Medical Surgical Final
In the postanesthesia care unit (PACU), an elderly client begins to behave erratically and is yelling out to the staff. What factor may be contributing to this behavior?
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The nurse hears the high-pressure alarm sound in a client's room. What does the nurse understand can cause the high-pressure alarm to sound
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A patient with a history of chronic respiratory illness exhibits nail clubbing. The nurse interprets this finding as indicating which of the following?
Hypoxia
A client who had abdominal surgery 4 days ago reports that "something gave way" when he sneezed. The nurse observes a wound evisceration. Which nursing action is the first priority?
Applying a stenle, moist dressing
An Asian-American child with a bleeding head injury was admitted to the emergency room. The nurse demonstrates cultural awareness to the parents if she states which of the following?
May I touch your son's head to look for cuts and bumps?
A client who will have his last chemotherapy cycle in 11 days becomes neutropenic. The client understands his condition when he states:
I'll monitor my temperature frequently and go to the nearest emergency room if my temperature rises above 100.4 F.
A client is evaluated for type 1 diabetes. Which client comment correlates best with this disorder?
I'm thirsty all the time. I just can't get enough to drink.
A nurse has an order from the physician to administer digoxin 0.25 mg orally. The nurse realizes this action takes place in which step of the nursing process?
Implementation
A nurse is documenting a patient's chief complaint/reason for seeking care in the medical record. Which of the following would be MOST appropriate?
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Which medication should a nurse have on hand when removing a sheath after cardiac catheterization?
Atropine - to increase the heart rate. Removal may cause vasovagal response or bradycardia
A nurse is reviewing the history and physical of a client admitted for a hemorrhoidectomy. Which predisposing condition does the nurse expect to see?
Constipation
The nurse is reviewing the chart of a client with swallowing problems. Which of the following factors would raise suspicion that the client has cancer of the esophagus?
Trouble swallowing feeling like something caught in throat
A nurse practitioner is preparing to perform a pelvic examination of an adult patient. When performing this assessment, the ideal position is:
Supine lithotomy
A patient's kidneys have just increased the amount of erythropoietin that they release. This action is likely a response to what feedback?
The patient has decreased oxygen tension
A nurse has developed a plan of care for a patient with a nursing diagnosis of "risk for spiritual distress." Which interventions would the plan most likely include?
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A nurse is caring for an elderly adult client admitted to the hospital from a nursing home because of a change in behavior. The client has a diagnosis of Alzheimer's disease and has started to experience episodes of incontinence. The hospital staff is having difficulty with toileting because the client wanders around the unit all day. To assist with elimination, a nurse should:
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A nursing assistant tells the nurse that a client with paraplegia has an area of skin breakdown on his left calf. When the nurse assesses the client, he is sitting on a cushion in a wheelchair and wearing specialty boots. The nurse notes a circular wound 2 cm × 2 cm × 0.25 cm on the posterior aspect of the calf. What most likely caused the client's skin breakdown?
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A patient undergoing rehabilitation reports problems with constipation. Which suggestion would be least appropriate?
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After educating a client on MyPyramid recommendations, the nurse realizes more education is needed when the client makes which of the following remarks?
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An elderly client with primary degenerative dementia is slow in following simple directions and indecisive selecting clothes to be worn for the day. What is the best approach to take?
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A 12-year-old girl fractured her right leg several weeks ago while skiing and is returning to the orthopedist to have her cast removed. What is of primary importance in your nursing management during cast removal?
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A 57-year-old client is seen at the free clinic. He has an edematous glans penis, pain, and an extremely constricted foreskin. What treatment would you expect the physician to prescribe?
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A client comes to the emergency department complaining of moderate to severe testicular pain and tenderness. Both testicles are swollen and a penile discharge is present. The client is diagnosed with viral orchitis. Which of the following would the nurse include in this client's plan of care?
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A client is postoperative and has not taken her pain medication. The nurse is performing an assessment at the beginning of her shift and determines that sensitization has occurred. The first nursing intervention is to
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A client who has recently undergone prosthetic heart valve replacement wants to know why she must take antibiotics following the procedure. What problem would the nurse explain to the client that the antibiotics are used to prevent?
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A client who is undergoing thoracic surgery has a nursing diagnosis of "impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis?
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A client with a pilonidal sinus undergoes surgery. Which of the following would the nurse include in the client's postoperative plan of care?
