Final Med Surg 2
Type I: reaction mediated by IgE antibodies.(allergies, anaphylaxis)
- IgE-mediated Anaphylaxis - Urticaria/angioedema - Allergic Rhinitis - Asthma -Latex allergy
manifestation of constipation
-Fewer than 3 bowel movements weekly -Bowel movements that are hard, small, or difficult to pass
Type III: reaction mediated by immune complexes IgG. (autoimmune)- -Lupus -Rheumatoid arthritis
-Lupus -Rheumatoid arthritis
What are the National Osteoporosis Foundation's Recommendations for who should get a baseline bone density test?
1. All women >65 yo and men >70 yo 2. All postmenopausal women with a Hx of fragility fracture 3. All postmenopausal women with at least 1 RF for osteoporosis 4. Adults with a disease or medication hx associated with bone loss
A client with multiple sclerosis tells the unlicensed assistive personnel (UAP) after physical therapy that she is too tired to take a bath. What is the priority nursing concern at this time? 1.Fatigue 2.Inability to perform activities of daily living (ADLs) 3.Decreased mobility 4.Muscular weakness
1. Fatigue
The nurse assesses a patient who is admitted after a traumatic brain injury (TBI) to the frontal lobe. The nurse correlates which clinical manifestations to damage to this area of the brain? 1. Sensation difficulty 2. Expressive speech difficulty 3. Color perception impairment 4. Long-term memory impairment
2. Expressive speech difficultly
Which principal risk factor should the nurse assess for during the health history in a patient who is suspected of having peptic ulcer disease? 1) Stress 2) Anxiety 3) H. pylori infection 4) Use of acetaminophen
3) H. pylori infection
Which medication, acting as a physical barrier, does the nurse anticipate for a patient diagnosed with gastritis? 1) Maalox 2) Mylanta 3) Pepcid 4) Carafate
4) Carafate
V2
4th intercostal space to the left of the sternum
V1
4th intercostal space to the right of the sternum
V5
5th intercostal space, anterior axillary line
V4
5th intercostal space, left midclavicular line
V6
5th intercostal space, midaxillary line
A patient diagnosed with Bells palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? A) Applying a protective eye shield at night B) Chewing on the affected side to prevent unilateral neglect C) Avoiding the use of analgesics whenever possible D) Avoiding brushing the teeth
A) Applying a protective eye shield at night
Cardiopulmonary resuscitation has been initiated on a client who was found unresponsive. When performing chest compressions, the nurse should do which of the following actions?
A) Perform at least 100 chest compressions per minute.
The nurse is planning discharge education for a patient with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the patient to avoid? A) Washing his face B) Exposing his skin to sunlight C) Using artificial tears D) Drinking large amounts of fluids
A) Washing his face
The nurse is providing care for a client who has experienced a type I hypersensitivity reaction. Which client would have this type of reaction? A. A client with an anaphylactic reaction after a bee sting B. A client with a skin reaction resulting from adhesive tape C. A client with a diagnosis of myasthenia gravis D. A client with rheumatoid arthritis
A. A client with an anaphylactic reaction after a bee sting
The nurse prepares to place the patient in skin traction. Which is the nurse's main concern before applying the skin traction? a.Obtain informed consent from patient. b.Verify that the patient assessment is complete. c.Prepare a sterile field for pin insertion. d.Assemble the overhead frame and pulleys.
Ans: b.Verify that the patient assessment is complete.
A client is experiencing a decreasing glomerular filtration. What laboratory values should the nurse expect to follow the change? Select all that apply. A. Serum creatinine increases B. Blood urea nitrogen (BUN) increases C. Creatinine clearance decreases D. Hypokalemia E. Hypophosphatemia
Ans:A,B,C
What test can you conduct to Assess Cranial Nerve IX?
Glossopharyngeal Nerve - Gag reflex, palate and uvula should be symmetrical.
