Med surge 2300 Unit 7

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?

A client with a nasogastric tube

Tiene dolor? Donde le duele?

Do you have pain? where does it hurt?

The nurse is assessing a client who had an ileostomy created three days ago for the treatment of irritable bowel disease. The nurse observes that the client's stoma is bright red and there are scant amounts of blood on the stoma. What is the nurse's best action?

Document these expected assessment findings

Crohn's disease is a condition of malabsorption caused by which pathophysiological process?

Inflammation of all layers of intestinal mucosa

A nurse is reviewing lab results for a client with an intestinal obstruction, and infection is suspected. What would be an expected finding?

Leukocytosis: , elevated hematocrit; low sodium, potassium, and chloride.

A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe?

Older adults often lack the classic signs and symptoms of pneumonia

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?

The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg. or higher.

A client has a newly created colostomy. After participating in counseling with the nurse and receiving support from the spouse, the client decides to change the colostomy pouch unaided. Which behavior suggests that the client is beginning to accept the change in body image?

The client touches the altered body part.

A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan?

Using strict hand hygiene

A client is admitted to the emergency department with reports right lower quadrant pain. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the health care provider immediately?

White blood cell (WBC) count 22.8/mm

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must:

continue to take antibiotics for the entire 10 days

Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections?

receiving vaccination

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?

Dyspnea and wheezing

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?

Encouraging increased fluid intake

In the prevention of occupational lung diseases, the nurse would direct preventive teaching to which high-risk occupations? Select all that apply.

Rock quarry worker Miner Stone cutter

When providing care for a client who has a diagnosis of irritable bowel syndrome (IBS), the nurse should collaborate with the client and prioritize what goal?

accurate identification of foods that trigger symptoms

Which would be least likely to contribute to a case of hospital-acquired pneumonia?

A nurse washes her hands before beginning client care.

Which long-term care facility resident most likely faces the greatest risk for aspiration?

A resident who suffered a severe stroke several weeks ago.

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first?

administer oxygen by nasal cannula as ordered.

A client has a 10-year history of Crohn disease and is seeing the physician due to increased diarrhea and fatigue. What is the recommended dietary approach to treat Crohn disease?

dietary approach varies

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia?

Encourage increased fluid intake

A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority?

Impaired gas exchange

A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be:

Ineffective airway clearance

A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan?

Placing the client in respiratory isolation

It is important for the nurse to monitor serum electrolytes in a patient with acute diarrhea. Select the electrolyte result that should be immediately reported.

Potassium of 2.8 mEq/L

During a community health fair, a nurse is teaching a group of seniors about promoting health and preventing infection. Which intervention would best promote infection prevention for senior citizens who are at risk of pneumococcal and influenza infections?

Receive vaccinations

Which technique does the nurse suggest to a client with pleurisy while teaching about splinting the chest wall?

Turn onto the affected side

A client presents to the emergency department with complaints of acute GI distress, bloody diarrhea, weight loss, and fever. Which condition in the family history is most pertinent to the client's current health problem?

Ulcerative colitis