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A critical care nurse is documenting their assessment of a client they are caring for. The client is status post resection of a brain tumor. The nurse documents that the client is flaccid on the left. What does this mean?
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A nurse enters a client's room to find the client combative and confused. The client is currently in Buck's traction and scheduled for surgery later that day. What is the most appropriate action for the nurse to take?
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The nurse is caring for a client scheduled for an emergency cardiac catheterization. The transport team arrives to take the client to the catheterization laboratory at the same time a group of men arrive to see the client. The client explains to the nurse that these men are the elders from her church who have come to perform a "laying on of hands" to help her come safely through the cardiac catheterization. The best response by the nurse is which of the following?
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The nurse is caring for a client who has just returned from the PACU after surgery for peptic ulcer disease. For what potential complications does the nurse know to monitor
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The nurse is caring for a client who is in contact isolation for an infection. The client informs the nurse that a shaman will be coming to visit and asks for privacy during that time. The most appropriate response from the nurse will be which of the following?
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The nurse is teaching a client how to self-administer insulin. The client inserts the needle into the abdomen, aspirates, and injects the insulin. What action will the nurse take?
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The plan of care for a client with anxiety includes a nursing diagnosis of ineffective coping. The nurse determines that the plan of care was successful when the client states which of the following?
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Which of the following solutions is hypotonic?
0.45% Na Cl, 2.5% dextrose in water, 0.33% NaCl
The nurse is doing a shift assessment on several patients after first taking report. An elderly patient is having her second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new reddened rash on the patient's chest. The patient should be asked what priority question regarding the presence of a reddened rash?
Are you allergic to any food or medication
The nurse is providing morning care for an elderly make patient who has been admitted to the hospital after an exacerbation of congestive heart failure. The patient admits to the nurse that he "can't seem to catch my breath these days." How should the nurse first respond to this patient's complaint of dyspnea?
Assess the circumstances surrounding the patient's shortness of breath.
The nurse begins a routine blood transfusion of packed red blood cells (PRBCs) at 1100. To ensure client safety, the unit of blood should be completely transfused by what time?
1500 and within 4 hours
A nurse is assisting with checking blood pressures at a local health care fair. To which client would the nurse pay particular attention?
A 40 year-old African American male
You are caring for a client diagnosed with a neurologic deficit. The client's family asks you what this means. What is your best answer?
A condition in which one or more functions of the central and peripheral nervous systems are decreased, impaired, or absent
A 21 year-old woman has been recently diagnosed with agoraphobia. Which of the following situations is most likely to cause the woman anxiety?
A fear of being in places it's hard to escape from - perceives environment as dangerous
To combat the most common adverse effects of chemotherapy, a nurse should administer an:
Antiemetic
A nursing priority in any care situation is the establishment and maintenance of a patent airway. Which of the following patients would likely require medical and nursing interventions to protect the airway?
A patient who has gone into anaphylactic shock after inadvertently eating shellfish
A patient with seasonal allergies has told the nurse that a colleague recommended pseudoephedrine hydrochloride (Sudafed) as a means of controlling signs and symptoms. The nurse should be aware that this drug provides relief for many patients but adverse effects include a risk of:
Anxiety
The physician is preparing to bivalve the client's cast. Which supplies should the nurse assemble?
Elastic compression bandages - splits the cast and spreads it to relieve pressure
In addition to teaching a client with constipation to increase dietary fiber intake to 25 g/day, which of the following would the nurse include as important?
Adding fiber rich foods to the diet gradually
A client with type 1 diabetes presents with a decreased level of consciousness and a finger stick glucose level of 39 mg/dl. His family reports that he has been skipping meals in an effort to lose weight. Which nursing intervention is most appropriate?
Administer 1 ampule of 50% dextrose solutions per physician's order - to restore the client's physiologic integrity
Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery?
Apply a compression dressing to the area - during surgery air is expelled through tissue - which is normal
A nurse is conducting an assessment of a patient's musculoskeletal system and assessing for joint function. How should the nurse best perform this assessment?
Assess the range of motion (ROM) of each of the patient's
A patient who suffered a T6 lesion during a spinal cord injury (SCI) 10 days ago is progressing with treatment and rehabilitation following the immediate treatment of his injury. When preparing to help the physical therapist mobilize the patient for the first time since the injury, the nurse should prioritize which of the following assessments?
