Term 2 Comp Exam

A client who is scheduled for an ileostomy surgery says to the nurse, "I'm afraid I won't be able to look at that stoma." Which response by the nurse would be most therapeutic?

"I'll make sure there is a familiar nurse here with you the first time." Telling the client that a familiar nurse will be with him the first time provides the client with reassurance that he will not be alone and will have the support of a familiar person to answer questions and provide comfort and support. Telling the client not to worry about it now, that everybody feels anxious, and that he'll do just fine discounts the client's feelings and is not therapeutic.

The nurse is caring for a client diagnosed with herpes zoster. Which statement by the client needs further clarification by the nurse?

"Once I get the infection, I cannot get it again." The nurse is correct to clarify that even though the client has herpes zoster, the client can get herpes zoster again. The virus is contagious and can reoccur. The other options are accurate statements that reflect the client's understanding.

A client has sustained a left femur fracture in a skiing accident. When is the nurse aware that the complication of a fat emboli typically occurs and should be monitored for closely?

48 to 72 hours The client should be monitored for symptoms of a fat embolism, and this typically occurs within 48 to 72 hours.

A client is prescribed pain medications. Which of the following interventions will enable the client to consume an adequate meal during treatment?

Administer the medication 30 to 45 minutes before meals. Some pain medications may cause nausea or sedation. However, pain medications administered 30 to 45 minutes before meals may enable the client to consume enough food. Administering the medication with plenty of fruit juice, intravenously, or 30 to 45 minutes after meals does not minimize the risk for imbalanced nutrition in a client with pain.

A client comes to the clinic and informs the nurse of a "painful area under the armpit." The nurse observes a 2-cm raised area that is erythremic and has a white substance inside of it. What does the nurse suspect the client may be experiencing?

An abcess To prevent the spread of pathogens to adjacent tissues, a fibrin barrier forms around the injured area. Inside the barrier, a thick, white exudate (pus) accumulates. This collection of pus is called an abscess, which may break through the skin and drain or continue to enlarge internally. A lesion would not be filled with pus, nor would a cancerous tumor. A fluid-filled vesicle is associated with a viral type illness.

A client with diabetes punctured the foot with a sharp object. Within a week, the client developed osteomyelitis of the foot. The client was admitted for IV antibiotic therapy. How long does the nurse anticipate the client will receive IV antibiotics?

At least 4 weeks Identification of the causative organism to initiate appropriate and ongoing antibiotic therapy for infection control. IV antibiotic therapy is administered for at least 4 weeks, followed by another 2 weeks (or more) of IV antibiotics or oral antibiotics.

Which of the following is a disadvantage of surgical debridement?

Bleeding A disadvantage of surgical debridement is bleeding. Scarring, loss of function, and contractures are not disadvantages of surgical debridement.

The nurse is assessing a client with cirrhosis of the liver. Which stool characteristic would the nurse expect the client to report?

Clay-colored or whitish Many clients report passing clay-colored or whitish stools as a result of no bile in the gastrointestinal tract. The other stool colors would not be indicators of obstructive jaundice but may indicate other GI tract disorders.

A client is receiving treatment for an acute episode of gout with colchicine. The nurse is administering the medication every 2 hours. What should the nurse be sure the client communicates so that the drug can be temporarily stopped? Select all that apply.

Diarrhea Intestinal cramping Nausea and vomiting Colchicine is administered every 1 or 2 hours until the pain subsides or nausea, vomiting, intestinal cramping, and diarrhea develop. When one or more of these symptoms occurs, the drug should be stopped temporarily. Tingling in the arms and increase in pain are not normal adverse reactions that are seen with this drug.

A client has delayed bone healing in a fractured right humerus. What should the nurse prepare the client for that promotes bone growth?

Electrical stimulation Delayed union may require surgical interventions to promote bone growth and correct the incorrect union. If necessary, prepare the client for use of electrical stimulation measures that promote bone growth, or for a bone graft. Administration of low-dose heparin would be used to prevent pulmonary embolism. Joint fusion may be used in the case of avascular necrosis. Administration of antibiotics would be used for the potential of infection or to treat an actual infection.

