Med Surg Test 1
The management of the patient's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the patient is managing the tube correctly?
"I flush my tube with water before and after each of my medications."
A community health nurse serves a diverse population. What individual would likely face the highest risk for parotitis?
An older adult whose medication regimen includes an anticholinergic
The nurse is providing care for a patient whose inflammatory bowel disease has necessitated hospital treatment. Which of the following would most likely be included in the patient's medication regimen?
Anticholinergic medications 30 minutes before a meal (The nurse administers anticholinergic medications 30 minutes before a meal as prescribed to decrease intestinal motility and administers analgesics as prescribed for pain)
The nurse is caring for a patient postoperative day 4 following a kidney transplant. When assessing for potential signs and symptoms of rejection, what assessment should the nurse prioritize?
Assessment of the quantity of the patient's urine output
A patient's NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next?
Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating.
A nurse is providing oral care to a patient who is comatose. What action best addresses the patient's risk of tooth decay and plaque accumulation?
Brushing the patient's teeth with a toothbrush and small amount of toothpaste
A nurse is aware of the high incidence of catheter-related bloodstream infections in patients receiving parenteral nutrition. What nursing action has the greatest potential to reduce catheter-related bloodstream infections?
Change the dressing no more than weekly.
The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurse's assessments most directly addresses a major complication of TPN?
Checking the patient's capillary blood glucose levels regularly
A patient's health decline necessitates the use of total parenteral nutrition. The patient has questioned the need for insertion of a central venous catheter, expressing a preference for a "normal IV." The nurse should know that peripheral administration of high-concentration PN formulas is contraindicated because of the risk for what complication?
Chemical phlebitis
A nurse is creating a care plan for a patient who is receiving parenteral nutrition. The patient's care plan should include nursing actions relevant to what potential complications? Select all that apply.
Clotted or displaced catheter Hyperglycemia Pneumothorax Line sepsis
A nurse is preparing to administer a patient's scheduled parenteral nutrition (PN). Upon inspecting the bag, the nurse notices that the presence of small amounts of white precipitate are present in the bag. What is the nurse's best action?
Contact the pharmacy to obtain a new bag of PN.
A patient with ESKD is scheduled to begin hemodialysis. The nurse is working with the patient to adapt the patient's diet to maximize the therapeutic effect and minimize the risks of complications. The patient's diet should include which of the following modifications? Select all that apply.
Decreased sodium intake Decreased protein intake Fluid restriction
A female patient has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this patient?
Drink liberal amounts of fluids. (The patient is encouraged to drink liberal amounts of fluids (water is the best choice) to increase urine production and flow, which flushes the bacteria from the urinary tract. Frequent voiding (every 2 to 3 hours) is encouraged to empty the bladder completely because this can significantly lower urine bacterial counts, reduce urinary stasis, and prevent reinfection. The patient should be encouraged to shower rather than bathe.)
The nurse is caring for a patient who is postoperative from having a gastrostomy tube placed. What should the nurse do on a daily basis to prevent skin breakdown?
Gently rotate the tube.
A nurse is caring for a patient who is receiving parenteral nutrition. When writing this patient's plan of care, which of the following nursing diagnoses should be included?
Ineffective Role Performance Related to Parenteral Nutrition
The nurse is caring for a patient after kidney surgery. The nurse is aware that bleeding is a major complication of kidney surgery and that if it goes undetected and untreated can result in hypovolemia and hemorrhagic shock in the patient. When assessing for bleeding, what assessment parameter should the nurse evaluate?
Level of consciousness
A nurse who provides care in a long-term care facility is aware of the high incidence and prevalence of urinary tract infections among older adults. What action has the greatest potential to prevent UTIs in this population?
Limit the use of indwelling urinary catheters.
The nurse has identified the nursing diagnosis of "risk for infection" in a patient who undergoes peritoneal dialysis. What nursing action best addresses this risk?
Maintain aseptic technique when administering dialysate.
