Med Surg Final
Masmarus
Calorie malnutrition atributing to muscle wasting. causes a deficiency in energy providing foods
The priority nursing assessment of a patient receiving IV nesiritide (Natrecor) to treat HF would be
Blood pressure
The nurse reviews a clients electrolyte result notes k+ 5.5. The nurse understands that a potassium value at this level woud be noted with which condition
Trauma burns
A 53 y/o pt with a history of dysrhythmias is to wear a holter monitor. The nurse should explain that Holter monitoring
is a portable electrocardiographic device
A 3 month old child is admitted with severe eczema. In planning the care of the child, the nurse plans to
keep the skin well hydrated
If a patient has an allergy to latex they will also have an allergy to what?
kiwi, bananas, avocado and chestnuts
A nurse is caring for a pt with cellulitis. Which of the following would the nurse anticipate? select all that apply?
Change dressings as ordered apply cool compresses as ordered administer fluids as ordered
Which of the following surgical procedures involves removal of a body organ?
Cholecystectomy
What allergy is it always important to ask about before surgery?
latex
When caring for a pt receiving conscious sedation, which of the following should the perioperative nurse routinely monitor?
level of conciousness
When assessing the skin of a new pt, she notes a raised red area. The nurse must remember what 3 things when assessing skin?
look, ask then touch
A 59-year-old man has presented to the emergency department with chest pain. Which of the following components of his subsequent blood work is most clearly indicative of a myocardial infarction (MI)?
Troponin
Which electrocardiographic (ECG) change will be of most concern to the nurse when admitting a patient with chest pain?
Troponin
Which information should the nurse include when teaching pt's about decreasing the risk for sun damage to the skin?
Try to stay out of the direct sun between 10am and 2pm
What contains recommended dietary information based on sex, age, pregnancy and lactation?
dietary reference intake
A pt with a perforated gastric ulcer is scheduled for surgery. The pt cannot sign the consent form b/c of sedation. The nurse should which most appropriate action in the care of this patient>
Obtain telephone consent from a family member
Why does dishiscence happen from 3 to 14 days
distention, vomitting, excessive coughing and infection
hyponatremia is cause by
diuretics, vomit, diarrhea, loss due to NG suction and heart failure
Which of the following nursing interventions does the nurse add to the care plan to help a pt with thick sputum mobilized and expectorate those secretions?
drink 3-4 liters of water a day
megablastic anemia
due to thiamine or B12 deficiency -decrease in purine and TMP = decrease in NA synthesis and affects cell division (marrow & gut) Seen more in Vegans
What is ablative surgery?
excision or removal of diseased body part( amputation, cholecystectomy, appendectomy)
What does Hypernatremia cause
fluid shift from the cells to the interstitial spaces resulting in cellular dehydration and interruption in the cellular process
A pt has just undergone a tonsillectomy. The most significant observation is?
frequent swallowing.
Which of the following instructions given to a patient who is about to undergo Holter monitoring is most appropriate?
"You will need to keep a diary of all your activities and symptoms."
A patient with a perforated gastric ulcer is scheduled for surgery. The patient cannot sign the operative consent form because of sedation. The nurse should take which most appropriate action in the care of this patient?
Obtain telephone consent from a family member, following agency policy.
A newly burned pt is admitted to the unit. The nurse measures the pt's urine output on an hourly basis, anticipating fluid balance problems related to fluid shifts. Which of the following hourly urine output rates will alert the nurse to potential problems?
20mL/hr
Potassium levels
3.5-5
Pt needs to urinate ____ every hour?
30mL
What age do you introduce fortified cereals
4-6 months
What is the normal WBC?
5,000-10,000
The nurse should inform the pt who is beginning therapy for TB that the drug regimen will continue for a minimum of?
6 months
IT takes how long to void?
6-8 hours
The nurse is caring for a pt who is in acute respiratory distress. The nurse closely monitors this patients SaO2. The nurse recognized that an SaO2 less than_____ is considered life threatening and requires immediate attention.
70%
You are assigned five patients on your nursing unit. Which patient is at most risk for pressure ulcers?
A 72 year old weighing 82lbs with incontinence.
Kwashiorkor
A disease of chronic malnutrition during childhood, in which a protein deficiency makes the child more vulnerable to other diseases, such as measles, diarrhea, and influenza. causes edema and ascites.