Which substance reduces the transmission of pain?

Endorphins Chemicals that reduce or inhibit the transmission of perception of pain include endorphins and enkephalin, which are morphinelike endogenous neurotransmitters . Acetylcholine, serotonin, and substance P are chemicals that increase the transmission of pain.

Which of the following conditions is the cause of thickening of the nail?

Fungal infection Long-standing poor circulation leads to nail thickening, especially of the lower extremities. Nails thicken when there is a fungal infection and poor circulation. Clubbing of the nails suggests a long-standing cardiopulmonary disease. Concave-shaped nails are a sign of iron-deficiency anemia. Myocardial infarction does not cause thickening of nails.

Which is a benefit of a continuous passive motion (CPM) device when applied after knee surgery?

It promotes healing by increasing circulation and movement of the knee joint. A CPM device applied after knee surgery promotes healing by increasing circulation and movement of the knee joint.

The nurse is performing assessment of the client's left upper quadrant. Mark the area in which the nurse is examining the client.

LUQ The left upper quadrant (LUQ) contains the left lobe of the liver, stomach, tail of the pancreas, splenic flexure of the colon, and portions of the transverse and descending colon.

While palpating a client's right upper quadrant (RUQ), the nurse would expect to find which structure?

Liver The RUQ contains the liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of the colon, portions of the ascending and transverse colon, and a portion of the right kidney. The sigmoid colon is located in the left lower quadrant; the appendix, in the right lower quadrant; and the spleen, in the left upper quadrant.

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?

Measure abdominal girth according to a set routine. If the abdomen appears enlarged, the nurse measures it according to a set routine. Measuring the abdominal girth is the most accurate method of determining an increase or decrease in abdominal distention. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis. The nurse would report to the physician about abdominal enlargement along with other parameters of the assessment.

The nurse is assisting with the physical examination of a client with a musculoskeletal disorder and observes the client's hands, which have the appearance shown in the accompanying image. With what condition is the client's appearance most consistent?

Osteoarthritis When osteoarthritis afflicts the hands, the fingers frequently develop painless bony nodules on the dorsolateral surface of the interphalangeal joints: Heberden's nodes (bony enlargement of the distal interphalangeal joints) and Bouchard's nodes (bony enlargement of the proximal interphalangeal joints).

The nursing instructor is teaching student nurses about venipuncture techniques and possible complications from the procedure. What can happen if the venipuncture device is left in the clients' vein too long?

Phlebitis can develop. Because the venous access device traumatizes the vein wall and disturbs the flow of blood cells in the vein, there is a potential for phlebitis, inflammation of the vein, and thrombus formation (development of a clot). Gangrene is not an issue; necrosis of the skin depends on the fluid being infused and if it has infiltrated; and warm compresses are used, not cold packs.

Which is a true statement regarding placebos?

Placebos should never be used to test a client's truthfulness about pain.

An enzyme that begins the digestion of starches is

Ptyalin Ptyalin, or salivary amylase, is an enzyme that begins digestion of starches. Pepsin, an important enzyme for protein digestion, is the end product of the conversion of pepsinogen from the chief cells. Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein. Bile is an enzyme secreted by the liver and gallbladder.

A nurse is assisting with preoperative care for a client who requires an appendectomy. The nurse is aware that the surgery will involve which abdominal quadrant? Mark the correct area.

RLQ

The nurse is administering furosemide to promote urinary excretion of excess fluids for a client with cirrhosis. When administering furosemide to this client, what should the nurse closely monitor?

Sodium level Diuretics such as furosemide must be administered with caution because long-term use can cause sodium depletion. The other levels do not relate to the administration of furosemide.

The nurse is caring for a client in the long-term care facility who had been living at home and being cared for by a family member. The family member states having had a difficult time getting the client to eat or drink and that the client developed a "bed sore." The nurse observes a serous drainage covering the dressing and a 2 x 2 cm crater that is 0.5 cm deep. What stage does the nurse document this pressure injury as?