Assessing the patient's respiratory rate
The client had a triple-lumen central catheter inserted in the right subclavian vein and will now receive total parenteral nutrition (TPN). The nurse includes which of the following in the plan of care?
Auscultate the lungs, check catheter site every two hours, monitor blood glucose levels every 6 hours
You are caring for a client who has had an automatic cardiac defibrillator implanted. What instructions should you provide your client?
Avoid devices with a magnetic field
A middle-aged male has been brought to the emergency department by ambulance after being found unconscious by police with injuries consistent with an assault. Injuries on the man's face and skull necessitate prompt assessment for traumatic brain injury. What neuroimaging tests are best able to yield clinically meaningful data?
CT and MRI
The intensive care nurse is contributing to the care of patient who has just been admitted with a presentation that is characteristic of shock. The nurse is providing constant assessment of numerous parameters but should know that a priority indicator of the patient's current status is:
Blood pressure
After undergoing a thyroidectomy, a client develops hypocalcemia and tetany. Which electrolyte should the nurse anticipate administering?
Calcium gluconate
The nurse has been asked to give a workshop on chronic obstructive pulmonary disease (COPD) for a local community group. When talking about what can be done for patients with COPD, the nurse encourages a COPD patient not to smoke because smoking has what effect?
Increase the amount of mucus production
You are caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery?
Encourage the client to move legs frequently and do leg exercises
The client is admitted to the intensive care unit following surgery. To monitor for accurate fluid intake and output, the client has an indwelling urinary catheter. To prevent an urinary tract infection (UTI), the nurse includes the following interventions in the care plan.
Ensure that collection bag is below the height of the patient's bladder
A patient who has a mandibular structural abnormality has just been admitted to the postsurgical unit from the PACU following surgical remodeling. To ensure this patient's safety, what action should the nurse prioritize?
Ensuring that wire cutters or scissors are available at the patient's bedside
A patient with ovarian cancer is admitted to the hospital for surgery, and the nurse is completing a health history on the patient. What clinical manifestations would the nurse expect to assess?
Increased abdominal girth
A 77-year-old female patient experienced an ischemic stroke 6 days ago and has a nasogastric (NG) tube in place to facilitate tube feeding. The care team has arranged for many of the patient's medications to be made available in liquid form but not all of her medications are available in liquid form. As a result, the nurses have been crushing some of the patient's pills and administering them with warm tap water. Which of the following medications should not be administered in this manner?
Enteric coated ASA
A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?
Cover the protruding internal organs with sterile gauze moistened with sterile saline solution
The nurse is doing triage at the emergency department when a middle-aged patient presents with abdominal pain and heartburn. The patient states the symptoms have persisted for several days following a particularly spicy meal. When assessing the patient, the nurse notes the patient has a history of acute gastritis. What complication should the nurse assess for?
Esophageal or pyloric obstruction related to scarring.
As a nurse completes the admission assessment of a client admitted for gastric bypass surgery, the client states, "Finally! I'll be thin and able to eat without much concern." How should the nurse intervene?
Evaluate the client's understanding of the procedure.
When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority?
Ineffective airway clearance related to edema of the respiratory passages
For a client with cardiomyopathy, the most important nursing diagnosis is:
Decreased cardiac output related to reduced myocardial contractility
A patient diagnosed with multiple sclerosis (MS) has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What would be the expected outcome of this medication?
Decreased muscle spasms of the lower extremities
The nurse is admitting a patient who is experiencing increased signs and symptoms of dilated cardiomyopathy (DCM). What changes in the heart characterize DCM?
Dilated ventricles without hypertrophy of the ventricles
Nursing management of the client with a urinary tract infection should include:
Discouraging caffeine intake
A client who recently had a stroke requires a cane to ambulate. When teaching about cane use, the nurse should explain that the reason for holding a cane on the uninvolved side is to:
Distributes weight away from the involved side
A nurse is caring for a client with left-sided heart failure. To reduce fluid volume excess, the nurse should anticipate using:
Diuretics - Lasix/furosemide to reduce total blood volume and circulating congestion
While participating in a disaster response exercise, a nurse has been reminded by the coordinators that triage in a mass casualty incident (MCI) event differs from triage in nondisaster circumstances. What principle will care providers use to guide the allocation of scarce health care resources in an MCI?
Do the greatest amount of good for the largest number of victims.
