydration, are routine once the healthcare provider prescribes a regular diet.
Endotracheal intubation and positive-pressure ventilation are instituted because of a client's deteriorating respiratory status. Which is the priority nursing intervention? Facilitate verbal communication Prepare the client for emergency surgery Maintain sterility of the ventilation system Assess the client's response to the mechanical ventilation
Assess the client's response to the mechanical ventilation The effectiveness of therapy is measured by the client's response. Endotracheal intubation does not permit verbal communication. Preparing the client for emergency surgery is presumptive; the database is inadequate for this conclusion. Maintaining sterility of the ventilation system is important but not the priority; the client is a higher priority than equipment. STUDY TIP: Becoming a nursing student automatically increases stress levels because of the complexity of the information to be learned and applied and because of new constraints on time. One way to decrease stress associated with school is to become very organized so that assignment deadlines or tests do not come as sudden surprises. By following a consistent plan for studying and completing assignments, you can stay on top of requirements and thereby prevent added stress.
A client has a large open abdominal wound. The healthcare provider's prescription states to cleanse the wound with normal saline, pack the wound with damp gauze, cover with abdominal pads, and secure with Montgomery straps twice a day. What should the nurse do to maintain sterility when changing the dressing? Use a separate square gauze to cleanse each half of the wound. Apply new Montgomery straps each time the dressing is changed. Hold the wet gauze with the tips of the forceps higher than the wrist. Cleanse the wound with wet sterile gauze from the center of the wound outward.
Cleanse the wound with wet sterile gauze from the center of the wound outward. should be cleansed from the center outward or from the top to the bottom; this ensures that cleansing is done from the least to the most contaminated area. A new sterile gauze square should be used for each swipe of the wound. More than two gauze squares will be needed to cleanse a large abdominal wound. Using the same gauze square again will contaminate the wound. Montgomery straps are changed only when they become soiled or begin to loosen from the client's skin. Montgomery straps are applied to each side of a wound. The central sections are folded back when the dressing is changed. When folded back in place over the new dressing and secured with a tie, they keep the dressing in place without having to replace the tape each time the dressing is changed. Forceps should always be held with the tips lower than the wrist. If held with the wrist lower than the tips of the forceps, cleansing solution can flow down the instrument and the hand and arm of the nurse, contaminating the fluid. When the wrist is then raised above the forceps, the contaminated fluid will flow back down the forceps into the wound.
A client is diagnosed with heart failure and is admitted for medical management. Which statement made by the client may indicate worsening heart failure? "I am unable to run a mile (1.6 kilometers) now." "I wake up at night short of breath." "My wife says I snore very loudly." "My shoes seem larger lately."
I am unable to run a mile now Increased shortness of breath is often an indicator of fluid overload in the heart failure client. Being unable to run a mile (1.6 kilometers), snoring loudly, and shoes seeming larger are not as related to heart failure as waking up at night with shortness of breath. STUDY TIP: In the first pass through the exam, answer what you know and skip what you do not know. Answering the questions you are sure of increases your confidence and saves time. This is buying you time to devote to the questions with which you have more difficulty.
A client who is receiving a 2-gram sodium diet asks for juice. How should the nurse respond? "I suggest you have pear nectar." "I suggest you have tomato juice." "Juice is not permitted on a low-sodium diet." "Juice between meals is not calculated into your diet."
I suggest you have pear nectar Pear nectar is low in sodium and therefore a better choice for this client. Tomato juice has a high sodium content; it should be avoided to prevent fluid retention. Low-sodium juices are permitted. The client is permitted low-sodium juice between meals. Test-Taking Tip: Pace yourself during the testing period and work as accurately as possible. Do not be pressured into finishing early. Do not rush! Students who achieve higher scores on examinations are typically those who use their time judiciously.
A nurse is caring for a client with a new colostomy. Which client outcome is most important for achievement of long-range goals associated with adjusting to a new colostomy? Mastery of techniques of colostomy care Readiness to accept an altered body function Awareness of available community resources Knowledge of the necessary dietary modifications
Readiness to accept an altered body function The client must be ready to accept changes in body image and function; this acceptance will facilitate mastery of the techniques of colostomy care and optimal use of community resources. Specific knowledge can be imparted only when an individual is ready to learn; it requires acceptance of a new body image.