Stage III Stage III has superficial skin impairment that progresses to a shallow crater that extends to the subcutaneous tissue. Stage I pressure sores are characterized by redness of intact skin. The reddened skin of a beginning pressure sore fails to resume its normal color, or blanch when pressure is relieved. Stage II is the same as stage I but has a blister or shallow break in the skin. Stage IV has tissue damage that is deeply ulcerated, exposing muscle and sometimes bone.

Which is the primary reason for placing a client in a horizontal position while smothering flames are present?

To keep fire and smoke form airway The primary reason the client is placed in a horizontal position while smothering flames is to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passages. The stop, drop, and roll method is a quick and efficient means to extinguish flames. If hypovolemic shock occurs, lowering the head will assist in promoting blood flow to the head.

The nurse is assessing a client with suspected cholelithiasis. What can the nurse expect to observe?

Urine that appears dark brown When a client is being assessed for cholelithiasis, the urine appears dark brown, whereas the stools may be light-colored. Bowel sounds are present because cholelithiasis does not cause lack of bowel motility. The stool does not contain blood or mucus.

Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client?

Weakness, diaphoresis, diarrhea 90 minutes after eating Dumping syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramping, and diarrhea from the rapid emptying of the chyme after eating. Elevated temperature and chills can be a significant finding for infection and should be reported. Constipation with rectal bleeding is not indicative of dumping syndrome.

A client is scheduled for a joint replacement surgery. Which action would be most important?

Withhold administration of aspirin before the surgery. If a client is scheduled for a joint replacement or other surgery, it is crucial for the nurse to withhold aspirin before surgery to reduce the risk of excessive bleeding. It is also essential to monitor the complete blood count, prothrombin time, bleeding, and clotting time to ensure that the client is able to control bleeding. The impact of fluid or solid food intake does not have as strong implications as the impact of aspirin intake before surgery. Having adequate sleep before surgery is helpful but is not the most important action.

A client with a diagnosis of acute appendicitis is awaiting surgical intervention. The nurse listens to bowel sounds and hears none and observes that the abdomen is rigid and board-like. What complication does the nurse determine may be occurring at this time?

peritonitis Lack of bowel motility typically accompanies peritonitis. The abdomen feels rigid and board-like as it distends with gas and intestinal contents. Bowel sounds typically are absent. The diagnosis of acute appendicitis correlates with the symptoms of rupture of the appendix and peritonitis. A paralytic ileus and gas alone do not produce these symptoms.

The nurse is aware that when glucocorticosteroids are administered, it is important that which of the following occurs?

taper does when discontinuing When administering glucocorticosteroids, it is important to taper the doses when discontinuing. Excessive sedation is not a side effect of glucocorticosteroids. Avoidance of alcohol and monitoring of blood levels are not indicated with use of glucocorticosteroids.

The nurse is triaging a client over the phone who states having a contact dermatitis rash. Which treatment option of over-the-counter preparations does the nurse suggest for the client? Select all that apply.

topical antihistamines 1820 cream Moisturizing cream Lanolin based ointment The nurse is correct to suggest that the client apply a topical antihistamine or hydrocortisone cream to the rash area. This is helpful to decrease itchiness and swelling. Moisturizing cream, some lanolin based, is helpful in restoring lubrication. Cosmetic lotions have a scent or color, which is not suggested for use on rashes.

The nurse is giving an educational talk to a local parent-teacher association. A parent asks how to help the family avoid community-acquired infections. What would be the nurse's best response to help prevent and control community-acquired infections?

"Make sure your family has all their childhood immunizations." To help prevent and control community-acquired infections, nurses should encourage childhood immunizations. Vaccines stimulate the body to produce antibodies against a specific disease organism. The immunization protects children as well as adults who may not have developed sufficient immunity. Following a proper diet and exercise regimen and going for regular checkups are important, but these measures do not help prevent or control community-acquired infections. Smoking cessation does not reduce the risk of such infections.