When preparing a pt for a thoracentisis, the nurse positions the patient?
Sitting on the side of the bed with arms on an overbed table
What occurs when the body lays flat?
Slow venus flow which can lead to thrombus formation
Modifiable risk factors for CAD
Smoking, HTN, Diabetes, obesity, diet, activity level, hyperlipidemia
What is the most abundant electrolyte
Sodium (Na+) Normal range is 135-145
If there is an abdominal surgery what do we teach?
Splinting with a pillow
The nurse is ordered to insert a indwelling catheter in a severely burned pt for which reason?
To measure hourly urine output.
How do you measure for distention?
Abdominal girth at the level of umbilicus
A pt with frequent upper respiratory infections is deagnosed with acute bronchitis. the nurse will expect to give which of the following medications? Select all that apply.
Albuterol(bronchodilator) Ampicillin(antibiotic) Cough Suppressants
A 91 y/o has COPD and complains of dyspnea and fatigue. Activity intolerance, related to an imbalance between the oxygen supply and demand is a nursing diagnosis for COPD. Which nursing intervention would be inappropriate?
Allow pt to take a shower.
What needs to be identified in the interoperative phase?
Always verify patient ID
A nurse is caring for a pt who has multiple types of skin lesions. which of the following skin lesions are suggestive of a malignant melanoma? select all that apply
An irregular colored mole
The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which of the following symptoms?
Anorexia and nausea
Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery includes monitoring for which of the following common complications?
Atrial dysrhythmias
A school nurse is seeing a 6 y/o because they have flat lesions that are clear in the center with erythemtous borders. In assessing a pt for tinea corporis, the nurse would check?
Anterior abdomen
What are the S&S of pulmonary embolism?
Anxiousness, restlessness, tachycardia, tachypneic, 90% SP02, dyspnea, substernal pain, coughing, hemoptysis, and fever.
When performing a surgical dressing change of a clinets abdominal dressing a nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should do which of the following in the initial care of this wound?
Apply a sterile dressing soaked in normal saline.
ABGs
Arterial Blood Gases pH 7.35- 7.45 HCO3 (Bicarbonate) normal values 22-26 mEq/L PaCO2 ( CO2 or carbon dioxide content) 35-45 mm Hg PaO2 (oxygen saturation in arteria blood)- 80-100 mm Hg
Ideally when do you provide teaching for surgery?
As soon as we know about the surgery.
The nurse would assess a patient with complaints of chest pain for which of the following clinical manifestations associated with a myocardial infarction (MI) (select all that apply)?
Ashen skin Diaphoresis Nausea and vomiting S3 or S4 heart sounds
An adult is eating lunch and suddntly stars to choke, gasp for breath and grab the throat. which of the following actions should the nurse take?
Ask the patient to speak
A nurse is caring for a patient immediately following a transesophageal echocardiogram (TEE). Which of the following assessments are appropriate for this patient (select all that apply)?
Assess for return of gag reflex. Monitor vital signs and oxygen saturation.
A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery?
Assess patency of the airway
An adult patient is admitted to the post anesthesia care unit following an abdominoperineal resection. Which action should the nurse take initially?
Assess respiratory function
Patient teaching after a tonsillectomy and adenoidectomy wound include which instruction
Avoid attempting to clear throat, coughing and sneezing, avoid vigorous blowing for 1-2 weeks, Notify the physician in case of bleeding, increased pain, fever or bleeding.
The nurse teaches an adolescent who has had a tonsillectomy which of the following?
Avoid coughing and clearing throat for the first week post op
What is the best instruction by the nurse regarding reducing the risk factors for melanomas?
Avoid exposure to the sun and use protective measures when exposure occurs.
Versed IM
Benzo (sedations per anesthesia)
In older adults, rapid infusion of fluids can lead to
heart failure
What is morbid obesity?
BMI over 40 or BMI > 35 with medical problem related to morbid obesity
An elderly patient with a 40-pack-year history of smoking and a recent myocardial infarction is admitted to the medical unit with acute shortness of breath; the nurse need to rule out pneumonia versus heart failure. The diagnostic test that the nurse will monitor to help in determining whether the patient has heart failure is
BNP
When is best to advise patients to ask for pain meds?
Before the pain appears
The nurse is caring for a pt after a bronchoscopy and biopsy. Which finidng, if noted in the pt should be reported immediately to the health care provider.