The nurse is caring for a client who is hyperventilating. The nurse recalls that the client is at risk for what? Respiratory acidosis Respiratory alkalosis Respiratory compensation Respiratory decompensation
Respiratory alkalosis Hyperventilation causes excess amounts of carbon dioxide (CO2) to be eliminated, causing respiratory alkalosis. Respiratory acidosis is caused by excess CO2 retained in the lungs from conditions such as hypoventilation or chronic obstructive pulmonary disease (COPD). Respiratory compensation and decompensation are terms not associated with this situation.
During a routine physical examination, an abdominal aortic aneurysm is diagnosed. The client immediately is admitted to the hospital, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when performing an assessment of this client? Severe radiating abdominal pain Pattern of visible peristaltic waves Visible pulsating abdominal mass Cyanosis with other symptoms of shock
Visible pulsating abdominal mass the heart contracts, an expanding midline mass may be visible to the left of the umbilicus. Severe radiating abdominal pain is not definitive for abdominal aortic aneurysm. There is no problem or pathology in the intestinal tract; patterning of visible peristaltic waves is associated with intestinal obstruction. Cyanosis with other symptoms of shock is not definitive for abdominal aortic aneurysm; pallor occurs with shock.
The diet prescribed for a client allows for 190 grams of carbohydrates, 90 grams of fat, and 100 grams of protein. The nurse calculates that this diet contains approximately how many calories? 920 1970 2470 2970
1970 This diet contains approximately 1970 calories. There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrates and protein. 190 x 4 = 760; 90 x 9 = 810; 100 x 4 = 400; 760 + 810+ 400 = 1970. 920 calories is an incorrect calculation; this is too few calories. 2470 and 2970 are incorrect calculations; both are too many calories. STUDY TIP: You have a great resource in your classmates. We all have different learning styles, strengths, and perspectives on the material. Participating in a study group can be a valuable addition to your nursing school experience.
A client receiving hemodialysis undergoes surgery to create an arteriovenous fistula. Before discharge, the nurse discusses care at home with the client and his wife. Which statement by the client's wife indicates that further teaching is required? "I must touch the shunt several times a day to feel for the bruit." "I have to take his blood pressure every day in the arm with the fistula." "He will have to be very careful at night not to lie on the arm with the fistula." "We really should check the fistula every day for signs of redness and swelling."
"I have to take his blood pressure every day in the arm with the fistula." Taking the blood pressure in the affected arm may injure the fistula. The presence of a bruit indicates that the circulation is not obstructed by a thrombus. Hemorrhage can occur in a matter of minutes if the cannula is dislodged. Redness and swelling are signs of infection, which is a complication of cannulization.
A client with a malignant parotid tumor is treated aggressively with radiation therapy and surgery. Postsurgical arterial blood gas results are as follows: pH 7.32, PCO2 53 mm Hg, and HCO3 25 mEq (25 mmol/L). The nurse should take which action? Obtain a prescription and administer a diuretic. Instruct the client to breathe into a rebreather bag at a slow rate. Ask the client to cough forcefully and take deep breaths. Obtain a prescription for sodium bicarbonate.
Ask the client to cough forcefully and take deep breaths. client is in respiratory acidosis probably caused by the depressant effects of anesthesia or a partially obstructed airway; these activities clear the airway and blow off CO2. Obtaining a prescription and administering a diuretic will not correct respiratory acidosis [1] [2] [3] and may aggravate it if potassium is depleted. Having the client breathe into a rebreather bag at a slow rate is the treatment for respiratory alkalosis; the client is in respiratory acidosis. Obtaining a prescription for the administration of sodium bicarbonate is not necessary if clearing of the airway rectifies the problem.
The nurse is providing postoperative care to a client on the second day after the client had a coronary artery bypass surgery. When assessing the water-seal chamber of the chest drainage device, the nurse observes that the fluid no longer fluctuates. What should the nurse do? Assess for obstructions in the chest tube Increase the amount of continuous suction Add sterile water to the water-seal chamber Make preparations to remove the chest tube
Assess for obstructions in the chest tube Fluid in the water-seal chamber should rise and fall as the client breathes in and out (tidaling) until the lungs have expanded completely; a lack of tidaling on the second postoperative day indicates that the tube is obstructed. Increasing the amount of suction is contraindicated without a prescription because it can traumatize pleural tissue. The level of the fluid, as long as it covers the tube in the water-seal chamber, does not affect tidaling. The lungs will not be fully expanded on the second postoperative day; the chest tube will remain in place.