What is the most common cause of acute glomerulonephritis? a. Streptococcal infection b. Cytomegalovirus c. Epstein-Barr virus d. Staphylococcal infection e. Systemic lupus erythematosus
Streptococcal infection
A client diagnosed with myasthenia gravis has been hospitalized to receive therapeutic plasma exchange (TPE) for a myasthenic exacerbation. The nurse should anticipate what therapeutic response? A. Permanent improvement after 4 to 6 months of treatment B. Symptom improvement that lasts a few weeks after TPE ceases C. Permanent improvement after 60 to 90 treatments D. Gradual improvement over several months
Symptom improvement that lasts a few weeks after TPE ceases
What tissue of the brain should be identified as part of the gray matter
The gray matter of the cerebrum consists of neuron cell bodies, dendrites, unmyelinated axons and neuroglia. Myelinated axons and neuroglia appear white and are insulated. - Nueron cell bodies - dendrites - unmyelinated axons and neuroglia
the cranial vault limits the amount of space available to compensate for changes in brain volume, how does the brain react to this increased volume?
To compensate: cerebrospinal fluid (CSF) or cerebral blood volume decreases to maintain normal ICP
A client has sought care, stating that the client developed hives overnight. The nurse's inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the client developed? A. Type I B. Type II C. Type III D. Type IV
Type I
A client is having a "fight or flight response" after receiving a bad disease prognosis. What affect will this have on the client's sympathetic nervous system? A. Constriction of blood vessels in the heart muscle B. Constriction of bronchioles C. Increase in the secretion of sweat D. Constriction of pupils
C. Increase in the secretion of sweat
The student nurse is preparing a teaching plan for a patient being discharged status post MI. What should the student include in the teaching plan? (Mark all that apply.) A. Need for increased fluid intake B. Need for early resumption of prediagnosis activity C. Need for careful monitoring for cardiac symptoms D. Need for dietary modifications E. Need for carefully regulated exercise
C. Need for careful monitoring for cardiac symptoms D. Need for dietary modifications E. Need for carefully regulated exercise Dietary modifications, exercise, weight loss, and careful monitoring are important strategies for managing three major cardiovascular risk factors: hyperlipidemia, hypertension, and diabetes. There is no need to increase fluid intake and activity should be slowly and deliberately increased
The nurse is caring for a client in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action? A. Position the client the high Fowler position as tolerated. B. Administer osmotic diuretics as prescribed. C. Participate in interventions to increase cerebral perfusion pressure (
C. Participate in interventions to increase cerebral perfusion pressure (CPP).
Which is usually the most important consideration in the decision to initiate antiretroviral therapy?
CD4+ counts
A client with acquired immune deficiency syndrome (AIDS) informs the nurse of difficulty eating and swallowing, and shows the nurse white patches in the mouth. What problem related to AIDS does the nurse understand the client has developed?
Candidiasis
Acute Renal Failure
Condition that occurs when something, such as a blockage, toxins, or sudden loss of blood flow causes a change in the filtering function of the kidneys
The nurse is caring for an adult client with heart failure who is prescribed digoxin. When assessing the client for adverse effects, the nurse should assess for which of the following signs and symptoms? Select all that apply. A. Confusion B. Shortness of breath C. Numbness and tingling in the extremities D. Chest pain E. Bradycardia F. Diuresis
Confusion and bradycardia
A 16-year-old has come to the clinic and asks to talk to a nurse. The nurse asks the teen what she needs and the teen responds that she has become sexually active and is concerned about getting HIV. The teen asks the nurse what she can do keep from getting HIV. What would be the nurse's best response? A) "There's no way to be sure you won't get HIV except to use condoms correctly." B) "Only the correct use of a female condom protects against the transmission of HIV." C) "There are new ways of p
D) "Other than abstinence, only the consistent and correct use of condoms is effective in preventing HIV."
An elderly patient is being discharged home. The patient lives alone and has atrophy of his olfactory organs. The nurse tells the patients family that it is essential that the patient have what installed in the home? A)Grab bars B)Nonslip mats C)Baseboard heaters D)A smoke detector
D) A smoke detector
The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of "ineffective cerebral tissue perfusion." What would be an expected outcome that the nurse would document for this diagnosis? A) Copes with sensory deprivation. B) Registers normal body temperature. C) Pays attention to grooming. D) Obeys commands with appropriate motor responses.
D) Obeys commands with appropriate motor responses.
