Medical Surgical Complex Test #4 Simple Nursing Questions

Child is nauseous not eating, maybe vomiting, do you still give insulin?

Yes, we give sick day insulin to prevent DKA, because glucose is high during times of illness.

Client diagnosed with melanoma. Which statement by a client indicates that education was effective?

It is highly metastatic.

What complication is a patient with cirrhosis at risk for?

Bleeding

Client with a small bowel obstruction suddenly develops tachycardia and tachypnea with a high fever. What is most likely the problem?

Bowel perforation notify HCP

Which client should the nurse assess first?

Epigastric pain after endoscopic retrograde cholangiopancreatography (ERCP).

Priority action for a client with bowel protruding through abdomen?

Call for help (the client needs emergency surgery and the nurse should not leave the client.

The nurse is caring for a client with ulcerative colitis. Which finding does the nurse determine is consistent with this diagnosis?

Decreased Hemoglobin

Following a gastrectomy. Which instructions should the nurse include to prevent dumping syndrome?

Divide meals into 6 small feedings.

A client has hepatitis, what advice should the nurse include regarding personal living?

Do not share personal care products (Toothbrushes, razors)

The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction?

"I should increase the fiber in my diet."

A client is admitted with hepatitis and complains of constant itching. What interventions would the nurse recommend? SATA

1. Apply a moisturizer. 2. Avoid the sun. 3. Apply a cold compress.

Which blood lab values are expected to be elevated in a client with worsening liver cirrhosis? SATA

1. Ammonia 2. Bilirubin 3. Prothrombin time (PT)

Which assessments would indicate if a client with cirrhosis has progressed to hepatic encephalopathy? SATA

1. Ask the client for their DOB, Name, Date, and Location. 2. Tell the client to extend their arms. 3. Compare ammonia blood levels with that of previous shifts.

Modes of Transmission for Hepatitis C? SATA

1. Blood. 2. Semen. 3. Vaginal secretions.

The nurse should incorporate which dietary plan to ensure optimal nutrition, during the acute phase of hepatitis? SATA

1. Consume multiple small meals throughout the day. 2. Allow the client to select foods that are most appealing. 3. Eliminate fatty foods from the meal trays until nausea subsides.

Interventions for a client with ulcerative colitis? SATA

1. Discuss plans to decrease client's stress. 2. Give analgesics as prescribed. 3. Increase protein foods with meals. 4. Monitor Inout & Output closely.

A client with worsening liver failure failure presents to the med-surg floor, which assessment findings should the nurse expect? SATA

1. Enlarged abdomen from ascites. 2. Bruise marks on the skin. 3. Fatigue and possible confusion.

A client admitted to the hospital. Which assessment findings would be consistent with acute pancreatitis? SATA

1. Gray-blue color at the flank. 2. Abdominal guarding and tenderness. 3. Left upper quadrant pain that radiates to the back.

Which food would be most appropriate for a patient who recently has a bout of acute pancreatitis? SATA

1. Grilled chicken and a baked potato. 2. Reduced fat cheese and whole wheat crackers.

The nurse teaching the client with viral hepatits, this disease is characterized by which specific assessment findings? SATA

1. Jaundice 2. Clay-colored stools 3. Elevated bilirubin levels 4. Dark or tea-colored urine.

Dietary alterations for clients with family history of colorectal cancer.

Add cabbage to the diet to reduce risks of colorectal cancer.

Client with cirrhosis, portal hypertension, ascites, and esophageal varices. Which of the following is correct patient teaching?

Avoid straining when having a bowel movement.

Which nursing action is important after a patient has a partial gastrectomy to prevent further complications?

Measure the patient's serum vitamin B12 level.

Which disorder does the nurse suspect in an elderly patient with a history of diverticulosis who reports rectal bleeding?

Colon Cancer

Client with a family history of colorectal cancer, with unexplained weight loss, change in bowel habits, & hemoglobin value of 9 compared to 14 just 12 months earlier. Which diagnostic test is expected?

Colonoscopy

A client just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication?

Fluid and Electrolyte imbalance

A nurse is assisting with a paracentesis for a patient with ascites caused by cirrhosis. Which action should the nurse take first?

Have the patient empty their bladder.

After performing a physical assessment and obtaining vital signs for a client with acute pancreatitis, which nursing intervention is the priority?

IV fluids and pain control.

A client recovering from a partial gastrectomy presents with vomiting, severe abdominal pain, blood pressure 105/62, heart rate 122//min, temperature 100.5 F. Which action should the nurse take?

Immediately notify the HCP or surgeon.

The nurse notes, widespread nevi across the body. Which characteristic, if demonstrated by one of the nevi, would cause the nurse to be concerned about malignancy?

Irregular border.

Client who has a new colostomy. The nurse should encourage which diet for the first 4 to 6 weeks postoperatively?

Low Fiber

Client with a history of cirrhosis, with suspected gastroesophageal varices. Which order would the nurse question?

New nasogastric tube insertion.

First action when a client with cirrhosis begins vomiting blood after a meal?

Obtain vital signs (probable esophageal varices)

A patient with cirrhosis and esphageal varices is vomiting, and the nurse notes hematemesis. Which action should the nurse take first?

Place the patient in the side-lying position.

Which nursing intervention would be the highest priority in managing a patient with ruptured esphageal varices?

Protecting the airway.

A client with cirrhosis, shows signs of hepatic encephalopathy. The nurse should plan a dietary consultation to limit which ingredient?

Protein

The nurse is caring for a patient with severe liver cirrhosis and imbalanced nutrition. Which nursing intervention would prevent malnutrition in this patient?

Provide oral care before meals.

The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the PCP?

Purple discoloration of the stoma.

The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, should the nurse mention to the primary health care provider.

Rebound Tenderness

What would the nurse advise a patient to avoid to minimize the risk of skin cancer?

Tanning beds.