A client is diagnosed with Hodgkin disease. Which lymph nodes does the nurse expect to be affected first? Cervical Axillary Inguinal Mediastinal
Cervical Painless enlargement of the cervical lymph nodes often is the first sign of Hodgkin disease, a malignant lymphoma of unknown etiology. Axillary node enlargement occurs after cervical lymph node enlargement. Inguinal node enlargement occurs later. Mediastinal node involvement follows after the disease progresses. Test-Taking Tip: Practicing a few relaxation techniques may prove helpful on the day of an examination. Relaxation techniques such as deep breathing, imagery, head rolling, shoulder shrugging, rotating and stretching of the neck, leg lifts, and heel lifts with feet flat on the floor can effectively reduce tension while causing little or no distraction to those around you. It is recommended that you practice one or two of these techniques intermittently to avoid becoming tense. The more anxious and tense you become, the longer it will take you to relax.
Highest risk for pneumonia (chart)
Chronic lung disease Client 4, who is an older adult with chronic lung disease and has received the pneumococcal vaccination more than 5 years ago, has the highest risk of pneumonia. An infection may occur because older adults with chronic lung disease are at a higher risk of infection. Client 1 received the pneumococcal vaccination in the last 3 months and thus has a lower risk of pneumonia. Client 2 received a pneumococcal vaccination in the last 2 years and may not have an elevated risk of pneumonia. Client 3 may have a lower risk of pneumonia due to receiving the pneumococcal vaccine a year ago.
While caring for a client with a nasal injury, the nurse also suspects a skull fracture. Which manifestation might have led the nurse to conclude this? Positive dipstick test Crackling of the skin on palpation Clearly visible fracture in the X-ray report Clear yellow halo ring structure on a filter paper
Clear yellow halo ring structure on a filter paper The drainage of cerebrospinal fluid (CSF) from the injured area indicates a skull fracture. The presence of a clear yellow halo ring-shape structure appearing on a piece of filter paper indicates the presence of CSF, an indication of a skull fracture. A positive dipstick test indicates the presence of sugar in the CSF. Crackling of the skin occurs with a normal nose injury. An X-ray may not detect the presence of CSF.
A client who had surgery for a resection of the colon and the formation of a colostomy is to be discharged in several days. What is a primary nursing intervention for this client? Determine the client's ability to care for the colostomy Show the client how to change the abdominal dressing Encourage the client to apply heat to the stoma opening Teach the client about the special lifelong dietary precautions
Determine the client's ability to care for the colostomy The client's feelings, knowledge, and skills concerning caring for the colostomy must be assessed before discharge. Generally, the client no longer needs a dressing on the incision by the time of discharge. Heat is not applied to the stoma. After a colostomy the client usually does not need a special diet; the client usually is instructed to eat a regular diet and to eliminate gas-producing foods.
A nurse is assessing a client for possible malabsorption syndrome. Which stool assessment finding will support this diagnosis? Melena Frank blood Fat globules Currant jelly consistency
Fat globules Undigested fat in the feces (steatorrhea) is associated with diseases of the intestinal mucosa (e.g., celiac sprue) or pancreatic enzyme deficiency. Darkening of feces by blood pigments (melena) is related to upper gastrointestinal (GI) bleeding. Bright red blood in the stool is related to lower GI bleeding (e.g., hemorrhoids). Stools containing blood and mucus (currant jelly stools) are associated with intussusception.
To manage heart failure a client has been taking several medications, including furosemide 40 mg by mouth twice a day. The client develops severe muscle cramps and fatigue, and laboratory tests confirm the presence of hypokalemia. Potassium chloride intravenously (IV) and ECG monitoring have been prescribed. Which ECG change associated with hypokalemia should the nurse expect to observe? Inverted P waves Flattened T waves Absence of U waves Elevated ST segment
Flattened T waves A flattened T wave is associated with hypokalemia. A depressed T wave indicates a problem with ventricular repolarization, a process involved in muscle contraction. Adequate potassium levels are needed for efficient muscle contraction. P waves may peak in hypokalemia. In hypokalemia, U waves appear. ST segment is depressed in hypokalemia.