A patient diagnosed with Bells palsy is having decreased sensitivity to touch of the involved nerve. What should the nurse recommend to prevent atrophy of the muscles? A) Blowing up balloons B) Deliberately frowning C) Smiling repeatedly D) Whistling
D) Whistling
A patient with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this patient? A) Cerebral angiography B) ABG analysis C) CT D) EEG
D. EEG
A patient with a tibia fracture was placed in an external fixator 24 hours ago. The nurse is completing pin care and notices redness at the pin site and a small amount of serous drainage. What action by the nurse is appropriate? a) Assess patient's hemoglobin and hematocrit. b) Prepare for surgical removal of the fixator. c) Document the findings. d) Notify the physician.
Document the findings. Explanation: Serous drainage and redness at the pin site is an expected finding for 24-48 hours postinsertion. The nurse should document the findings and continue to monitor the site. The physician does not need to be notified unless other signs and symptoms are present. The fixator does not need to be removed at this time. The greatest concern is for infection; assessing the hemoglobin and hematocrit are not relevant to assessing for infection.
A patient has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication? A) Vigilant monitoring of fluid balance B) Continuous BP monitoring C)Serial arterial blood gases (ABGs) D)Monitoring of the patient's airway for patency
Vigilant monitoring of fluid balance
Patient has aortic stenosis they tell the nurse "ive been feeling so tired lately that I take a nap in my recliner every afternoon" on assessment the nurse notes an occasional dry cough, faint crackles in the base of the lungs, pressure's a little bit up, and they've gained 2.5kg (5.5 lbs). What assessment findings require further action?
Dry cough, crackles in lungs, blood pressure, and weight gain. Most likely reveals heart failure.
A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) a. Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L c. Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor
ANS: b. Serum potassium of 2.9 mEq/L d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor
Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome? 1. An exaggerated startle reflex and memory changes. 2. Cogwheel rigidity and inability to initiate voluntary movement. 3. Sudden severe unilateral facial pain and inability to chew. 4. Progressive ascending paralysis of the lower extremities and numbness.
ANS: 4) Progressive ascending paralysis of the lower extremities and numbness.
A nurse cares for a client with hepatitis C. The client's brother states, "I do not want to contract this infection, so I will not go into his hospital room." How should the nurse respond? a. "If you wear a gown and gloves, you will not get this virus." b. "Viral hepatitis is not spread through casual contact." c. "This virus is only transmitted through a fecal specimen." d. "I can give you an update on your brother's status from here."
Ans: B
A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease? Select one: a. A 45-year-old American Indian woman with diabetes mellitus b. A 32-year-old Asian-American man with colorectal cancer c. A 53-year-old postmenopausal woman who is on hormone therapy d. An 86-year-old man with a history of asthma
ANS: A 45-year-old American Indian woman with diabetes mellitus
A patient is being given a medication that stimulates her parasympathetic system. Following administration of this medication, the nurse should anticipate what effect? A)Constricted pupils B)Dilated bronchioles C)Decreased peristaltic movement D)Relaxed muscular walls of the urinary bladder
ANS: A) Constricted pupils
A patient with an inoperable brain tumor has been told that he has a short life expectancy. On what aspects of assessment and care should the home health nurse focus? Select all that apply. A) Pain control B) Management of treatment complications C) Interpretation of diagnostic tests D) Assistance with self-care E) Administration of treatments
ANS: A) Pain control
The nurse is conducting an admission assessment on a male client. Which assessment data does the nurse identify as a risk factor for cardiovascular disease? Select all that apply. A. BMI of 26 B. BP of 120/66 mm Hg C. Triglycerides 140 mg/dl D. Moderate exercise for 20 to 30 minutes weekly E. Exposure to secondhand cigarette smoke F. History of repeated streptococcal tonsillitis G. Family history of cardiovascular disease
ANS: A,D,E,G
A nurse is caring for a client with hepatic encephalopathy. The nurse's assessment reveals that the client exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4
ANS: C
Lymphocytes are produced and stored in all the following except: a. The thymus b. The brain c. Lymph node origins d. the spleen e. Lymphoid nodules
Ans: B
The nurse is discharging a patient home after surgery for trigeminal neuralgia. What advice should the nurse provide to this patient in order to reduce the risk of injury? A) Avoid watching television or using a computer for more than 1 hour at a time. B) Use OTC antibiotic eye drops for at least 14 days. C) Avoid rubbing the eye on the affected side of the face. D) Rinse the eye on the affected side with normal saline daily for 1 week.
