Med Surg 102 Exam

Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is: A. Blood pressure. B. Renal output. C. Heart rate. D. Breath Sounds

A. Blood Pressure Rationale: By the time the blood pressure drops, damage has already been occurring at the cellular and tissue levels. Therefore, the patient at risk for shock must be monitored closely before the blood pressure drops.

The nurse is conducting a community education class on gastritis. The nurse includes that chronic gastritis caused by Helicobacter pylori is implicated in which disease/condition? A. Peptic ulcers B. Systemic infection C. Colostomy D.Pernicious anemia

A. Peptic Ulcers Rationale: Chronic gastritis caused by Helicobacter pylori is implicated in the development of peptic ulcers. Chronic gastritis is sometimes associated with autoimmune disease, such as pernicious anemia, but not as a cause of the anemia. Chronic gastritis is not implicated in system infections and/or colostomies.

The nurse recognizes that the client diagnosed with a duodenal ulcer will likely experience A. Vomiting B. Weight loss C. pain 2 to 3 hours after a meal. D. Hemorrhage

C. pain 2 to 3 hours after a meal. Rationale: The client with a duodenal ulcer often awakens between 1 and 2 with pain, and ingestion of food brings relief. Vomiting is uncommon in the client with duodenal ulcer. Hemorrhage is less likely in the client with duodenal ulcer than in the client with gastric ulcer. The client with a duodenal ulcer may experience weight gain.

A client with early-stage rheumatoid arthritis asks the nurse what the client can do to help ease the symptoms of the disease. What would be the best response by the nurse? A. "The doctor could prescribe antihypertensive drugs." B. "The doctor could prescribe anti-inflammatory drugs." C. "The doctor could prescribe antineoplastic drugs." D. "The doctor could prescribe antipyretic drugs."

B. "The doctor could prescribe anti-inflammatory drugs." Rationale: Drug therapy using anti-inflammatory and immunosuppressive agents is the mainstay for alleviating symptoms. Antipyretic and antihypertensive drugs are not prescribed for autoimmune diseases. An antineoplastic drug is not ordered for an autoimmune disorder until it is in its late stages and uncontrolled by the first-line drugs.

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages? A. A weak and thready pulse B. A slow but steady pulse C. A rapid, bounding pulse D. A slow and imperceptible pulse

C. A rapid, bounding pulse Rationale: A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible and pulse rhythm changes from regular to irregular.

Peptic ulcer disease occurs more frequently in people with which blood type? B A AB O

O Rationale: People with blood type O are more susceptible to peptic ulcers than those with blood type A, B, or AB.

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? A. contacting the surgeon B. assessing for impaired blood flow to the area of evisceration. C. monitoring for pallor and mottled appearance of the wound D. applying sterile dressings with normal saline over the protruding organs and tissue

applying sterile dressings with normal saline over the protruding organs and tissue Rationale: The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.

A client with gastric ulcers caused by H. pylori is prescribed metronidazole. Which client statement indicates to the nurse that teaching about this medication was effective? A. "It might cause a metallic taste in my mouth." B. "I can take this medication with my blood thinner." C. "I can have an alcoholic drink in the evenings." D. "My appetite may increase while taking this medication."

A. "It might cause a metallic taste in my mouth." Rationale: Metronidazole is a synthetic antibacterial and antiprotozoal agent that assists with eradicating H. pylori bacteria in the gastric mucosa when given with other antibiotics and proton pump inhibitors. This medication may cause a metallic taste in the mouth. It should not be taken with anticoagulants as it will increase the blood thinning effects of warfarin. Alcohol should be avoided while taking this medication. This medication may cause anorexia and not an increased appetite

A nurse is developing a plan of care for a client who has gastroesophageal and reflux disease (GERD). The nurse should plan to monitor the client for which of the following complications? A. Aspiration B. Infection C. Anemia D. Weight Loss

A. Aspiration Rationale: Aspiration is a common complication of GERD, which results when the esophageal sphincter malfunctions and allows gastric acid and undigested food to back up into the esophagus. This places the client at risk for aspiration. GERD causes effortless, uncontrolled regurgitation whether the client is in an upright position or reclining. The most common results of regurgitation are heartburn and indigestion; however aspiration is also possible. Therefore the nurse should monitor the client for crackles in the lung fields, which are an indication of aspiration.