Bronchospasm
3 systems that keep ph in normal ranges
Buffer, magnesium and kidneys
When assessing a patient with a myocardial infarction which is the objective data
hypertension vomiting diaphoresis cardiac rhythm changes
Respiratory acidosis is caused by
hyperventilation
Trasusseau
hypocalcemia (inflate cuff, hand and finger twitch)
Hyponatremia causes
hypothermia, hypotension, confusio, muslce weakness and if severe enough can cause seizure
The nurse is providing care for a patient who has decreased cardiac output related to heart failure. The nurse recognizes that cardiac output is
Calculated by multiplying the patient's stroke volume by the heart rate.
Why would dishiscence happen after 2 weeks?
Cachexia (malnutrition, wasting)
A patient with a diagnosis of heart failure has been started on a nitroglycerin patch by his primary care provider. This patient should be advised to avoid
Drugs to treat erectile dysfunction.
Glucose of 250 and over are at risk for?
DKA
The nurse is providing teaching to a patient recovering from an MI. Discussion regarding resumption of sexual activity should be
Discussed along with other physical activities.
Seperation or rupture of incision?
Dishiscence
Edema and pulmonary congestion are treated with
Diuretics, restriction of sodium diet and fluid intake
A woman who is to have surgery tomorrow denies any fears or worries about the upcoming surgery. However, she talks incessantly about trivial matters and is constantly rearranging the items on her bedside stand. What is the most appropriate action for the nurse to take?
During preoperative teaching, encourage her to ask questions and express concerns.
Alernation in potassium in the body an lead to?
Dysrhythmias
The nurse identifies which s/s as an early idication of fluid volume excess?
Edema
What is monitored for during fluid excess?
Edema b/c they can have skin breakdown so change pos. frequently (pitting is +1)
A patient admitted from the emergency department with a diagnosis of heart failure has edema in his lower extremities. Which nursing intervention would aid in decreasing the edema?
Elevate lower extremities
Which nursing intervention reduces myocardial oxygen demand?
Elevating the head of the bed 30 to 45 degrees
An adult has returned to the surgical floor following and abdominal cholecystectomy and an uneventful stay in the post anesthesia room. Which nursing action should be the highest priority?
Encourage her to take deep breaths
Nursing for distention includes
Encourage mvmt q2 hr Limit ice Singulitus(hiccups) offer warm liquids constipation
Upon admission assessment, the nurse notes clubbing of the patient's fingers. Based on this finding, the nurse will question the patient about which of the following disease processes?
Endocarditis
A female client has just returned to a nursing unit following bronchoscopy. A nurse would implement which of the following nursing interventions for this client?
Ensure that the gag reflex has returned
"Complete Protiens" foods
Examples: rice and beans, fish, chicken, eggs, pork beef
What kind of diet has diahhrea, streatorrhea, flatulence
Fat controlled diet
Which of the following should be the nurses preoperative consideration when the pt states that she takes garlic pills every day?
Garlic may increase bleeding
What do the muslces store in the liver?
Glycogen
A nurse is developing a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?
Have the client void immediately before going into surgery.
Full liquid diet includes anything that is not a solid
includes pudding, ice cream, sherbert and strained soups
A pt who is sceduled for a hysterectomy reports using Ginko bilboa to improver her memory. which of the following questions is the most important for the nurse to ask the pt?
Have you been taking this herb in the last 2 weeks?
Following an AMI, a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response, which of these assessment data would indicate that the exercise level should be decreased?
Heart rate increases from 66 to 90 beats/min.
A patient with a non-ST segment elevation myocardial infarction (NSTEMI) is receiving heparin. What is the purpose of the heparin?
Heparin will prevent the development of clots in the coronary arteries.
Chvostek's sign
Hypocalcemia (facial muscle spasm upon tapping)
The nurse identifies nasogastric drainage, vomiting, diarrhea and the use of diuretics likely cause which electrolyte imbalance
Hypokalemia
A nurse is assessing a patients skin. The nurse notes clubbing. The prudent nurse is aware that this is a result from
Hypoxemia
The nurse has conducted preoperative teaching for a patient for surgery in 1 week. The pt has a history of arthritis and has been taking aspirin. The nurse determines that the pt needs additional teaching if the pt makes which statement.
I need to continue to take the aspirin until the day of surgery.
