NUCO 3110 Med/surg Quiz 5+6

A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding? A. Obtain a venous duplex ultrasound. B. Obtain impedance plethysmography. C. Monitor Homan's sign. D. Apply cold therapy to the affected leg.

A. Feedback: Venous duplex ultrasonography is a noninvasive diagnostic test that assesses the flow of blood and is used to detect distal deep vein thrombosis (DVT).

A charge nurse is supervising a newly licensed nurse care for a client who is receiving a transfusion of packed RBC. The nurse suspects a possible hemolytic reaction. After stopping the blood transfusion, which of the following actions by the new nurse requires intervention by the charge nurse? A. The nurse initiates an infusion of 0.9% sodium chloride. B. The nurse collects a urine specimen. C. The nurse sends a blood specimen to the laboratory D. The nurse starts the transfusion of another unit of blood product.

Ans: D Feedback: When suspecting a hemolytic reaction, the nurse should immediately stop the transfusion of all blood products. The transfusion of additional products can increase the client's risk for further complication.

A student nurse is learning about blood transfusion compatibilities. What information does this include? (Select all that apply) A. Donor blood type A can donate to recipient blood type AB. B. Donor blood type B can donate to recipient blood type O. C. Donor blood type AB can donate to anyone. D. Donor blood type O negative can donate to anyone. E. Donor blood type A can donate to recipient blood type B.

A, D

A nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension. The nurse recognizes which of the following laboratory findings as indicating the client's gastrointestinal (GI) tract is digesting and absorbing blood? A. Elevated blood urea nitrogen (BUN) B. Elevated HbA1c C. Decreased chloride D. Decreased bilirubin

A. Feedback: As the body digests blood, BUN rises. An elevated BUN is an indication of GI bleeding.

A nurse is caring for a client who has diverticular disease. When palpating the client's abdomen, in which of the following locations should the nurse expect the client to report abdominal pain? A. lower left quadrant B. upper left quadrant C. lower right quadrant D. upper right quadrant

A. Feedback: The nurse should expect the client to have abdominal pain in the lower left quadrant of the abdomen. The disease is usually found in the sigmoid colon, where high pressure to move fecal contents from the rectum causes pouch formation.

A nurse is preparing to administer a unit of packed red blood cells to a client. Which of the following actions should the nurse plan to take? A. Check the unit of blood with an assistant personal (AP). B. Pre-medicate the client with an antiemetic. C. Plan to infuse the unit of blood over 6 hr. D. Remain with the client for the first 15 minutes of the transfusion.

Ans: D. Two RNs or an RN and a practical nurse (PN) (in certain institutions) can check a unit of blood before it is transfused. This action is outside the scope of practice for an AP. The client might require premedication with an antipyretic, but not an antiemetic. The unit of blood should infuse within 4 hr to reduce the risk for bacteria growth. The nurse should remain with the client for the first 15 to 30 minutes of the transfusion to monitor for a transfusion reaction, which occurs often during the first 50 mL of the transfusion.

A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload? A. Flushing B. Dyspnea C. Bradycardia D. Vomiting

B. Feedback: Circulatory overload causes dyspnea, cough, rales, tachycardia, and jugular vein distention.

A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for? A. elevated sodium level B. decreased potassium level C. elevated magnesium level D. decreased calcium level

B. Feedback: Hypokalemia is an electrolyte imbalance in which the serum potassium level is less than 3.5 mEq/L. Hypokalemia may be the result of diuretic use, diarrhea, vomiting, and prolonged nasogastric suctioning.

A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid A. Nonfat milk B. Chocolate C. Apples D. Oatmeal

B. Feedback: The client should avoid foods that reduce pressure on the lower esophageal sphincter. These include fatty and fried foods, chocolate, caffeine, alcohol, and carbonated drinks.

A nurse is reviewing a client?s laboratory results and finds the hemoglobin is 7.8 g/dL and the hematocrit is 23.5%. The nurse recognizes that the client is at risk for which of the following? A. Prolonged bleeding B. Cellular hypoxia C. Impaired immunity D. Fluid retention

B. Feedback: The client's laboratory results indicate anemia, which places the client at risk for cellular hypoxia.

A nurse is caring for a client who is to receive a unit of packed RBCs. The nurse should prime the blood administration tubing using which of the following IV solutions? A. Lactated Ringer's solution B. 0.9% sodium chloride C. Dextrose 5% in water D. Dextrose 5% in 0.45% sodium chloride

B. Feedback: The nurse should prime the tubing with 0.9% sodium chloride, as this is the only IV solution that does not hemolyze RBCs.