You are caring for a client who has premature ventricular contractions. What sign or symptom is observed in this client?
Fluttering and heart skipping
With which disorder is jugular vein distention prominent?
Heart failure - elevated venous pressure exhibited as JVD, indicates the hearts failure to pump
A client is experiencing muscle weakness and an ataxic gait. The client has a diagnosis of multiple sclerosis (MS). Based on these symptoms, the nurse formulates "Impaired physical mobility" as one of the nursing diagnoses applicable to the client. What nursing intervention should be most appropriate to address the nursing diagnosis?
Help the client perform ROM exercises every 8 hours - promotes muscle tone and joint flexibility
A 38-year old female client has begun to suffer from rheumatoid arthritis. She is also being assessed for disorders of the immune system. She works as an aide at a facility which cares for children infected with AIDS. Which of the following factors will hold the greatest implications during the client's assessment?
Her use of other drugs - nurse needs to review patient's drug history
A group of students is reviewing information about oral cancers in preparation for an examination. The students demonstrate a need for additional review when they identify which of the following as a risk factor?
History of GERD Risks: dietary deficiency, smoked meat ingestion, exposure to sun and wind, alcohol and tobacco use
A client is taking 50 mg of oral spironolactone twice a day to assist with blood pressure control. While the nurse is performing the morning assessment, the client reports nausea, general muscle cramps, and weakness. The ECG strip shows a peaked, narrow T-wave, which is a change. What electrolyte imbalance does the nurse suspect?
Hyperkalemia (high potassium)
A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what?
Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis
A mother brings her teenage son to the clinic, where tests show that he has hepatitis A virus (HAV). They ask the nurse how this could have happened. Which of the following explanations would the nurse correctly identify as possible causes?
Infection at school - Suboptimal sanitary habits - Consumption of sewage contaminated water or shellfish
A client has intermittent asthma attacks. Which of the following therapies does the nurse teach the client to use at home when experiencing an asthma attack?
Inhaled albuterol - ventolin
A patient has safely given birth to her first child, a healthy baby boy. The obstetrical nurse who provided labor support is aware that the infant possesses natural (innate) immunity that can protect him from many pathogens. Which of the following statements most accurately describes an aspect of natural immunity?
Innate immunity is dependent on the ability of the cells to differentiate between "self" and "non-self" cells.
A client with severe respiratory compromise due to pulmonary edema has just been admitted to the ICU. What medications would be necessary for the nurse to administer?
Inotropic agent - change the force of hearts contraction
Total parenteral nutrition (TPN) has been ordered for a male patient who has been experiencing a severe and protracted exacerbation of Crohn's disease. Before TPN can be initiated, the patient requires:
Insertion of central venous access device
A client has been admitted with diarrhea. He has mild dehydration (less than 5%). The nurse is reviewing the laboratory report of the stool specimen, as indicated in the following: WBC: Mildly elevated RBC: Few Bacteria: Positive for Escherichia coli Ova and parasites: Negative Based on the laboratory report, what should the nurse do first?
Institute enteric precautions and prevent infection
A 62-year-old male patient has been prescribed allopurinol (Zyloprim) for the treatment of gout. When providing health education to this patient about his new medication, the nurse should know that this drug achieves a therapeutic effect by:
Interrupting the breakdown of purines
A client is in Buck's traction after fracturing his right hip. The nurse should include which action in the care plan?
Maintaining correct body alignment
A patient interested in acupuncture asks a nurse, "Just exactly what does it do?" What would the nurse explain
It changes the flow of energy and helps healing
You are caring for a client on total parenteral nutrition (TPN). You know TPN is only used when a client is very malnourished, or the client cannot consume food or liquids for an extended period of time. What is the most important aspect of TPN?
It is individualized to the client - TPN uses solution of nutrients to meet client's caloric and nutritional needs
The nurse should notify the healthcare provider before administering fresh frozen plasma (FFP) based on which assessment finding?
Jugular vein distention
A 74-year-old client is on the hospital unit where you practice nursing. She will be undergoing rhinoplasty and you are completing her admission assessment and paperwork. She reports medications she uses on a daily basis, which you record for her chart. Which of her daily medications will result in constipation?