The nurse cares for a client receiving a blood transfusion. The nurse observes which symptom if fluid overload occurs during the transfusion?
Increased BP Increased Pulse Increased RR
When caring for a pt with severe burns, the nurse can expect to administer pain medications via which route?
Intravenous
The nurse is admitting a patient who is scheduled to undergo a cardiac catheterization. Which of the following allergies is most important for the nurse to assess before this procedure?
Iodine
What do we want to increase in adolescents?
Iron and calcium
During the preoperative assessment of a pt scheduled for a cholecystectomy at an outpatient center, the pt tells the nurse that she uses St. johns wart to keep her spirits up. Why should the nurse notify the anesthesiologist about this use of st johns wart?
It may prolong the effects of anesthetics.
What is the term for yellow skin color?
Jaundice
An unconscious male client is admitted to an emergency room. Arterial blood gas measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, a normal oxygen level, and an elevated potassium level. These results indicate the presence of:
Metabolic Acidosis
Why does dishiscence happen during the first 3 days?
More than likely due to sutures
Any patient that has surgery on brain or eyes encourage them
NOT to cough
The evening nurse reviews the nursing documentation in the pt's chart and notes that the day nurse has documented that the pt has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the pts sacral area?
Partial thickness skin loss of the dermis.
The nurse identifies the problem of a potentioal complication for a pt in acute congestive heart failure. For which early symptom of this problem does the nurse assess?
Pink frothy sputum
A postoperative client asks a nurse why it is so important to deep breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to:
Pneumonia
A patient admitted with HF appears very anxious and complains of shortness of breath. Which of the following nursing actions would be appropriate to alleviate this patients anxiety (select all that apply)?
Position patient in a semi-Fowlers position. Administrate ordered morphine sulfate. Instruct patient on the use of relaxation techniques. Use a calm, reassuring approach while talking to patient.
What is determined by urine specific gravity?
Pt hydration status
We dont use SCD's on?
Pt with active DVT
Nursing interventions for evisceration
Put pt NPO, Call MD to report, place pt in fowlers or semi fowlers.
What is the first sign of hemorrhage?
Restlessness
Which electrocardiographic (ECG) change will be of most concern to the nurse when admitting a patient with chest pain?
ST segment elevation
The nurse is carign for a postoperative client who has a drain inserted into the surgical wound. Which action should the nurse avoid in the care of the drain?
Secure the drain by curling or folding it and taping it firmly to the body
A nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?
Serous drainage
The intervention for dermatitis medicamentosa is to?
Stop the medication
The nurse has initiated measures to promote suppuration of the carbuncle. Which of the following would indicate that these measures have been successful?
The area has began to drain exudate.
Which client is at risk for the development of a sodium level at 130mEq/L?
The client who is taking diuretics
A victim has just received an electrical burn. The primary concern is?
The likelihood of cardiac arrest.
The nurse observes a student nurse suction the right bronchus of a patient via tracheostomy. The nurse determines care is appropriate if the student nurse places the patients head in which positions?
The patients head turned to the left.
A nurse in monitoring a group of pts's for increased risk for developing pneumonia. Which of the following patients should the nurse expect to be at risk? Select all that apply?
The pt with dysphagia, The patient with aids, The patient with a head injury on the ventilator
On postoperative day 4 after undergoing a total hip replacement. He is diagnosed as having a pulmonary emblism. Pulmonary embolism may occur as a postoperative complication of
Thrombosis
The nurse is caring for a person who has severe poison ivy. Soaks with Burrows solution are ordered. What is the primary reason for using Burrows solution soaks?
To help dry oozing leasions
If you have a pressure ulcer with 70% slough covered what stage would you document?
Unstageable
If you have a pressure ulcer with black necrotic covering what stage would you document?
Unstageable
What is anticoagulant therapy used for?
Used in the prevention of forming new clots. Will not dissolve clots.
An alert and oriented elderly pt is aditted to the hosptial for treatment of cellulitis of the left shoulder after an arthroscopy. Which fall prevention strategy is most appropriate for this pt?
Using a night light in the bathroom.
Which of the following is a priority in the nursing assessment of a pt preoperatively?
Verification of pt's identification
The nurse prepares to care for a pt with cellulitis in the lower leg. The nurse anticipates that which of the following will be prescribed for the pt?
Warm compresses to the affected area.
Best way to measure weight is by?