A nurse is preparing to place a patient's ordered nasogastric tube. How should the nurse best determine the correct length of the nasogastric tube?
Place distal tip to nose, then ear tip and end of xiphoid process.
A nurse is providing care for a patient who is postoperative day 2 following gastric surgery. The nurse's assessment should be planned in light of the possibility of what potential complications? Select all that apply.
Pneumonia Metabolic imbalances Atelectasis
The nurse's comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages?
Presence of a painless sore with raised edges
A nursing educator is reviewing the care of patients with feeding tubes and endotracheal tubes (ET). The educator has emphasized the need to check for tube placement in the stomach as well as residual volume. What is the main purpose of this nursing action?
Prevent aspiration
A patient on the critical care unit is postoperative day 1 following kidney transplantation from a living donor. The nurse's most recent assessments indicate that the patient is producing copious quantities of dilute urine. What is the nurse's most appropriate response?
Recognize this as an expected finding.
A patient who suffered a stroke had an NG tube inserted to facilitate feeding shortly after admission. The patient has since become comatose and the patient's family asks the nurse why the physician is recommending the removal of the patient's NG tube and the insertion of a gastrostomy tube. What is the nurse's best response?
Regurgitation and aspiration are less likely
A patient has been diagnosed with an esophageal diverticulum after undergoing diagnostic imaging. When taking the health history, the nurse should expect the patient to describe what sign or symptom?
Regurgitation of undigested food
A nurse is caring for a patient with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this patient, what nursing diagnosis should the nurse prioritize?
Risk for Infection Related to the Presence of a Subclavian Catheter
The nurse who is leading a wellness workshop has been asked about actions to reduce the risk of bladder cancer. What health promotion action most directly addresses a major risk factor for bladder cancer?
Smoking cessation
A nurse is presenting a class at a bariatric clinic about the different types of surgical procedures offered by the clinic. When describing the implications of different types of surgeries, the nurse should address which of the following topics? Select all that apply.
Specific lifestyle changes associated with each procedure Implications of each procedure for eating habits Effects of different surgeries on bowel function
A patient with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the patient's post-procedure care?
Strain the patient's urine following the procedure.
A nurse is caring for a patient hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize?
Strategies for avoiding irritating foods and beverages
The clinic nurse is preparing a plan of care for a patient with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach?
Teach the patient to perform pelvic floor muscle exercises.
A nurse on the renal unit is caring for a patient who will soon begin peritoneal dialysis. The family of the patient asks for education about the peritoneal dialysis catheter that has been placed in the patient's peritoneum. The nurse explains the three sections of the catheter and talks about the two cuffs on the dialysis catheter. What would the nurse explain about the cuffs? Select all that apply.
The cuffs stabilize the catheter. The cuffs provide a barrier against microorganisms. The cuffs prevent the dialysate from leaking. The cuffs are made of Dacron polyester.
A nurse is planning discharge teaching for a 21-year-old patient with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the patient's coping after discharge?
The family's ability to provide emotional support
The nurse is caring for acutely ill patient. What assessment finding should prompt the nurse to inform the physician that the patient may be exhibiting signs of acute kidney injury (AKI)?
The patient's average urine output has been 10 mL/hr for several hours. (Oliguria (<500 mL/d of urine) is the most common clinical situation seen in AKI)
A female patient has been prescribed a course of antibiotics for the treatment of a UTI. When providing health education for the patient, the nurse should address what topic?
The risk of developing a vaginal yeast infection as a consequent of antibiotic therapy
A patient admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely the best choice for this patient?
Tofu
A nurse is creating a care plan for a patient with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube?
Use a combination of at least two accepted methods for confirming placement. (air auscultation and check pH of residual)
A patient is postoperative day 1 following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate?
Wash the area around the tube with soap and water daily.
The nurse is caring for a patient with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The patient has an elevated phosphorus level and has been prescribed calcium acetate to bind the phosphorus. The nurse should teach the patient to take the prescribed phosphorus-binding medication at what time?
With each meal