A client comes to the emergency department complaining of localized pain and swelling of the lower leg. Ecchymotic areas are noted. History reveals that the client got hit in the leg with a baseball bat. Which of the following would the nurse suspect as most likely? A. Contusion B. Sprain C. Fracture D. Strain

A. Contusion Rationale: The client's description of blunt trauma by a baseball bat and localized pain in conjunction with swelling and ecchymosis would most likely suggest a contusion. A fracture would be manifested by pain, loss of function, deformity, swelling, and spasm. A sprain would be manifested by pain and swelling; ecchymosis may appear later. A strain is characterized by inflammation, local tenderness, and muscle spasms.

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply. A. Insert a swab into the wound. B. Use the same swab for both wound sites. C. Touch the swab to the intact skin at the wound edges. D. Place the swab in the culture tube when done. E. Press and rotate the swab several times over the wound surfaces. F. Tap the outside of the culture tube with the swab before placing it in the tube.

A. Insert a swab into the wound. E. Press and rotate the swab several times over the wound surfaces. D. Place the swab in the culture tube when done. Rationale: The nurse should carefully insert the swab into the wound and then press and rotate the swab several times over the wound surfaces. After collecting the specimen, the nurse should place the swab back in the culture tube. The nurse should be careful to keep the swab and the inside of the culture tube sterile at all times. This means that the nurse should avoid touching the swab to intact skin at the wound edges or to the outside of the tube, as this would contaminate both the swab with organisms not in the wound and the areas that the swab touches with organisms found in the wound. A different swab, not the same, should be used for each wound site to prevent cross-contamination.

A client is brought to the emergency department after injuring the right arm in a bicycle accident. The orthopedic surgeon tells the nurse that the client has a greenstick fracture of the arm. What does this mean? A. One side of the bone is broken and the other side is bent. B. The fracture line extends through the entire bone substance. C. Bone fragments are separated at the fracture line. D. The fracture results from an underlying bone disorder.

A. One side of the bone is broken and the other side is bent. Rationale: In a greenstick fracture, one side of the bone is broken and the other side is bent. A greenstick fracture also may refer to an incomplete fracture in which the fracture line extends only partially through the bone substance and doesn't disrupt bone continuity completely. (Other terms for greenstick fracture are willow fracture and hickory-stick fracture.) The fracture line extends through the entire bone substance in a complete fracture. A fracture that results from an underlying bone disorder, such as osteoporosis or a tumor, is a pathologic fracture, which typically occurs with minimal trauma. Bone fragments are separated at the fracture line in a displaced fracture.

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment: A. Oxygen at 2 L/min by nasal cannula B. Dopamine (Intropin) intravenous solution C.. NS at 60 mL/hr via an intravenous line D. Morphine 2 mg intravenously

A. Oxygen at 2 L/min by nasal cannula Rationale: In the early stages of cardiogenic shock, the nurse first administers supplemental oxygen to achieve an oxygen saturation exceeding 90%. The nurse may then administer morphine to relieve chest pain and/or to reduce the workload of the heart and decrease client anxiety. Intravenous fluids are given carefully to prevent fluid overload. Vasoactive medications, such as dopamine, are then administered to restore and maintain cardiac output.

