Med Serg 1 Prep U Chapters 12, 13, & 19!

0.45% NaCl

A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering?

first intention.

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:

Provide oral care every 2-3 hours.

A nurse is caring for a client with acute renal failure and hypernatremia. In this case, which action can be delegated to the nursing assistant?

Wound dehiscence

A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for?

Extracellular fluid volume deficit

A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following?

The client had a liver transplant 2 years ago.

A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?

bicarbonate-carbonic acid buffer system

A nurse is providing client teaching about the body's plasma pH and the client asks the nurse what is the major chemical regulator of plasma pH. What is the best response by the nurse?

Urine pH of 3.0

A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation?

275-300 mOsm/kg

A patient's serum sodium concentration is within the normal range. What should the nurse estimate the serum osmolality to be?

Moisten sterile gauze with normal saline and place on the protruding organ.

A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first?

"I saw you grimacing during the dressing change. Please explain the reason you refused the pain medication."

A teenage client is undergoing a dressing change to burns on the thigh. The client refuses pain medication and states, "I do not hurt, and I don't need it." He is withdrawn, grimaces, and turns away during the dressing change. He was last medicated 8 hours ago. What is the best statement by the nurse?

Hypokalemia

An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use?

130 mEq/L (130 mmol/L)

At which serum sodium concentration might convulsions or coma occur?

maintaining pulmonary ventilation.

The primary objective in the immediate postoperative period is

Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad

Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)?

Tolerance

You are caring for a client who needs to ambulate. What considerations should be included when planning the postoperative ambulatory activities for the older adult?

drug therapy

A 64-year-old client is experiencing joint pain on a regular basis and asks the nurse what the options are beyond heat and the yoga exercises the client has been doing. What does the nurse describe as the cornerstone treatment modality for pain?

Continue with frequent client assessments.

A PACU nurse is caring for a postoperative client who received general anesthesia and has a hard, plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and 98% oxygen saturation. The client is minimally responsive to painful stimuli. What action by the nurse is most appropriate?

experiences pain within tolerable limits.

A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client?

Ice bag

A client arrives in the orthopedic clinic with complaints of twisting the right ankle while playing softball. The nurse collects data including complaints of pain and swelling in the right ankle. What intervention will the nurse provide that will decrease vasodilation and reduce localized swelling?

Ensure the client knows to taper down the dose if it is discontinued by the care provider.

A client being treated for rheumatoid arthritis has been prescribed a glucocorticosteroid. How should the nurse best ensure this client's safety during treatment?

Respiratory alkalosis

A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings?

auscultate bowel sounds.

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

neuropathic and chronic

A client has a long history of diabetes mellitus and developed diabetic neuropathy more than 25 years ago. The client is without breakthrough pain at this point in time. How would this client's pain be classified?

Increases arterial pH

A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level?

third-spacing

A client has been admitted to the hospital unit with signs and symptoms of hypovolemia; however, the client has not lost weight. The client exhibits a localized enlargement of her abdomen. What condition could the client be presenting?

Light-headedness or paresthesia

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

visceral

A client is admitted with generalized abdominal pain, nausea, vomiting, and hypotension. The client has not passed stool in over 1 week and has been in pain for the past 4 days. Which type of pain would you expect the client to be experiencing?

Assess for signs and symptoms of fluid volume deficit.

A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate?

Programming the dosage and time interval into the device

A client is being taught to self-administer a narcotic analgesic by means of an intravenous PCA pump system. Which of the following would help prevent accidental overdosage?

Addiction

A client is being treated in a substance abuse unit of a local hospital. The nurse understands that when this client has compulsive behavior to use a drug for its psychic effect, the client needs to be monitored for which effect?

tingling sensation in the fingers

A client is diagnosed with hypocalcemia and the nurse is teaching the client about symptoms. What symptom would the nurse include in the teaching?

neuropathic pain

A client is on a second round of radiation therapy for an inoperable tumor, and asks the nurse for medication to help with pain. The nurse suspects that the client's pain is the result of nerve damage from the radiation. Which type of pain is the client likely experiencing?

electrocardiogram (ECG) results

A client is taking spironolactone to control hypertension. The client's serum potassium level is 6 mEq/L. What is the nurse's priority during assessment?

calcium 12.9 mg/dL (3.2 mmol/L)

A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values. sodium 137 mEq/L (137 mmol/L)potassium 4.6 mEq/L (4.6 mmol/L)chloride 94 mEq/L (94 mmol/L)calcium 12.9 mg/dL (3.2 mmol/L) What laboratory value is of highest concern to the nurse?

That the client's past experiences with pain may influence her perception of current pain

A client reports abdominal pain as "8" on a pain intensity scale of 0-10 thirty minutes after receiving an opioid intravenously. Her past medical history includes partial-thickness burns to approximately 60% of her body several years ago. The nurse assesses

Provide the client with a patient-controlled analgesia (PCA) pump.

A client sustained severe burns over both lower extremities 1 week ago. The client informs the nurse that he had to wait for 30 minutes last night to receive pain medication, which caused the pain not to be relieved after administration. What suggestions could the nurse make to the physician to provide adequate relief of pain?

Assess the reason for the client's anxiety.

A client who fell at home is hospitalized for a hip fracture. The client is in Buck's traction, anticipating surgery, and reports pain as "2" on a pain intensity scale of 0 to 10. The client also exhibits moderate anxiety and moves restlessly in the bed. The best nursing intervention to address the client's anxiety is to

Applying a sterile, moist dressing

A client who had abdominal surgery 4 days ago reports that "something gave way" when he sneezed. The nurse observes a wound evisceration. Which nursing action is the first priority?