A client with a pulmonary embolus is intubated and placed on mechanical ventilation. What nursing action is important when suctioning the endotracheal tube? Apply negative pressure while inserting the suction catheter. Hyperoxygenate with 100% oxygen before and after suctioning. Suction two to three times in succession to effectively clear the airway. Use rapid movements of the suction catheter to loosen secretions.
Hyperoxygenate with 100% oxygen before and after suctioning. Suctioning also removes oxygen, which can cause cardiac dysrhythmias; the nurse should try to prevent this by hyperoxygenating the client before and after suctioning. Suction should be applied only while removing the catheter to prevent trauma to the trachea. Suction only as needed; excessive suctioning irritates the mucosa, which increases secretion production. Using rapid movements of the suction catheter to loosen secretions may cause tracheal damage.
A client with bronchial pneumonia is having difficulty maintaining airway clearance because of retained secretions. To decrease the amount of secretions retained, what should the nurse do? Administer continuous oxygen Increase fluid intake to at least 2 L a day Place the client in a high-Fowler position Instruct the client to gargle deep in the throat using warmed normal saline
Increase fluid intake to at least 2 L a day Increased fluid intake helps to liquefy respiratory secretions, which promotes expectoration. Oxygen may dry the mucous membranes, which may thicken secretions; oxygen should be administered only when necessary. Placing the client in a high-Fowler position promotes retention of secretions; supine, prone, and Trendelenburg positions promote removal of secretions via gravity. Retained secretions are in the bronchi and trachea; gargling lubricates only the oropharynx. STUDY TIP: The old standbys of enough sleep and adequate nutritional intake also help keep excessive stress at bay. Although nursing students learn about the body's energy needs in anatomy and physiology classes, somehow they tend to forget that glucose is necessary for brain cells to work. Skipping breakfast or lunch or surviving on junk food puts the brain at a disadvantage.
A thallium scan is prescribed for a client with a history of chest pain. Which information should the nurse include when explaining the purpose of the test to the client? It monitors action of the heart valves. It assesses myocardial ischemia and perfusion. It visualizes ventricular systole and diastole. It identifies the adequacy of electrical conductivity
It assesses myocardial ischemia and perfusion. Thallium imaging is used to assess myocardial ischemia or necrotic muscle tissue related to angina or myocardial infarction. Necrotic or scar tissue does not extract the thallium isotope, leading to cold spots. Action of the heart valves is available from an echocardiogram or, if indicated, from a cardiac catheterization with an angiography. Visualization of the ventricular systole and diastole is determined by cardiac angiography. Identifying the adequacy of electrical conductivity is determined by an electrocardiogram (ECG).
The nurse in the postanesthesia care unit is caring for a client who had a left-sided pneumonectomy. Which goal is priority? Replace blood loss Maintain ventilatory exchange Maintain closed chest drainage Replace supplemental oxygenation
Maintain ventilatory exchange Oxygen and carbon dioxide exchange is essential for life and is the priority. Blood replacement is not the priority. Closed chest drainage is unnecessary with a left-sided pneumonectomy because there is no lung to reinflate. Supplemental oxygenation is not the priority. STUDY TIP: Laughter is a great stress reliever. Watching a short program that makes you laugh, reading something funny, or sharing humor with friends helps decrease stress.
The nurse notices sudden bursts of fast rhythm that end abruptly. The heart rate is 220 beats per minute during these bursts, but the P waves are very difficult to see. The QRS interval is normal. The nurse notifies the primary healthcare provider. Which rhythm did the nurse share with the primary healthcare provider? Sinus tachycardia Atrial tachycardia Ventricular tachycardia (VT) Paroxysmal supraventricular tachycardia (PSVT)
Paroxysmal supraventricular tachycardia (PSVT) PSVT occurs above the ventricles, and it has an abrupt onset and cessation. Sinus tachycardia results when the sinoatrial (SA) node fires faster than 100 beats per minute. Onset is gradual rather than abrupt. PR interval is 0.12 to 0.20 seconds. P and QRS waves are consistent in shape. Atrial tachycardia is a rapid rhythm that arises from an ectopic focus in the atria. Because the P wave arises outside the sinus node, the shape is different from the sinus P wave. VT occurs at a rate greater than 100 beats per minute, but the rate is usually around 150 beats per minute and may be up to 250 beats per minute. Depolarization of the ventricles is abnormal and produces a widened QRS complex. The client may or may not have a pulse.