A nurse is caring for a client who had a gastric resection to treat adenocarcinoma of the stomach. The client tells the nurse in the PACU that he does not remember why the surgeon said he had to have a tube in his nose. The nurse should explain that the NG tube serves which of the following purposes? A. Prevents excessive pressure on suture lines B. Allows gastric lavage after surgery C.Allows early postoperative feeding D. Facilitates obtaining gastric specimens for testing

A. Prevents excessive pressure on suture lines Rationale: The NG tube remains in place after surgery to prevent excessive pressure on suture lines postoperatively. It drains the air and fluid that can cause pressure from inside the gastrointestinal tract. In doing so it also prevents vomiting and GI distention

The nurse is gathering a health history for a client with osteoarthritis. What clinical manifestation will the nurse expect to find? A. early morning stiffness B. small joint involvement C. subcutaneous nodules D. joint pain that increases with rest

A. early morning stiffness Rationale: Osteoarthritis is characterized by early morning stiffness that decreases with activity. Large joints are usually involved with osteoarthritis. Joint pain is a constant with osteoarthritis. Clients with rheumatoid arthritis have subcutaneous nodules.

A client is experiencing vomiting and diarrhea for 2 days. Blood pressure is 88/56, pulse rate is 122 beats/minute, and respirations are 28 breaths/minute. The nurse starts intravenous fluids. Which of the following prescribed prn medications would the nurse administer next? A. ondansetron B. magnesium hydroxide C. meperidine D. loperamide

A. ondansetron Rationale: An antiemetic medication, such as ondansetron (Zofran), is administered for vomiting. It would be administered before loperamide (Imodium) for diarrhea so the client would be able to retain the loperamide. There is no indication that the client requires medication for pain (meperidine [Demerol]) or heartburn (magnesium hydroxide [Maalox]).

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury? A. stage IV B. stage I C. stage II D. stage III

A. stage IV Rationale: Stage IV pressure injuries are characterized as exposing muscle and bone and may have slough and a foul odor. Stage I pressure injuries are characterized by intact but reddened skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage.

What is the priority intervention for a client who has been admitted repeatedly with attacks of gout? A. Insert a Foley catheter B. Assess diet and activity at home C. Place client on bed rest D. Increase fluids

B. Assess diet and activity at home Rationale: Clients with gout need to be educated about dietary restrictions in order to prevent repeated attacks. Foods high in purine need to be avoided, and alcohol intake has to be limited. Stressful activities should also be avoided. The nurse should assess to determine what is stimulating the repeated attacks of gout. The other interventions are not appropriate for a client with this problem.

An x-ray demonstrates a fracture in which a bone has splintered into several pieces. Which type of fracture is this? A. Depressed B. Comminuted C. Impacted D. Compound

B. Comminuted Rationale : A comminuted fracture may require open reduction and internal fixation. A compound fracture is one in which damage also involves the skin or mucous membranes. A depressed fracture is one in which fragments are driven inward. An impacted fracture is one in which a bone fragment is driven into another bone fragment.

The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. Emergency medical services (EMS) is notified by the neighbor. Which nursing action is helpful while waiting for the ambulance? A. Cover the client with a blanket. B. Elevate the legs higher than the heart. C. Shake the client to arouse. D. Place a cool compress on head.

B. Elevate the legs higher than the heart. Rationale: The client has shallow respiration and a weak pulse implying limited circulation and gas exchange. Most helpful would be to elevate the legs higher than the heart to promote blood perfusion to the heart, lungs, and brain. A cool compress would not be helpful nor would shaking the client to arouse. A client can be covered with a blanket, but this is not the most helpful.

Which medication is classified as a histamine-2 receptor antagonist? A. Lansoprazole B. Famotidine C. Esomeprazole D. Metronidazole

B. Famotidine Rationale: Famotidine is a histamine-2 receptor antagonist. Lansoprazole and esomeprazole are proton pump inhibitors (PPIs). Metronidazole is an antibiotic.

A nurse practitioner prescribes drug therapy for a patient with peptic ulcer disease. Choose the drug that can be used for 4 weeks and has a 90% chance of healing the ulcer. A. Famotidine B. Omeprazole C. Cimetidine D. Nizatidine

B. Omeprazole Rationale: Omeprazole (Prilosec) is a proton pump inhibitor that, if used according to the health care provider's directions, will result in healing in 90% of patients. The other drugs are H2 receptor antagonists that need to be used for 6 weeks.