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse recognize as a risk factor for this condition? A. History of bulimia B. History of NSAID use C. Drinks green tea D. Has a glass of wine with dinner each day

B. Feedback: The nurse should recognize that long-term use of NSAIDs is a risk factor for peptic ulcer disease. NSAIDs break down the mucosal barrier and cause production of prostaglandins to decrease, which results in local gastric mucosal injury.

Which electrolyte imbalance can occur related to a blood transfusion? A. Hyponatremia B. Hyperkalemia C. Hypocalcemia D. Hyperglycemia

B. Feedback: Electrolyte imbalances are possible as a result of transfusions, especially with packed red blood cells (PRBCs). During transfusions, some cells are damaged, releasing potassium and raising the patient's serum potassium level above normal (hyperkalemia). This problem is more likely when the blood being transfused has been frozen or is several weeks old.

A nurse is caring for a client who develops a pulmonary embolism. The patient is having chest pain and their pulse oximeter is reading 86%. Which of the following interventions should the nurse implement first? A. Give morphine IV B. Administer oxygen therapy C. Start an IV infusion of lactated Ringer's D. Initiate cardiac monitoring

B. Feedback: It is important to manage the client's pain because this can reduce oxygen consumption and limit the harmful effects of catecholamines, which are released when the client experiences pain; however, another intervention should be implemented by the nurse first. The greatest risk to the safety of a client who has a pulmonary embolism is hypoxemia with respiratory distress and cyanosis. Oxygen therapy should be applied by the nurse using a nasal cannula or mask. Pulse oximetry should be initiated to monitor oxygen saturation Crystalloids are administered via continuous IV bolus to maintain cardiac output and prevent shock; however, another intervention is the priority action for the nurse to take. The client who develops a pulmonary embolism is likely to have cardiac manifestation as a result of decreased tissue perfusion. It will be important to monitor the client's cardiac rhythm for T-wave and ST-segment changes as well as right ventricular failure or myocardial infarction. There is, however, another intervention that is the priority.

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? A. Furosemide B. Dexamethasone C. Heparin D. Atropine

C. Feedback: A pulmonary emboli is a condition in which the pulmonary blood flow is obstructed, resulting in hypoxia and possible death. Most often caused by a blood clot, treatment such as heparin, an anticoagulant, is used to prevent the enlargement of the existing clot or formation of new clots.

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray? A. Lemon sherbet B. Plain yogurt C. Cranberry juice D. Carrot juice

C. Feedback: Cranberry juice is an acceptable component of a clear liquid diet, along with apple juice and grape juice.

A nurse is providing discharge instructions to a client who developed deep-vein thrombosis (DVT) postoperatively and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include? A. Applying cool compresses to her legs B. Wearing loose, non-constricting stockings C. Flexing her knees and feet frequently D. Taking an NSAID tablet daily

C. Feedback: Leg, ankle, and foot exercises can help improve circulation and prevent venous stasis while the client is resting.

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning? A. Hypoactive bowel sounds in two quadrants B. Request for a cup of tea and some toast C. Passage of flatus D. Abdominal distention

C. Feedback: Passing flatus and belching indicate the return of peristaltic activity.

A nurse is reviewing the medical record of a client who reports drinking three to four glasses of wine each night and taking 3,000 mg of acetaminophen daily. Which of the following laboratory values is the priority for the nurse to assess? A. Amylase B. Creatinine C. Aspartate aminotransferase (AST) D. Antidiuretic hormone (ADH)

C. Feedback: The greatest risk to this client is liver injury from the combined adverse effects of alcohol and acetaminophen. Therefore, the priority laboratory value for the nurse to evaluate is AST because an elevated level is an indication of liver damage.

A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan? A. Include foods high in starch and proteins. B. Include foods high in fiber. C. Avoid foods high in fat. D. Avoid foods high in sodium.

C. Feedback: The nurse should instruct the client to follow a low-fat diet to decrease episodes of biliary colic. A client who has chronic cholecystitis has intolerance to fatty foods.

A nurse is providing teaching to a client who has a new colostomy. Which of the following information should the nurse include in the teaching? A. "You can expect fecal output within 24 hours." B. "You will need to increase your dietary intake of raw vegetables." C. "You can expect the stoma to be purplish in color for the first week." D. "You may experience a small amount of bleeding around the stoma."

D. Feedback: A small amount of bleeding around the stoma and its stem can occur. However, the client should report an increase in bleeding to the surgeon.