Water balance
hypokalemia can lead to
Weak heart and an ileus
A patient in the intensive care unit with ADHF complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All these medications have been ordered for the patient. The first action by the nurse will be to
administer IV morphine sulfate 2 mg
The nurse identifies the collaborative problem of potential complication: pulmonary edema for a patient in ADHF. When assessing the patient, the nurse will be most concerned about
an oxygen saturation of 88% on room air.
Pt is blind (not my plate) what do you do?
ask them if they need help
How long should SCD's be worn post op?
at lteast 72 hours
A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. The patient has pitting edema in both ankles, blood pressure (BP) of 170/100, an apical pulse rate of 92, and respirations 28. The most important assessment for the nurse to accomplish next is to
auscultate lung sounds
which pt teaching would help to prevent venous stasis
avoid crossing the legs at the knee elecate legs when lying in bed or sitting wear elastic stockings when ambulating
A pt is admitted with a diagnosis of possible aortic aneurysm. In assessing her, it is most important to monitor her
blood pressure
Which of the following are included when assessing a mole? select all that apply
borders, color, size
A nurse is monitoring the status of a post-operative client. The nurse would become most concerned with which of the following signs that could indicate an evolving complication?
increasing restlessness
Serosanguineous
clear, pink, thin and watery
The pt age 26 is hospitalized with cardiomyopathy. While obtaining a nursing history from her the nurse recognizes that the increased incidence of cardiomyopathy in young adults who have minimal risk factors for cardiovascular disease is related to
cocaine use
The patient has been hospitalized for congestive heart failure 3 times in the last 4 months. While preparing the discharge teaching plan, the nurse assesses that he does not comply with his medication regimen. The nurses immediate course of action would be
collect more information to identify his reasons for non compliance
A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply:
contact the surgeon instruct the client to remain quiet prepare the client for wound closure document the findings and actions taken
After an infuenza like illness, the pt complains of chills and small petechiae in his mouth and legs A heart murmur is detectable. These are characteristic signs of
inefective endocarditis
A pt age 34 is diagnosed with inefective endocarditis. The nurse identifies the nursing diagnosis of Activity intolerance related to generalized weakness for him. Which intervention does the nurse plan while he is febrile?
decreaded activity
The nurse is caring for a patient receiving IV furosemide (Lasix) 40 mg and enalapril (Vasotec) 5 mg PO bid for ADHF with severe orthopnea. When evaluating the patient response to the medications, the best indicator that the treatment has been effective is
decreased dyspnea with the head of the bed at 30 degrees.
A nurse is developing a list of home care instructions for a client being dischared after a laraoscopic cholecystectomy. Which of the following instructions would be the least appropriate to include in the postoperative discharge plan of care?
deep breathing exercises
What are older adults at risk for after surgery?
dehydration and perstasis
Why is surgery performed?
diagnose, cure, palliate, prevent, explore, and/or provide cosmetic improvement.
What are s/s of dehydration?
mild disoreintation thirst, dry mucous membranes poor skin turgor increase hr decrease bp flat neck veins
Nursing for ventilation (remember MAPPET)
monitor for hypoxia ABG Pulse OX Pain meds Early ambuation Turn, cough
A pt has heart failure. His physician orders include complete bed rest. the nurse knows that his order means he
must remain as quiet as possible, with any task requiring physical effort done for him.
What are the signs of digoxin toxicity
nausea, bradycardia, headache and visual disturbance
How long can SCD's be taken off for?
no longer than 30 minutes at a time
Snack during pregnancy and to help with lactation
nuts
A pt has a diagnosis of heart failure. When the nurse walks into his room he is leaning over his bedside table and is short of breath. The medical term to describe his respiratory status is
orthopnea
The pt achieves comfort in breathing only when he assumses a sitting position. This is described as
orthopnea
During the nursing history and physical assessment of a pt with left sided heart failure, which finding might the nurse expect to find related to the pt's diagnosis?
orthopnea eith bubbling crackles throughout the lungs
A central venous pressure line is inserted in a client. Following the catheter insertion, the client reports dyspnea, shortness of breath and chest pain.The nurse understands the most probable cause of these symptoms is?
