Med Surge MidTerm

A triage nurse in the emergency department is assessing a client who presented with reports of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this client's presentation?

"How many alcoholic drinks do you typically consume in a week?"

The nurse is caring for a client with sepsis. The licensed provider has ordered 125mg of Vancomycin to be given over 2 hours daily. The pharmacy sends up vancomycin and the label reads, "Vancomycin 125mg in 250ml of normal saline". How many ml per hour would you give this client?

125 ml/hr

Order: Heparin 1.3 units/kg/minute Available: Heparin 125 units/mL Clients Weight; 275 lbs What is the rate mL/hr.

78 mL/hr

A nurse is assessing a client's stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding?

A nurse is assessing a client's stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding?

The nurse is monitoring a client with a diagnosis of peptic ulcer(s). Which assessment finding would most likely indicate perforation of an ulcer?

A rigid, board-like abdomen

A nurse is performing a musculoskeletal assessment of a client with arthritis. During passive range-of-motion exercises, the nurse hears an audible grating sound. The nurse should document the presence of what assessment finding?

Crepitus

Which finding is likely in the nurse's assessment of a client who has a large bowel obstruction?

Abdominal distention

Which action would the nurse plan when admitting a patient with acute diverticulitis plan for initial care?

Administer IV fluids.

A client has cirrhosis and 4+ pitting edema. Which focused data would the nurse assess?

Albumin level

Which action would the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy?

Ask the patient to extend both arms forward.

A 50-year-old client has arrived for a colonoscopy and states she is worried that the gastroenterologist will find cancer. Which assessment finding would the nurse expect for a client who is in the early stages of colon cancer?

Asymptomatic

A nurse is assessing the neurovascular status of a client who has had a leg cast recently applied. The nurse is unable to palpate the client's dorsalis pedis or posterior tibial pulse and the client's foot is pale. What is the nurse's most appropriate action?

Contact the primary care provider promptly.

A group of recent graduate nurses are in orientation reviewing the risk factors for osteoporosis with the nursing educator. Which of the following risk factors should the educator describe?

small frame and female sex

A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments?

Daily weights and abdominal girth measurement

A nurse is caring for a client who just has been diagnosed with a peptic ulcer. When teaching the client about his new diagnosis, how should the nurse best describe it?

Erosion of the lining of the stomach or intestine

The nurse is reviewing the medication list for a client who reports they take medication for gastroesophageal reflux disease (GERD). The client ask the nurse to confirm what medication is used for this condition.

Famotidine

A client just had an arthroscopy done as an outpatient procedure and is getting ready to discharge home. The nurse caring for the client should teach the client to monitor closely for what post procedure complication?

Fever

An adult client is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the client has completed the test?

Fluids must be increased to facilitate the evacuation of the stool.

During a health education session, a participant asked about the hepatitis A virus. What prevention measure should the nurse recommend for preventing infection with this virus?

Following proper hand-washing techniques

A client who is being treated for cirrhosis comes to the outpatient clinic for a follow-up appointment. During this appointment, the client states, "I haven't had an alcoholic drink for 8 months." In analyzing the lab values below, which is the best statement to describe the client's disease progression?

Fortunately, your labs are greatly improved."

The nurse on a medical surgical floor has a new client being admitted with increased intra-abdominal pressure and weakening of the diaphragmatic muscle. The client presents with nausea, vomiting, dysphagia, and a feeling of fullness. The nurse would understand that this client is potentially experiencing what condition?

Hiatal Hernia

A nurse is caring for a client in an outpatient interventional radiology unit who undergoes paracentesis weekly. During this visit, the nurse observes the client to be more confused and with more abdominal swelling than usual. What is the most appropriate action by the nurse?

Immediately notify the health care provider

A client requires long-term systemic corticosteroid therapy for the treatment of contact dermatitis. Which of the following effects has been associated with the chronic use of corticosteroids?

Increased blood glucose levels

A 35-year-old client presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the health care provider, what intervention should the nurse prioritize?

Insertion of a nasogastric tube

The nurse is preparing to perform a client's abdominal assessment. What examination sequence should the nurse follow?

Inspection, auscultation, percussion, and palpation

A client who underwent a gastric resection 3 weeks ago is having their diet progressed on a daily basis. Following the latest meal, the client reports dizziness and palpitations. Inspection reveals that the client is diaphoretic. What is the nurse's best action?

Monitor the client closely for further signs of dumping syndrome.

A nurse is assessing a client for risk factors known to contribute to osteoarthritis. What assessment finding should the nurse interpret as a risk factor?

Obese

NumberAn 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days. The nurse notes that the site is now swollen and warm to the touch. The client should undergo diagnostic testing for what health problem?s

Osteomyelitis

A nurse is caring for a client who is postoperative day 1 following a total arthroplasty of the right hip. How should the nurse position the client?

Place a ppillow between legs

A client was fitted with an arm cast after fracturing the humerus. Twelve hours after the application of the cast, the client tells the nurse that the injured arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action?

Prepare the client for opening or bivalving of the cast.

Which information from a 70-year-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C?

The patient used IV drugs about 30 years ago.

A client is brought to the emergency department by ambulance after stepping in a hole and falling. While assessing the client the nurse notes that the client's right leg is shorter than the left leg; the right hip is noticeably deformed and the client is in acute pain. Imaging does not reveal a fracture. What is the most plausible explanation for this client's signs and symptoms?

Traumatic hip dislocation

A 32-year-old female is admitted to the emergency department for abdominal pain that has worsened over the past 2 days. She states that she has a history of ulcerative colitis and that it has "never been this bad." She is lying still on the bed and reluctant to turn for an assessment. Vital signs are blood pressure 132/88 mm Hg, pulse 98 bpm, respirations 26 and shallow, temperature 101°F (38.3°C). The abdomen is slightly distended, with rebound tenderness noted upon gentle palpation of the left upper quadrant. The patient reports having 8 diarrhea bowel movements in the last 24 hours, with blood noted in most of them. She also reports feeling "so tired" all the time and having nausea but no vomiting. She has only had water to drink for the last 24 hours because she has not been hungry. She rates the abdominal pain at an "8" as long as she does not move. Lab results include hemoglobin 12 g/dL, hematocrit 37.2%, sodium 136 mEq/L, and potassium 4.2 mEq/L.

Your Answer: 32 Female hx of UC VS within normal except Temp of 101, Pain level = 8, "tiredness and nausea", Bloody stool 8X q day H&H low Abdominal exam slightly distended, rebound tenderness in LUQ Temp 101 concerning, abdominal suggest bowl perforation