A nurse is providing instructions about pursed lip breathing for a client who has COPD with emphysema. This breathing technique accomplishes which of the following? A. Increases oxygen intake B. Promotes carbon dioxide elimination C. Uses the intercostal muscles D. Strengthens the diaphragm

B. Promotes carbon dioxide elimination Rationale: A client who has COPD with emphysema should use pursed lip breathing when experiencing dyspnea. This simple method slows the clients pace of breathing, making each breath more effective. Purse lipped breathing releases trapped air in the lungs and prolong exhalation in order to slow the breathing rate. This improved breathing pattern moves carbon dioxide out of the lungs more efficiently.

A client has a cerebrovascular accident and is incontinent of bowel and bladder. Incontinence of urine in this client is related to A. enuresis. B. neurogenic bladder. C. cystocele. D.overactive bladder.

B. neurogenic bladder. Neurologic injury after a stroke or spinal cord injury can disrupt normal patterns of urinary elimination. This condition is called neurogenic bladder. A cystocele is a herniation of the urinary bladder. Enuresis is the clinical term for bedwetting. An overactive bladder is the term used when a person has increased urinary urge, increased urinary frequency, or both.

A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction? A. "Apply heat packs for the first 24 hours, then apply ice packs for the next 48 hours." B. "Apply heat packs for the first 24 to 48 hours." C. "Apply ice packs for the first 24 to 48 hours, then apply heat packs." D. "Apply ice packs for the first 12 to 18 hours."

C. "Apply ice packs for the first 24 to 48 hours, then apply heat packs." Rationale: The nurse should instruct the client to apply ice packs to the injured area for the first 24 to 48 hours to reduce swelling and then apply heat to increase comfort, promote reabsorption of blood and fluid, and speed healing. Applying ice for only 12 to 18 hours may not keep swelling from recurring. Applying heat for the first 24 to 48 hours would worsen, not ease, swelling. Applying ice 48 hours after the injury would be less effective because swelling already has occurred by that time.

A patient is scheduled for a Billroth I procedure for ulcer management. What does the nurse understand will occur when this procedure is performed? A. The antral portion of the stomach is removed and a vagotomy is performed. B. A sectioned portion of the stomach is joined to the jejunum. C. A partial gastrectomy is performed with anastomosis of the stomach segment to the duodenum. D. The vagus nerve is cut and gastric drainage is established.

C. A partial gastrectomy is performed with anastomosis of the stomach segment to the duodenum. Rationale: A Billroth I procedure involves removal of the lower portion of the antrum of the stomach (which contains the cells that secrete gastrin) as well as a small portion of the duodenum and pylorus. The remaining segment is anastomosed to the duodenum. A vagotomy severs the vagus nerve; a Billroth I procedure may be performed in conjunction with a vagotomy. If the remaining part of the stomach is anastomosed to the jejunum, the procedure is a Billroth II.

The nurse is educating a client about the risks of stroke related to the new prescription for a COX-2 inhibitor and what symptoms to report. Which COX-2 inhibitor is the nurse educating the client about? A. Ibuprofen B. Tolmetin sodium C. Celecoxib D. Piroxicam

C. Celecoxib Rationale: The COX-2 inhibitor celecoxib (Celebrex) is associated with an increased risk of cardiovascular events, including myocardial infarction and stroke.

The nurse is preparing to educate a client with rheumatoid arthritis on long-term effects of prednisone therapy. Which topic will the nurse include in the teaching? A. Report weight gain to your health care provider immediately. B. Decrease food intake to two meals per day. C. Eat a lower calorie diet to manage weight gain. D. Make sure to fast for at least 12 hours per day

C. Eat a lower calorie diet to manage weight gain. Rationale: Common side effects of prednisone include weight gain and increased hunger. The nurse should educate the client on eating a well-balanced diet with a decreased calorie intake. Weight gain is common so it does not need to be reported immediately. A client should not decrease number of meals and should not fast as this can cause malnutrition and decreased energy to deal with chronic disease.