pneumothorax
Vitals during recover
q15x4 q30x4 qhrx4
sanguineous
reddish, thin and watery
functions of sodium
regulate fluid and acid/base balance, maintain BP and volume, nerve transmission and muscle contraction Stimulate conduction of nerve impulses Contractibility of muscles
The nurse cares for an older client admitted to the hospital for persitant vomiting and adbominal pain. A NG tube is inserted and connected to suction, and an IV infusion of 1000mL of DW5 with 20 mEq of potassium chloride has been added to the infusion. For which reason?
replaces the potassium lost during suction
A pt presents to the primary care clinic reporting frequent scratching and itching of the skin that is worse at night. The nurse concludes that the pt most likely has which of the following conditions.
scabies
The primary mode of transmission for herpes simplex is?
skin to skin contact
The nurse is assessing an older adults skin. The assessment will involve inspecting the sking for color, pigmentation, and vascularity. The critical component in the nurses assessment is noting the?
skin turgor
A pt age 72 was admitted to the medical unit with a diagnosis of angina pectorsis. Characteristics and symptoms include
substernal pain that radiates down the left arm.
urgent surgery
surgery that is not an emergency, but must be done within a reasonably short time frame to preserve health
what is pallative surgery?
surgery used for comfor, reduce symptoms , not to cure
When providing discharge teaching to a pt with endocarditis regarding prevention of infections what would the nurse stress?
taking antibiotics as prescribed
Mechanical soft diet is used for who
those who have trouble chewing and swallowing and those with mouth sores
The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestations would the nurse expect to note in the client?
twitching
incomplete protein sources
vegetable proteins (grains, legumes, nuts, seeds, and vegetables)
Modifiable risk factors for CAD
weight diet and excercise
A pt with angina pectoris is being discharged with nitroglycerin tablets. Which of the instructions does the nurse include in the teaching
when your chest pain begins, lie down and place one table under your tongue. if the pain continues take another tablet in 5 minutes.
Sodium is retained
while potassium is excreted
The nurse would include which of the following priority interventions in the plan of care for a pt diagnosed with herpes zoster?
Monitor skin integrity for secondary bacterial infections
During an assessment of a pt with asthma, the nurse recognizes that the symptoms that occur are related to which primary physiological feature of asthma?
Narrowing of the airway.
A patient is admitted to the hospital after sustaining severe electrical burns. A tracheostomy is performed and the patient is unable to use either hand. It is most important for the nurse to take which of the following actions?
Obtain a blow touch call bell.
The nurse is instructing a hospitalized pt with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the patient to assume?
Sitting on the side of the bed and leaning on an overbed table
A male patient has presented with respiratory effort that was strnuous, struggling and had a snoring sound. This is classified as what kind of respiration?
Stertorous
A pt has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported?
Sudden chest pain.
The removal of fluid from the pleural space by thoracentesis presents a possible danger in removing fluid too rapidly. How much fluid removal is recommended at one time?
1300-1500mL at one time
The nurse is speaking with a 15 y/o that has acne vulgaris. When the nurse explains this condition, it is important to?
Explore how this condition is affecting his self image
The clinic nurse is on call this weekend to answer calls for a pediatric office. A mom calls the clinic about her child who is experiencing a sever asthma attack that is not responding to medication. The nurse knows this is life threatening and instructs the mom to call EMS. What is the term associated with this?
Acute on chronic asthama exacerbation
The nurse is caring for an adult who has herpes zoster. What medication is most likely to be administered to this patient?
Acyclovir
An adult patients is admitted to the post anesthesia care unit following an abdominoperineal resection. Which action should the nurse take initially?
Assess respiratory function
When performing a skin assessment, the nurse notes angiomas on the chest of an older pt. Which action should the nurse take next?
Assess the pt for evidence of liver disease.
When a pt has experienced a pneumothorax, chest auscultation reveals?
Bilateral unequal breath sounds with no breath sounds over the affected area
Ecpected findings in a pt with obstructive sleep apnea would include which fo the following. Select all that apply.
Complaints of daytime sleepiness, Elevated BP, Morning H/A
A patient who has had abdominal surgery complains of feeling as though something gave way in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision Which nursing interventions should the nurse take? Select all that apply.
Contact the surgeon, place moist sterile gauze over site, prepare patient for surgery and document the findings.
A nurse is teaching with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan?
Cool wet clothes or compresses can be used to reduce swelling Use an OTC antihistamine to reduce itching Take cool tepid baths several times daily to reduce itching.
Which finding would alert the nurse that a complication has resulted as part of the flu?
Crackles in the lungs.
