Med surg

Which statements made by the client demonstrate a correct understanding of the home care of an ascending colostomy? Select all that apply. 1. "I Will clarify with my healthcare provider before taking enteric- coated medications. 2. "I Will irrigate the colostomy to promote regular bowel movements." 3. "I Will limit eating food such as broccoli and cauliflower to reduce odor." 4. "I Will restrict my fluid intake to 2000 mL of fluid today. 5. "I Will wait for the patch to become completely full before emptying the contents."

1. "I Will clarify with my healthcare provider before taking enteric- coated medications. 3. "I Will limit eating food such as broccoli and cauliflower to reduce odor."

The nurse is collecting data from a client with acute diverticulitis. Which of the following findings would be essential to follow up? 1. Abdominal pain has progressed to the left upper quadrant. 2. Hemoglobin of 11.2 g/dL 3. Lying on side with knees drawn up to the abdomen and trunk flexed. 4. WBC count of 12,000/mm

1. Abdominal pain has progressed to the left upper quadrant.

The nurse assesses a child with intussusception. Which assessment findings require priority intervention? 1. Abdominal rigidity with guarding. 2. Absence of tears in crying child with IV start. 3. Blood-streaked mucus stool in diaper 4. Sausage-shaped right sided mass on palpation

1. Abdominal rigidity with guarding.

A nurse is reinforcing discharge instructions with a client following a partial gastrectomy. Which of the following instruction should the nurse include to prevent dumping syndrome? Select all that apply 1. Add high-protein foods to the diet 2. Consume high-carbohydrate meals. 3. Eat small, frequent meals. 4. Increase intake of fluids with meals 5. Lie down after eating

1. Add high-protein foods to the diet 3. Eat small, frequent meals. 5. Lie down after eating

The nurse is reinforcing teaching a proper technique for colostomy irrigation for the home health client. Which action indicates that further instruction is required? 1. Attaches an enema set to the irrigation bag, lubricates it, gently inserted into the stoma and holds it in place.

1. Attaches an enema set to the irrigation bag, lubricates it, gently inserted into the stoma and holds it in place.

The nurse is screening clients for those at risk of developing a hiatal hernia. Which of the following factors would increase of clients risk for developing hiatal hernia? Select all that apply 1. BMI greater than 30 kg/m 2. Frequent heavy lifting 3 colorectal polyps 4. advanced age 5. pregnancy 6. male sex

1. BMI greater than 30 kg/m 2. Frequent heavy lifting 4. advanced age 5. pregnancy

A client for days post colostomy is preparing to be discharged home. Which findings are concerning and should be further investigated. Select all that apply 1. Client states, "I Will need home health to empty the pouch." 2. Client states, "There is a little gas in the colostomy bag." 3. No vowels sounds are present in the client reports nausea. 4. Skin surrounding the stoma is red and excoriated 5. Stoma is red, edematous, and smaller than the previous day

1. Client states, "I Will need home health to empty the pouch." 3. No vowels sounds are present in the client reports nausea. 4. Skin surrounding the stoma is red and excoriated

The nurse is caring for a client with cirrhosis who has ascites, peripheral edema, shortness of breath, fatigue, generalize discomfort. Which of the following action should the nurse take? Select all that apply 1. Assist the client to ambulate in the hallway every shift. 2. Encourage the client to increase sodium intake. 3. Maintain the client in semi fowler position. 4. Provide an alternating air pressure mattress for the client 5. Use music to provide distraction for the client

3. Maintain the client in semi fowler position. 4. Provide an alternating air pressure mattress for the client 5. Use music to provide distraction for the client

The nurse is reinforcing teaching to a client with hiatal hernia. Which statement by the client indicates that further teaching is needed? 1. "I need to raise the head of my bed on blocks by at least 6 inches." 2. "I Will remain sitting up for several hours after I eat any food." 3. "If my reflux and abdominal pain don't improve, I might need surgery." 4. "Losing weight may reduce my reflux, so I plan to take a weight -lifting class."

4. "Losing weight may reduce my reflux, so I plan to take a weight -lifting class."