The nurse observes the following pattern on a client's electrocardiogram (ECG) strip. What dysrhythmia does the nurse identify?2939913424 Asystole Atrial flutter Ventricular fibrillation Premature ventricular complex
Premature ventricular complex Beats 2 and 4 are premature ventricular complexes or beats. The impulse originates in the ventricles, and it occurs before the next expected ventricular beat. Asystole is characterized by an absence of electrical and mechanical cardiac activity, with no countable heartbeat. Atrial flutter is characterized by an atrial rate of 250 to 350 regular beats per minute, more than 100 irregular ventricular beats per minute, a sawtooth P wave, variable PR intervals, and normal QRS complexes. Ventricular fibrillation is characterized by lack of organization in electrical impulses, conduction of impulses, and ventricular contractions.
The family of a client with right ventricular heart failure expresses concern about the client's increasing abdominal girth. What physiologic change should the nurse consider when explaining the client's condition? Loss of cellular constituents in blood Rapid osmosis from tissue spaces to cells Increased pressure within the circulatory system Rapid diffusion of solutes and solvents into plasma
Rapid osmosis from tissue spaces to cells Failure of the right ventricle causes an increase in pressure in the systemic circulation. To equalize this pressure, fluid moves into the tissues, causing edema, and into the abdominal cavity, causing ascites; ascites leads to an increased abdominal girth. There is no loss of the cellular constituents in blood with right ventricular heart failure. Ascites is the accumulation of fluid in an extracellular space, not intracellular. The opposite of rapid diffusion of solutes and solvents into plasma results when there is a pressure increase in the systemic circulation. Test-Taking Tip: Come to your test prep with a positive attitude about yourself, your nursing knowledge, and your test-taking abilities. A positive attitude is achieved through self-confidence gained by effective study. This means (a) answering questions (assessment), (b) organizing study time (planning), (c) reading and further study (implementation), and (d) answering questions (evaluation).
A nurse is caring for a client who had a bronchoscopy one hour ago. Which nursing action is most appropriate for assessing the return of the client's gag reflex? Ask the client to say several words. Give the client a small swallow of water. Stroke the anterior third of the client's tongue.
Stroke the anterior third of the client's tongue. Touch the client's pharynx with a tongue depressor. Gently touching the pharynx with a tongue depressor is a safe and reliable method of testing the gag reflex. Talking can occur without the gag reflex. Giving the client a small swallow of water can cause choking and aspiration if the gag reflex has not returned. Stroking the posterior, not the anterior, portion of the tongue may elicit the gag reflex.
A client has contrast medium injected into the brachial artery so that a cerebral angiogram can be performed. What nursing assessment is most essential immediately after the procedure? Stability of gait Presence of a gag reflex Blood pressure in both arms Symmetry of the radial pulses
Symmetry of the radial pulses Trauma to the artery can interfere with circulation to the accessed extremity; this is most easily assessed by checking the pulses bilaterally. The client is prescribed bed rest after the procedure, so gait is not assessed. The gag reflex is not affected by the test. The blood pressure should not be taken in the affected arm; the increase in pressure may initiate bleeding.
A client with a history of type 1 diabetes is experiencing progressive problems with venous stasis. The client tells the nurse, "I bumped my leg a week ago, and now it has an open draining area just above the ankle." Which information is most important for the nurse to explore when collecting the client's health history? The type of treatment and care the client is receiving What dosage and type of insulin the client is taking and how often The number of family members that are experiencing similar problems How many times a day the client voids and the frequency of bowel movements
The type of treatment and care the client is receiving Asking what type of treatment the client is receiving and how the client is managing care will elicit a variety of data such as medications, diet, and other aspects of care and even includes the care of the new wound. Although it is important to know about the client's insulin use, the information is too limited and does not include how the client is caring for the new wound or for the diabetes itself. Although information about a client's bowel and bladder habits is important, it is not the priority. Although information about the client's children is important, determining the number of family members the client has and whether they are having similar problems is not the priority.