Cimetidine (Tagamet) is prescribed for a pt with major burns. In teaching the pt about the drug, the nurse explains that it is used to prevent the development of which generalized stress response to burn injury.
Curlings ulcer
A 29 y/o pt is receiving acyclovir for genital herpes. Which of the following would indicate a therapeutic response?
Decrease in pain
The nurse is caring for a client who is experiencing orthopnea. The nurse recalls that which is the correct definition of this term?
Difficulty breathing in a supine position
The ER nurse is assessing a patient who has sustained blunt injury to the chest wall. Which finding would indicate the presence of a pnuemothorax in this patient?
Diminished Breath sounds
When assessing respiratory status, the nurse observes a respiratory rate of 20/min and symmetrical expansion of the chest. The nurse should?
Document all observations.
The nurse is caring for a pt admitted for the second time this month with chronic bronchitis. The nurse would expect his skin color to appear?
Dusky
The nurse is caring for a patient who ask"the doctor told me that COPD was really a lot of different diseases. Does that mean I have more than one disease?" The nurse recalls that which of the following is classified as COPD disorder?
Emphysema
An 83-year-old admitted with a temp of 102, chest pain and fatigue. The chest x ray shows an accumulation of fluid in the pleural space, which the physician attempts to remove by performing a thoracentisis. The exudate is purulent and requires a chest tube for drainage. The puruent exudate is called?
Empyema
An adult has returned to the surgical floor following an abdominal cholecystectomy and an uneventful stay in the post anesthesia room. Which nursing action should be the highest priority?
Encourage her to take deep breaths
Melanocytes give rise to the pigment melanin, which is responsible for skin color. Where can the melanocytes be found?
Epidermis
The nurse is developing a health promotion plan for an older adult who worked int the landscaping business for 40 years. the nurse will plan to teach the pt about how to self assess for which clinical manifestations?
Erythema Actinic keratosis
A 52 y/o pt had a laryngectomy for treatment of cancer of the larynx. A nursing diagnosis for the patient with a laryngectomy would be impaired verbal communication related to removal of the larynx. The correct nursing intervention would be?
Have a pad and pen or pencil available.
A pt is admitted after several episodes of expectorating frothy, bright red blood from the lungs. This is called?
Hemoptysis
A pt with herpes simplex virus 1 comments that she hopes she never gets another lesion on her lip like this one. What is the nurses best response?
Herpes simplex virus 1 can be reactivated at any time
The nurse is caring for a pt hospitalized with acute exacerbation of COPD. Which finding would the nurse expect to note on assessment of this patient. Select all that apply.
Hyperinflated chest on chest x ray Decreased oxygen saturation with mild exercise.
The nurse has conducted preoperative teaching for a patient for surgery in 1 week. The patient has a history of arthritis and has been taking aspirin. The nurse determined that the patient needs addition teaching if the patient makes which statement?
I need to continue to take the aspirin until the day of surgery.
The pt with pulmonary edema will likely receive all of the following treatments except?
IV infusion of NS
Which of the following nursing diagnoses does the nurse develop for a newly admitted patient with pulmonary emboli?
Impaired gas exchange.
A child has been sent to the school nurse with pruritis and honey colored crust on the lower lip and chin. The nurse believes these lesions most likely are?
Impetigo
A pt in the dermatology clinic is scheduled for removal of a 15mm multicolored and irregular mole from the upper back. The nurse should prepare the pt for which type of biopsy?
Incisional biopsy
The nurse is assessing a pt with multiple traumas who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?
Increased respiratory rate.
The nurse is monitoring the status of a postoperative patient. The nurse would become most concerned with which sign that could indicate an evolving complication?
Increasing restlessness.
On auscultation of a pt's thorax, the nurse hears short, high pitched sounds just before the end of inspiration in the right and left lower lobes. The nurse records this finding as which respiratory sound.
Inspiratory wheezes in both lungs.
The home health nurse is making a visit to a pt recently diagnosed and discharged from the hospital with a diagnosis of COPD. The nurse observes that when the pt becomes a little SOB she adjusts her oxygen to a higher level. What is the priority action?
Instruct the pt on safe oxygen use and not adjusting oxygen to higher levels.
A 30 year old african american is post op surgery 6 months. Her incisional site is now raised and indurated and shiny. This tissue growth is most likely?