Laxative- constipation from chronic use of laxatives causes a loss of motility
A home care nurse enters the home of a client and notices that the client's son is noticeably intoxicated. The son, who is slurring his words, is becoming increasingly agitated. Which action by the home care nurse would be most appropriate? 18. The nurse reviewing laboratory results of a client recovering from abdominal surgery notices an elevated number of reticulocytes. What is the nurse's first action?
Leave the home after rescheduling appointment
A 30-year-old client gave birth to her second son 4 months ago and is presenting at the primary care group where you practice nursing. She reports significant left breast pain, edema, redness, and an elevated temperature. What would you expect the physician to order?
NSAID, antibiotic
A client is admitted to the intensive care unit with a sustained blood pressure of 240/160 mm Hg. Which vasoactive drug does the nurse anticipate receiving an order from the physician to begin?
Nitropusside
The emergency department nurse is caring for a patient who has gone into cardiac arrest. The nurse is performing external defibrillation. Which of the following is a vital step in the procedure?
No one is to be touching the patient when a shock is delivered
A nurse is planning a group teaching session on the topic of urinary tract infection (UTI) prevention. Which point should the nurse include?
Notify physician if urinary urgency, burning, frequency, or difficulty occurs
The nursing profession and nurses as individuals have a responsibility to promote activities that foster well-being. What has most influenced the nurse to play this vital role?
Nurses have a long-established credibility with consumers
Staff nurses in an ICU setting have noticed that their patient's required fewer interventions for pain when the ICU was quiet. They passed their observations on to a nurse researcher and asked the researcher to design a study about the effects of noise on the pain levels of hospitalized patients. How does this demonstrate the primary purpose of nursing research?
Nursing research contributes to the scientific base of nursing practice.
A client comes to the emergency department and is bleeding profusely. Blood transfusion is ordered and the client is being typed and cross-matched. While awaiting the results, the physician orders a unit of packed red blood cells to administered stat. Which blood type would the nurse expect to be used?
O - Negative
The nurse is caring for a combative and confused client with a fractured hip who is trying to get out of bed. What actions are appropriate for the nurse to take?
Obtain physicians order for restraints have family stay with the patient, be familiar with hospital restraint policy Help
An elderly client is preparing to undergo surgery. The nurse participates in preoperative care knowing that which of the following is the underlying principle that guides preoperative assessment, surgical care, and postoperative care for older adults?
Older clients have less physiologic reserve or ability to regain physical equilibrium than younger adults
A 49-year-old man with a history of poorly controlled type 1 diabetes has developed osteomyelitis adjacent to a chronic diabetic ulcer on his great toe. The patient has been informed that medical treatment for osteomyelitis requires a longer course of antibiotics than most other infections because:
Osteomyelitis involves the active infection of bone tissue, which is largely avascular
The nurse is caring for a patient with metastatic bone cancer. The patient asks the nurse why he has had to keep getting larger doses of his pain medication and it doesn't seem to affect him. What is the nurse's best response?
Over time you become more tolerant to the drug
Which action would be most appropriate when evaluating a client's neck for thyroid enlargement?
Palpate the thyroid gland gently - inspect for enlargement and gently palpate
A nurse is taking a newly admitted patient's health history, and the patient states that she has had ongoing problems with a "pinched nerve." In addition to the potential for pain, the nurse should consider the fact that physical pressure that is placed on nerves can often lead to what?
Paresthesia's
A patient has been brought to the emergency department with multiple trauma after a motor vehicle accident. After immediate threats to life have been corrected, the nurse and trauma team should:
Perform a rapid physical assessment
The nurse reviewing laboratory results of a client recovering from abdominal surgery notices an elevated number of reticulocytes. What is the nurse's first action?
Perform an abdominal assessment
Nursing care for a client in addisonian crisis should include which intervention?
Place the client in a private room - due to reduced ability to reduce stress
The client is planned to have a splenectomy. The nurse should prepare which medication to administer to this client?
Pneumococcal vaccine - risk for infection is greatly increased
An 80-year-old female patient has been admitted to the hospital and lives with numerous health problems, which include osteoporosis. The patient's medication regimen includes calcitonin nasal spray, vitamin D and calcium supplements, and a bisphosphonate that is administered weekly. When administering the patient's bisphosphonate, the nurse should:
Position the patient in high fowler's after giving the drug
The nurse is conducting an assessment of a patient's nutritional status prior to post pyloric intubation. When assessing the patient's most recent laboratory values the nurse should pay particular attention to the patient's level of:
Prealbumin
Nursing students are reviewing information about the causes associated with low vision and blindness. The students demonstrate a need for additional review when they identify which of the following as a common cause in older adults?