A nurse is assisting with the orientation of a newly hired graduate. Which of the following behaviors of the graduate nurse would the other nurse identify as not adhering to strict infection control practices? A. Swabbing the port of a central line for 15 seconds with an alcohol pad prior to medication administration B. Wearing clean gloves when inserting a needle in preparation of starting intravenous fluids C. Hanging tape on the bedside table when changing a wet-to-dry sterile dressing D. Rubbing the hands together with antiseptic solution until dry when exiting the client's room

C. Hanging tape on the bedside table when changing a wet-to-dry sterile dressing Rationale: The Centers for Disease Control and Prevention do not recommend hanging tape on bedside tables, siderails, linens, or clothing to use for dressings. The other options are activities that are proper infection control practices.

Which of the following is the most common complication associated with peptic ulcer? A. Abdominal pain B. Elevated temperature C.Hemorrhage D. Vomiting

C. Hemorrhage Rationale: Hemorrhage, the most common complication, occurs in 28% to 59% of patients with peptic ulcers. Vomiting, elevated temperature, and abdominal pain are not the most common complications of a peptic ulcer.

The nurse is discussing the new medication that a client will be taking for treatment of rheumatoid arthritis. Which disease-modifying antirheumatic drug (DMARD) will the nurse educate the client about? A. Celecoxib B. Methylprednisolone C. Methotrexate D. Mercaptopurine azathioprine

C. Methotrexate Rationale: Methotrexate is a DMARD that reduces the amount of joint damage and slows the damage to other tissues as well. Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID). Methylprednisolone is a steroid to reduce pain and inflammation and slow joint destruction. Mercaptopurine azathioprine is a cytotoxic drug.

A patient arrives in the emergency department with complaints of chest pain radiating to the jaw. What medication does the nurse anticipate administering to reduce pain and anxiety as well as reducing oxygen consumption? A. Meperidine B. Codeine C. Morphine D. Hydromorphone

C. Morphine Rationale: If a patient experiences chest pain, IV morphine is administered for pain relief. In addition to relieving pain, morphine dilates the blood vessels. This reduces the workload of the heart by both decreasing the cardiac filling pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload). Morphine also decreases the patient's anxiety and reduces the respiratory rate, and thus oxygen consumption.

The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed? A.Increase in diastolic pressure B.Decrease in respiratory rate C. Narrowed pulse pressure D.Increase in systolic blood pressure

C. Narrowed pulse pressure Rationale: Pulse pressure correlates well with stroke volume. Pulse pressure is calculated by subtracting the diastolic measurement from the systolic measurement; the difference is the pulse pressure. Normally, the pulse pressure is 30 to 40 mm Hg. Narrowing or decreased pulse pressure is an earlier indicator of shock than a drop in systolic BP. Decreased or narrowing pulse pressure is an early indication of decreased stroke volume.

A client sustains an injury to the ligaments surrounding a joint. What will the nurse identify this injury as? A. Strain B. Contusion C. Sprain D. Fracture

C. Sprain Rationale: A sprain is an injury to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A contusion is a soft tissue injury resulting from a blow or blunt trauma. A fracture is a break in the continuity of a bone.

When a client is in the compensatory stage of shock, which symptom occurs? A.Urine output of 45 mL/hr B. Respiratory Acidosis C. Tachycardia D. Bradycardia

C. Tachycardia Rationale: The compensatory stage of shock encompasses a normal BP, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.