Keloid
When caring for a patient receiving conscious sedation, which of the following should the perioperative nurse routinely monitor?
Level of consciousness.
Which areas of the brain are responsible for the basic rhythm and depth of respiration's?
Medulla oblongata and pons varolii
A 62 y/o pt has a diadnosis of herpes zoster. The primary problem for the pt is?
Pain and pruritus
A pt is admitted for possible carcinoma of the larynx. The first sign or symptom that may be present in this is often?
Persistent hoarseness
A pt is being seen in the emergency room with epistaxis. The correct nursing interventions would include all of the following except?
Placing he pt in the fowlers position with the head hyperextended.
A postoperative patient asks the nurse why it is so important to deep-breathe and cough after surgery. The nurse incorporates the understanding that retained pulmonary secretions in a postoperative patient can lead to which condition?
Pneumonia
The nurse instructs a pt to use the pursed lip method of breathing and the patient asks the nurse about the purpose of this type of breathing. The nurse responds knowing that the primary purpose of pursed lip breathing is to promote which outcome?
Promote carbon dioxide elimination
The nurse is caring for a pt that is over heparinized. What medication does the nurse expect to administer?
Protamine sulfate
A pt has just been diagnosed with psoriasis asks the nurse what should be done to prevent family members from getting the condition. What should the nurse include when responding to this condition?
Psoriasis is not contagious, so no special precautions are necessary.
For which patient is it most important for the nurse to provide teaching on ways to prevent the spread of the condition?
Pt with tinea corporis
Which respiratory condition is characterized by pink frothy sputum?
Pulmonary edema
A 22y/o is admitted with acute asthma. A noninvasive method of monitoring of SaO2 for assessment of gas exchange in which a probe is applied to a finger, toe, earlobe or nose is called?
Pulse oximetry
A patient has an inhalation burn injury. Which of the following is a medical emergency?
Respiratory Stridor
A 68 y/o pt with COPD has a markedly increased need for protein and calories to maintain an adequate nutritional status. To help this patient get the nutrition he needs, the nurse would encourage him to?
Rest 30 minutes before eating.
A patient is scheduled for rhinoplasty. It is most important for the nurse to place the patient in which of the following positions?
Semi-Fowlers.
The nurse assesses a patients surgical incision for sign of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?
Serous drainage.
A 28 y/o man received severe burns of the chest, abdomen, back, legs, and hands when the house caught fire. In the emergency room, a nasogastric tube was inserted and the pt was ordered NPO. What is the primary reason for the nurse to keep this pt NPO?
To help prevent paralytic ileus
The appropriate nursing intervention for a pt age 40 who is diagnosed with active TB would be?
To place the patient on airborne isolation precautions.
A pt has developed severe dermatitis and states that the itching is severe and cannot keep from scratching. Which instruction would be most helpful in managing the pruritus?
Use cool, wet dressing and baths to promote vasoconstriction
What would be the priority for the nurse to stress to the 17 y/o girl who has been prescribed Accutane for acne?
Use dependable birth control to avoid pregnancy.
Which of the following is a priority in the nursing assessment of a patient postoperatively?
Verification of patients identification.
The nurse is providing teaching to a mother of a child with pediculosis. What is important teaching that the nurse should include?
Wash all the clothing and linens
An elderly pt is admitted with emphysema. The first sign or symptom is usually?
dyspnea
A pt with legionnaire's disease is likely to exhibit?
dyspnea and tachycardia
Your pt has sustained thermal burns to 18% of her body surface areas. The nurse is aware that after 72 hours the most common causes of burn related death is?
infection
Which may indicate a malignant melanoma in a nevus on a pt arm?
irregular border of the mole
A nurse in the clinic is caring for a pt whose wife states he woke up this morning confused. The pt reports chills and chest pain that worsens on inspiration. Which of the following would be the nurses priority?
obtain a baseline vital sign and oxygen saturation
The nurse is caring for a patient diagnosed with pnuemothorax. The baseline oxygen sat is 80% and baseline RR is 26. A chest tube is inserted, which would indicate an improvement in the pt's condition?
oxygen Sat of 90%
A patients blood is too thin from receiving high doses of coumadin(warfarin). What medication would the nurse anticipate administering?
vitamin K
What is the most effective method to prevent the spread of infection to others when the nurse is changing the dressing over a wound infected with staphylococcus aureus?
wash hands and properly dispose of soiled dressings