ANS: C) Avoid rubbing the eye on the affected side of the face.
Which of the following physiological changes take place during fight or flight? A) pupils constrict B) heart rate slows C) digestion is inhibited D). all of these options
ANS: C) Digestion is inhibited.
13. A client is admitted with Guillain-Barré syndrome (GBS). What assessment takes priority? a. Bladder control b. Cognitive perception c. Respiratory system d. Sensory functions
ANS: C) Respiratory system
The nurse is teaching a patient diagnosed with multiple sclerosis (MS) how to reduce complications and exacerbations of the disease. Which patient statement should indicate to the nurse that further teaching is necessary? A) "I need to avoid getting overheated." B) "I should make sure to get plenty of sleep each night." C) "I think that I will try t'ai chi." D) "I should start a regular jogging program."
ANS: D) "I should start a regular jogging program."
The nurse has just completed discharge teaching for a client who had aortic valve replacement with a mechanical heart valve. Which statement by the client indicates that teaching has been effective? A) "I'm glad that I can continue taking my Ginkgo biloba." B) "I will increase my intake of leafy green vegetables." C) "I will start applying vitamin E to my chest incision after showering." D) "I will shave with an electric razor from now on."
ANS: D) "I will shave with an electric razor from now on."
A patient is scheduled for a total hip replacement and the surgeon has explained the risks of blood loss associated with orthopedic surgery. The risk of blood loss is the indication for which of the following actions? A) Use of a cardiopulmonary bypass machine B) Postoperative blood salvage C) Prophylactic blood transfusion D) Autologous blood donation
ANS: D) Autologous blood donation
A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. Urinary output less than intake b. Bruising at the insertion site c. Slurred speech and confusion d. Discomfort in the left leg
ANS: c. Slurred speech and confusion
The nurse is monitoring a client with a severe head injury for signs and symptoms of increasing intracranial pressure. Which finding is most indicative of increasing intracranial pressure? A. Tachypnea B. Increased Restlessness C. Intermittent tachycardia D. Polydipsia
Ans: B
Type IV: delayed reaction mediated by cellular response -
Allergic contact dermatitis - Tuberculin Reactions - Delayed type reactions - Cell mediated immunity -Skin graft rejection
The nurse is doing discharge teaching with a client who has coronary artery disease. The client asks why he has to take an aspirin every day if he doesn't have any pain. What would be the nurse's best response?
An aspirin a day can help prevent some of the blockages that can cause chest pain or heart attacks
The nurse is mentoring a student nurse in the intensive care unit while caring for a client with meningococcal meningitis. Which action by the student requires that the nurse intervene most rapidly? 1.Entering the room without putting on a protective mask and gown 2.Instructing the family that visits are restricted to 10 minutes 3.Giving the client a warm blanket when he says he feels cold 4.Checking the client's pupil response to light every 30 minutes
Ans 1
The nurse is planning teaching for a client newly diagnosed with Sjogren's syndrome. Which measures will the nurse include in the teaching plan. Select all that apply. 1. Chewing sugar-free gum or using artificial saliva. 2. Scheduling regular dental appointments. 3. Showering with lukewarm water and avoiding harsh soaps. 4) using OTC decongestants to alleviate nasal symptoms 5. Using over-the-counter lubricants to ease vaginal dryness
Ans: 1, 2, 3, 5
The nurse is preparing a teaching tool about the cardiac electrical conduction system. In which order should the nurse explain the route of the action potential? 1) Impulse travels to the bundle of His 2) Sinoatrial node fires in the right atrium 3) Impulse extends through Purkinje fibers 4) Impulse travels through bundle branches 5) Impulse travels to the atrioventricular node 6) Impulse spreads through atrial myocardium
Ans: 2,6,5,1,4,3
The nurse is caring for an acutely ill patient who has central venous pressure monitoring in place. What intervention should be included in the care plan of a patient with CVP in place? 1) Apply antibiotic ointment to the insertion site twice daily. 2) Change the site dressing whenever it becomes visibly soiled. 3) Perform passive range-of-motion exercises to prevent venous stasis. 4) Aspirate blood from the device once daily to test pH.
Ans: 2: Change the site dressing whenever it becomes visibly soiled.
A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations? A. Hepatic encephalopathy B.