The nurse is caring for a client with ankylosing spondylitis. Which educational information will the nurse provide to this client? A. Use of cough surpressants B. Use of diuretics C. Use of analgesics D. Use of laxatives

C. Use of analgesics Rationale: Ankylosing spondylitis (AS) is a chronic inflammatory disease of the spine. Back pain is the characteristic feature. AS affects the cartilaginous joints of the spine and surrounding tissues, making them rigid, decreasing mobility, and leading to kyphosis or a stooped position. Constipation, chronic cough, and peripheral edema are not symptoms associated with AS.

A client is recovering from an attack of gout. What will the nurse include in the client teaching? A. Weight loss will reduce inflammation. B. Weight loss will increase uric acid levels and reduce stress on joints. C. Weight loss will reduce uric acid levels and reduce stress on joints. D. Weight loss will reduce purine levels.

C. Weight loss will reduce uric acid levels and reduce stress on joints. Rationale: Weight loss will reduce uric acid levels and reduce stress on joints. Weight loss will not reduce purine levels, reduce inflammation, or increase uric acid levels.

The type of fracture described as having one side of the bone broken and the other side bent would be: A. oblique. B. transverse. C. greenstick. D. spiral.

C. greenstick Rationale: A greenstick fracture is the type of fracture described as having one side of the bone broken and the other side bent. An oblique fracture occurs at an angle across the bone. A spiral fracture is a fracture that twists around the shaft of the bone. A transverse fracture is a fracture that is straight across the bone.

A client with peptic ulcer disease must begin triple medication therapy. For how long will the client follow this regimen? A. 7 to 9 days B. 4 to 6 days C. 15 to 20 days D. 10 to 14 days

D. 10 to 14 days Rationale: Recommended therapy for 10 to 14 days includes triple therapy with two antibiotics (e.g., metronidazole [Flagyl] or amoxicillin [Amoxil] and clarithromycin [Biaxin]) plus a proton pump inhibitor (e.g., lansoprazole [Prevacid], omeprazole [Prilosec], or rabeprazole [Aciphex]), or quadruple therapy with two antibiotics (metronidazole and tetracycline) plus a proton pump inhibitor and bismuth salts (Pepto-Bismol).

A client comes to the clinic after developing a headache, abdominal pain, nausea, hiccupping, and fatigue about 2 hours ago. The client tells the nurse that the last food was buffalo chicken wings and beer. Which medical condition does the nurse find to be most consistent with the client's presenting problems? A. Duodenal ulcer B. Gastric ulcer C. Gastric cancer D. Acute gastritis

D. Acute gastritis Rationale: A client with acute gastritis may have a rapid onset of symptoms, including abdominal discomfort, headache, lassitude, nausea, anorexia, vomiting, and hiccupping, which can last from a few hours to a few days. Acute gastritis is often caused by dietary indiscretion-a person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms. A client with a duodenal ulcer will present with heartburn, nausea, excessive gas and vomiting. A client with gastric cancer will have persistent symptoms of nausea and vomiting, not sudden symptoms. A client with a gastric ulcer will have bloating, nausea, and vomiting, but not necessarily hiccups.

What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing? A. transparent film B. alginate C. hydrogel D. hydrocolloid

D. Hydrocolloid Rationale: Hydrocolloids are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment, provide minimal to moderate absorption of drainage, maintain a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing. Hydrogels maintain a moist wound environment and are best for partial or full-thickness wounds. Alginates absorb exudate and maintain a moist wound environment. They are best for wounds with heavy exudate. Transparent films allow exchange of oxygen between wound and environment. They are best for small partial-thickness wounds with minimal drainage.