Presbyopia
A critical care nurse is aware of the high incidence and prevalence of ventilator-associated pneumonia (VAP) in high-acuity settings. In order to reduce patients' risks of developing VAP, what intervention should the nurse prioritize?
Provide frequent thorough mouth care
A nurse is teaching nitroglycerin to a client with hospitalized client with coronary artery disease who is being discharged. The nurse tells the client that nitroglycerin has which of the following actions?
Reduces myocardial oxygen consumption - Dilates blood vessels - Decreases ischemia - Relives pain
Medical management of cardiac failure, whether it is right-sided or left-sided, demonstrates similar methodology. Measures such as dietary modifications, lifestyle changes, medications to reduce dyspnea and relieve anxiety, etc. are all used with one primary intention. What is the primary goal in the medical management of heart failure?
Reducing cardiac workload
The nurse is visiting a client at home with intractable cancer pain. The client has a transdermal fentanyl patch on her right chest area. It is most important for the nurse to:
Remove the heating pad on the chest area
The nurse is preparing to perform the care of a patient's tracheostomy tube. Which of the following actions should the nurse perform during this procedure?
Remove the soiled twill tape after new tape has been put in place Perform deep suctioning before and after the trach care
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?
Respiratory isolation for possible TB
A 55-year-old man presents at the clinic complaining of erectile dysfunction. The patient has a history of diabetes mellitus. The health care provider orders tadalafil (Cialis) to be taken 1 hour before sexual intercourse. The nurse reviews the patient's history prior to instructing the patient on the use of this medication. What disorder will contraindicate the use of tadalafil (Cialis) and sildenafil (Viagra)?
Retinopathy
A client with Alzheimer's disease is being treated for malnutrition and dehydration. The nurse decides to place him closer to the nurses' station because:
Risk for injury because of tendency to wander
A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?
Risk for injury related to neurologic deficit
A 73-year-old client has been diagnosed with epididymitis after examination and diagnostic tests ordered by a physician with the urology group where you practice nursing. What treatment would you expect the physician to order?
Scrotol elevation and comfort measures
A nurse is assessing a client of African-American descent. The nurse understands that carrier testing for which condition would be most appropriate for this client?
Sickle cell anemia
An 84-year-old woman is to receive 2 units of packed red blood cells. During the transfusion of the first unit at 125 mL/hour, the client reports shortness of breath 30 minutes into the process. The client exhibits the vital signs shown in the accompanying table. The best nursing intervention is to:
Slow the rate of infusion and obtain an order for furosemide (Lasix)
The nurse is conducting a patient teaching with a patient who has just been prescribed lansoprazole (Prevacid). What statement would indicate that the patient correctly understands the action of this medication?
This medication inhibits acid secretions
A patient with angina is beginning nitroglycerin. Before administering the drug, the nurse informs the patient that, immediately after administration, the patient may experience what?
Throbbing headache or dizziness
The nurse is assisting with the preparation of a patient who will undergo a radioactive iodine uptake (RAIU) test. The nurse should understand that this patient is being assessed for dysfunction of the:
Thyroid gland
A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside?
Suction machine with catheters
While preparing a client for an upper GI endoscopy (esophagogastroduodenscopy), the nurse should implement which interventions?
The client shouldn't eat or drink for 6-12 hours before the procedure to ensure GI tract is clear. Client will receive conscious sedation to help him relax.
Before using a defibrillator to terminate ventricular fibrillation, a nurse should check the synchronizer switch. Why is this check so important?
The defibrillator won't deliver a shock if the synchronizer is turned on
While teaching a CPR class, a student in the class asks what the difference is between cardioversion and defibrillation. What would be the nurse's best response?
The difference in the timing of the delivery of the electrical current.
. A patient has been scheduled for cardioversion for treating a tachyarrhythmia that has not responded appreciably to pharmacologic treatment. In anticipation of this procedure, what patient education should the nurse provide?
Your healthcare provider will likely ask you to alter your normal medication routine before the procedure, so be sure to follow those instruction's closely
A client has lung cancer and underwent chemotherapy and radiation treatment. The tumors continue to grow and have metastasized. The nurse assesses the client is in the dying phase of the Trajectory Model of Chronic Illness.