Ans: A
A nurse is teaching a client how to manage an external fixation device upon discharge. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply) p 459 A) "I will clean the pins twice a day." B) "I will use a separate cotton swab for each pin." C) "I will report loosening of the pins to my doctor." D) "I will move my leg by lifting the device in the middle." E) "I will report increased redness at the pin sites."
Ans: A, B, C, E
The RN supervising a senior nursing student is discussing methods for preventing acute kidney injury (AKI). Which points would the RN be sure to include in this discussion? Select all that apply a. Encourage patients to avoid dehydration by drinking adequate fluids. b. Instruct patients to drink extra fluids during periods of strenuous exercise. c. Immediately report a urine output of less than 2 mL/kg/hr. d. Record intake and output and weigh patients daily. e. Monitor laboratory value
Ans: A,B,D,E
The nurse is caring for a patient with a newly applied cast to the lower extremity. The patient continues to complain of pain despite medication and repositioning. What should the nurse do first?
Assess the temperature of the toes, sensation to touch, and capillary refill.
The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client? A. Position the client supine. B. Maintain head of bed (HOB) elevated at 30 to 45 degrees. C. Position client in prone position. D. Maintain bed in Trendelenburg position.
B) Maintain head of bed (HOB) elevated at 30 to 45 degrees.
In the course of a focused neurologic assessment, the nurse is palpating the client's major muscle groups at rest and during passive movement. Data gleaned from this assessment will allow the nurse to describe which of the following aspects of neurologic function? A) Muscle dexterity B) Muscle tone C) Motor symmetry D) Deep tendon reflexes
B) Muscle tone
A patient with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a patient with this diagnosis? A) Pain upon ankle dorsiflexion of the foot B) Neck flexion produces flexion of knees and hips C) Inability to stand with eyes closed and arms extended without swaying D) Numbness and tingling in the lower extremities
B) Neck flexion produces flexion of knees and hips
Assessment is crucial to the care of patients with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply. A) The ability to select mediations for the neurologic dysfunction B) Understanding of the tests used to diagnose neurologic disorders C) Knowledge of nursing interventions related to assessment and diagnostic testing D) Knowledge of the anatomy of the nervous system E) The ability to interpret the results of diagnostic tests
B) Understanding of the tests used to diagnose neurologic disorders C) Knowledge of nursing interventions related to assessment and diagnostic testing D) Knowledge of the anatomy of the nervous system
The nurse educator is reviewing the assessment of cranial nerves. What should the educator identify as the specific instances when cranial nerves should be assessed? Select all that apply. A) When a neurogenic bladder develops B) When level of consciousness is decreased C) With brain stem pathology D) In the presence of peripheral nervous system disease E) When a spinal reflex is interrupted
B) When level of consciousness is decreased C) With brain stem pathology D) In the presence of peripheral nervous system disease
A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the ED. The nurse should gauge the client's LOC on the results of what diagnostic tool? A. Monro-Kellie hypothesis B. Glasgow Coma scale C. Cranial nerve function D. Mental status examination
B. Glasgow Coma scale
Immediately following a patient's cardiac catheterization, what are the highest priority interventions when the patient returns to his room? (Select all that apply.) A. Allowing the patient to rest B. Taking the patient's vital signs C. Administering oxygen via mask D. Monitoring the electrocardiogram (ECG) E. Assessing the pulses distal to the catheterization site
B. Taking the patient's vital signs E. Assessing the pulses distal to the catheterization site
V3
Between V2 and V4
Type II: cytotoxic reaction mediated by IgG or IgM antibodies.
Blood transfusion reaction - Goodpasture's Syndrome (Make abs against antigen in kidney and lung) - Myasthenia Gravis - Autoimmune Hemolytic Anemia.
A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this patient? A) All at one time, to provide a longer rest period B) Before meals, to stimulate her appetite C) In the morning, with frequent rest periods D) Before bedtime, to promote rest
C) In the morning, with frequent rest periods
The critical care nurse is admitting a client in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this client? A. Suctioning secretions B. Facilitating ABG analysis C. Providing ventilatory assistance D. Administering tube feedings
C) Providing ventilatory assistance
A 48-year-old patient has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize what implication of this diagnosis? A) The patient will likely require lifelong treatment with anticholinergic medications. B) The patient has a disproportionate risk of developing myasthenia gravis later in life. C) The patient needs to be assessed for MS. D) The disease is self-limiting and the patient will achieve pain relief over time.