A nurse is caring for a client who is postoperative following a laparotomy. The client has an indwelling catheter and a Jackson Pratt drain in place. Which of the following findings indicate the client is developing a postoperative complication? A. Pain scale score of 5 out of 10 B. Urine output of 65 ml/hr. C. 20 ml of bright red drainage from drain D. Pulse oximetry of 85%

D. Pulse oximetry of 85% Rationale: After abdominal surgery, clients should have an oxygen saturation above 93%. A client whose oxygen saturation is 85% has hypoxemia and requires immediate intervention Pain scale 5 out of 10 is an expected finding after surgery, Clients recovering from abdominal surgery should have a urinary output that exceeds 30ml/hr, drainage of 20ml bright red fluid immediately after surgery is an expected finding for an adult

Which of the following is the most successful treatment for gastric cancer? A. Chemotherapy B. Palliation C. Radiation D Removal of the tumor

D. Removal of the tumor Rationale: There is no successful treatment for gastric carcinoma except removal of the tumor. If the tumor can be removed while it is still localized to the stomach, the patient may be cured. If the tumor has spread beyond the area that can be excised, cure is less likely.

A client is recovering from gastric surgery. Toward what goal should the nurse progress the client's enteral intake? A. Three meals and three snacks and 120 mL fluid daily B. Six small meals and 120 mL fluid daily C. Three meals and 120 ml fluid daily D. Six small meals daily with 120 mL fluid between meals

D. Six small meals daily with 120 mL fluid between meals Rationale: After the return of bowel sounds and removal of the nasogastric tube, the nurse may give fluids, followed by food in small portions. Foods are gradually added until the client can eat six small meals a day and drink 120 mL of fluid between meals.

A client is preparing for discharge to home following a partial gastrectomy and vagotomy. Which is the best rationale for the client being taught to lie down for 30 minutes after each meal? A. Removes tension on internal suture line B. Provides much needed rest C. Allows for better absorption of vitamin B12 D. Slows gastric emptying

D. Slows gastric emptying Rationale: Dumping syndrome is a common complication following subtotal gastrectomy. To avoid the rapid emptying of stomach contents, resting after meals can be helpful. Promoting rest after a major surgery is helpful in recovery but not the reason for resting after meals. Following this type of surgery, clients will have a need for vitamin B12 supplementation due to absence of production of intrinsic factor in the stomach. Resting does not increase absorption of B12 or remove tension on suture line.

The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock? A. ESR: 19 mm/hour B. Hemoglobin: 14.2 g/dL C. Potassium: 4.8 mEq/L D. WBC: 42,000/mm3

D. WBC: 42,000/mm3 Rationale: Septic shock has the highest mortality rate and is caused by an overwhelming bacterial infection; thus, an elevated WBC can indicate this type of shock. The other lab values are within normal limits.

A client is newly diagnosed with a peptic ulcer. For which medications will the nurse prepare teaching for this client? Select all that apply. A. Omeprazole B. Warfarin C. Bismuth subsalicylate D.Diphenhydramine E. Metronidazole

Metronidazole, Bismuth subsalicylate, Omeprazole Rationale: In the past, stress and anxiety were thought to be causes of peptic ulcers, but research has documented that most peptic ulcers result from infection with H. pylori, which may be acquired through ingestion of food and water. Because of this, antibiotics such as metronidazole are used to treat peptic ulcers. Bismuth salts, such as bismuth subsalicylate, potentiate the effects of an antibiotic and also have antacid properties. Proton pump inhibitors, such as omeprazole, reduce the amount of hydrochloric acid produced by stomach cells. Anticoagulants, such as warfarin, and antihistamines, diphenhydramine, are not used to treat peptic ulcer disease.

A client's BUN test results are significantly elevated. When reviewing the client's history, which finding is consistent with BUN elevation other than renal compromise?

The client is dehydrated. Rationale: The BUN test measures the amount of urea nitrogen in the blood. Urea, the major nitrogenous end-waste product of metabolism, is formed in the liver. The bloodstream carries urea from the liver to the kidneys for excretion. When the kidneys are diseased, they are unable to excrete urea adequately, and urea begins to accumulate in the blood, causing BUN to rise. Normal BUN is 8 to 25 mg/100 mL. Because other factors, such as high dietary intake of protein, fluid deficit, infection, gout, or excessive breakdown of protein stores, can also elevate BUN, it is not a highly sensitive indicator of impaired renal function.