The nurse provide direct and supportive care to patients and their family through hospice programs
A 24-year-old man has suffered extensive head and neck injuries in a motorcycle accident and has been admitted to the intensive care unit (ICU) in apparent neurogenic shock. Which of the following are characteristics of this patient's diagnosis?
The patient has adequate blood volume but is profoundly vasodilated.
A 19-year-old woman had a mandibular osteotomy (jaw surgery) performed early this morning and is being assessed by the nurse after being transferred from the PACU. The nurse has asked the patient about her pain, to which the patient has responded, "I'm not really having any pain, but I've got a dull ache all around my jaw that's really bad." How should the nurse best interpret this patient's statement?
The patient is experiencing pain but is describing it in different terms.
An increase in the osmolality of a patient's blood has prompted the release of antidiuretic hormone (ADH) from the patient's posterior pituitary gland. What effect will result from the release of this hormone?
The patient's kidneys will reabsorb more water than usual.
A 50-year-old woman has a long history of hospital admissions related to alcohol abuse and consequent liver failure. During this present admission, the patient has been diagnosed with hepatic encephalopathy and prescribed lactulose (Cephulac). During morning report, the nurse learns that the previous nurse withheld the patient's latest dose of lactulose because the patient had two loose bowel movements during the shift. How should the nurse interpret the previous nurse's action?
The previous nurse should have administered the lactulose because it's necessary to remove access ammonia.
A patient who is currently in the hospital recovering from orthopedic surgery has always considered herself to be a "borderline diabetic" who prides herself on maintaining acceptable blood glucose levels through diet and lifestyle modifications. Consequently, she is surprised that her primary care provider has ordered a sliding scale of insulin while she is in the hospital. Why might this patient require insulin at this particular time?
The stress of hospitalization and surgery may cause increased release of glucocorticoids.
A woman has been brought to the emergency department (ED) by her distraught husband who believes that she has had a stroke. A rapid assessment by the care team confirms that the husband's suspicions are likely accurate, and the woman is being screened for the possible administration of recombinant tissue plasminogen activator (r tPA). Which of the following factors would contraindicate the use of tPA?
The woman's stroke has a hemorrhagic etiology
A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose?
To prevent stroke by removing atherosclerotic plaques blocking cerebral flow
A patient with chest trauma is admitted to the ICU. The nurse notes the patient's chest and neck are swollen and there is a crackling sensation when palpated. The nurse knows the patient has subcutaneous emphysema. If this condition becomes severe, what treatment is most likely indicated?
Tracheostomy
The client, an 83-year-old man, is admitted with heart failure. The nurse is aware that education needed prior to discharge includes which of the following?
Try to avoid emotional stress and take part in mild physical stress only- stress has adverse effects on the heart
A nurse caring for a patient with diabetes insipidus is reviewing the patient's laboratory results. What is an expected urinalysis finding?
Urine specific gravity 1.001 to 1.005
A client is actively bleeding from esophageal varices. Which of the following medications would the nurse most expect to be administered to this client?
Vasopressin (Pitressin) - been used for years 25 years to control bleeding has a direct vasoconstriction activity
The nurse is working on the renal transplant unit. To reduce the risk of infection in a patient with a transplanted kidney, it is imperative for the nurse to do what?
Wash hands carefully and frequently
A nurse is providing discharge instructions for a client who fell from a bicycle, resulting in a fractured jaw. The client underwent surgical intervention with rigid fixation. The nurse includes in the instruction:
Ways to obtain supplemental nutrition
A child goes to the school nurse and complains of not being able to hear her teacher. What test could the school nurse perform to make a general estimate of hearing loss?
Whisper test
A comatose patient is receiving oral care. What oral care regimen would be most effective in decreasing the patient's risk of tooth decay and plaque accumulation?
Wiping the teeth and gums with gauze pad
A female patient is sufficiently stable to be transferred from the PACU to the postsurgical unit following her total hip replacement surgery early this morning. When preparing to admit this patient, the nurse on the postsurgical unit should anticipate that the patient will require what positioning?
With her legs slightly abducted
A 60-year-old woman has been brought to the emergency department (ED) by ambulance after she experienced a sudden onset of dyspnea and phoned 911. The woman is obese but claims an unremarkable medical history and denies chest pain. When assessing this patient, the nurse in the ED should be aware that:
Women often present with an MI much differently than do men.