C) The patient needs to be assessed for MS.
The nurse is caring for a client with a brain tumor. What drug would the nurse expect to be prescribed to reduce the edema surrounding the tumor? A. Solumedrol B. Dextromethorphan C. Dexamethasone D. Furosemide
C. Dexamethasone
Where do you hear aortic regurgitation?
In a patient with aortic regurgitation the typical murmur is a decrescendo early-diastolic blowing murmur, best heard on the left lower sternal border, around the 3rd and 4th intercostal spaces.
You are the clinic nurse caring for a patient with a recent diagnosis of myasthenia gravis. The patient has begun treatment with pyridostigmine bromide (Mestinon). What change in status would most clearly suggest a therapeutic benefit of this medication? A) Increased muscle strength B) Decreased pain C) Improved GI function D) Improved cognition
Increased muscle strength
Droplet precautions are for what diseases?
Influenza (Flu) Meningitis Mumps Pneumonia
During a shift assessment, the nurse is identifying the client's point of maximum impulse (PMI). Where will the nurse best palpate the PMI? A) Left midclavicular line of the chest at the level of the nipple B) Left midclavicular line of the chest at the fifth intercostal space C) Midline between the xiphoid process and the left nipple D) Two to three centimeters to the left of the sternum
Left midclavicular line of the chest at the fifth intercostal space
A nurse caring for a client who has ulcerative colitis. The provider prescribes bed rest with bathroom privileges. When the client asks the nurse why he has to stay in bed, which of the following responses should the nurse provide? a. "You need to conserve energy at this time." b. "Lying quietly in bed helps slow down the activity in your intestines." c. "Staying in bed promotes the rest and comfort you need." d. "Staying in bed will help prevent injury and minimize your fall risk.
Lying quietly in bed helps slow down the activity in your intestines
Contact precautions are used for what types of diseases?
MRSA, CDIFF, VRE
The nurse is working with a client who is newly diagnosed with MS. What basic information should the nurse provide to the client? A. MS is a progressive demyelinating disease of the nervous system. B. MS usually occurs more frequently in men. C. MS typically has an acute onset. D. MS is sometimes caused by a bacterial infection.
MS is a progressive demyelinating disease of the nervous system.
When caring for a client with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would most likely elicit a response from cranial nerve VII? A) Palpate trapezius muscle while client shrugs shoulders against resistance. B) Administer the whisper or watch-tick test. C) Observe for facial movement symmetry, such as a smile. D) Note any hoarseness in the client's voice
Observe for facial movement symmetry, such as a smile.
The nurse is caring for a client with an external fixator that requires pin care twice a day. The nurse observes that there is a new purulent drainage around one of the pins. What intervention should the nurse anticipate doing? a) Apply ointment to the pin site. b) Scrubbing the drainage from around the pin site c) Applying iodine-based solution d) Obtaining a culture
Obtaining a culture Explanation: A culture should be obtained if purulent drainage is present. Drainage should be gently removed, not scrubbed. Iodine-based products interfere with tissue healing and are not recommended for cleaning pin sites. Ointment should not be applied to the pin site unless specifically ordered.
Airborne precautions are for what 4 diseases?
SARS TB Measles (Rubeola) Varicella (chicken pox) (Wear N95 mask)
A nurse walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. Which is the next nursing action?
Start chest compressions
Nursing interventions for after a cardiac catheterization
assess for hematoma & bleeding first hour: assess vitals every 15 min second hour: every 30 minutes After check each hour. assess pulses teach patient on 6 hour bedrest
A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the client's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? a. Allow the client to rest quietly. b. Assess the client for bleeding. c. Document the findings in the chart. d. Medicate the client for pain.
b. Assess the client for bleeding.
A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?
before the examination, your provider will give you a sedative that will make you sleepy
sigmoid colostomy stool
formed stool
passive artificial immunity
injection of antibodies
Descending Colostomy stool
semiformed
ascending colostomy stool
semiliquid gas is common
passive immunity
temporary immunity that develops as a result of natural or deliberate exposure to an antibody Placenta Breast milk
Transverse Colostomy stool
thick liquid to soft consistency/liquid to pasty