Prepare to assist with ventilation.

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

malignancy is causing the electrolyte imbalance.

A client with cancer is being treated on the oncology unit for bilateral breast cancer. The client is undergoing chemotherapy. The nurse notes the client's serum calcium concentration is 12.3 mg/dL (3.08 mmol/L). Given this laboratory finding, the nurse should suspect that the

active transport

A client with hypervolemia asks the nurse what mechanism in the sodium potassium pump will move the excess body fluid. What is the nurse's best answer?

hydrochlorothiazide

A client with mild fluid volume excess is prescribed a diuretic that blocks sodium reabsorption in the distal tubule. Which diuretic does the nurse anticipate administering to this client?

furosemide

A client with severe hypervolemia is prescribed a loop diuretic and the nurse is concerned with the client experiencing significant sodium and potassium losses. What drug was most likely prescribed?

Neuropathic pain

A client, who had an above the knee amputation of the left leg related to peripheral vascular disease from uncontrolled diabetes, complains of pain in the left lower extremity. What type of pain is the client experiencing?

Ask about the client's bowel pattern.

A home health nurse is visiting a client who has been taking the same dose of acetaminophen/hydrocodone for 2 months. To monitor for the presence of expected side effects of this medication, what should the nurse include in the assessment of the client?

Encourage the client to ambulate as soon as possible after surgery.

A nurse asks a client who had abdominal surgery 1 day ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene?

Evisceration

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding?

280 mOsm/kg.

A nurse can estimate serum osmolality at the bedside by using a formula. A patient who has a serum sodium level of 140 mEq/L would have a serum osmolality of:

Prolonged in duration.

A nurse documents the presence of chronic pain on an electronic health record. Choose a description that could be used. The pain can be:

Position the client in the side-lying position.

A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse?

The client is displaying early signs of shock.

A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition?

first intention

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:

Position the client in Fowlers position. Don sterile gloves. Lubricate the sterile suction catheter. Insert suction catheter into the lumen of the tube. Apply intermittent suction while withdrawing the catheter.

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order.

Intermediary

A patient who underwent abdominal surgery 3 hours ago has started to hemorrhage. The nurse would classify this type of hemorrhage has which of the following?

The Hemovac drain isn't compressed; instead it's fully expanded.

A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage?

The client can be discharged from the PACU.

A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client?

Pink color

A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem?

Inform the primary health care provider about the use of salicylates before any procedure, and avoid over-the-counter analgesics consistently without consulting a physician.

About which issue should the nurse inform clients who use pain medications on a regular basis?

Chest pain

Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism?

avoid aspiration.

It is important for the nurse to assist a postsurgical client to sit up and turn the head to one side when vomiting in order to

increased breathing effort and weight gain.

Early signs of hypervolemia include

Severity of the pain as judged by the patient

The nurse, as a member of the patient's health care team, obtains pain assessment information to identify goals for pain management. Select the most important factor that the nurse would use for goal setting:

First intention

The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by:

Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms.

The physician has prescribed 0.9% sodium chloride IV for a hospitalized client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply.

Arterial blood gas (ABG) analysis

To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?

Ambulating the client as soon as possible

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes:

Pulmonary Embolism

What complication is the nurse aware of that is associated with deep venous thrombosis?

Pulmonary embolism

What complication is the nurse aware of that is associated with deep venous thrombosis?

Pneumonia

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?

A systolic blood pressure lower than 90 mm Hg

What measurement should the nurse report to the physician in the immediate postoperative period?

An outside interpreter should be used.

When caring for a patient who is deaf, which of the following should be used to elicit information regarding the patient's level of pain?

Intervertebral disk herniation

When drafting a nursing care plan for a patient in pain, it is important for the nurse to determine if the pain is acute or chronic. Choose an example of chronic pain.

pH 7.48

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?

Ginkgo

When taking a client history, the nurse notes that the client is taking herbal remedies in addition to acetaminophen. Which herb, when taken in conjunction with acetaminophen, enhances the risk of bleeding?

Subacute

When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation, although the patient's breathing appears normal, the nurse identifies that the patient may be suffering from which type of hypoxemia?

Hypoventilation

Which could be a potential cause of respiratory acidosis?

Potassium

Which electrolyte is a major cation in body fluid?

Confusion and seizures

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?

Pallor

Which is a classic sign of hypovolemic shock?

Oral

Which is a correct route of administration for potassium?

Rectal

Which is a gastrointestinal route for administration of analgesics?

Sodium Bicarbonate

Which medication does the nurse anticipate administering to antagonize the effects of potassium on the heart for a patient in severe metabolic acidosis?

Sodium

Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality?

Short duration

Which of the following is a disadvantage to using the IV route of administration for analgesics?

Risk for impaired gas exchange

Which of the following is the most important potential nursing diagnosis for the client receiving opiate therapy?

Collaborate with the client about his or her goal for a level of pain relief.

Which of the following nursing interventions contributes to achieving a client's goal for pain relief?

Intravenous

Which route of administration of medication is preferred in the most acute care situations?

Endorphins

Which substance reduces the transmission of pain?

Reinforcing the dressing or applying pressure if bleeding is frank

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Increased sensitivity to medications

The nurse understands that which of the following physiologic changes that influence the pain response occur in the gerontologic population?

Parathyroid hormone (PTH)

The calcium concentration in the blood is regulated by which mechanism?

Although patients may need increasing levels of opioids, they are not addicted.

The nurse understands that which statement is true about tolerance and addiction?

osmosis

Fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area?

Respiratory

The nurse's major area of assessment for a patient receiving patient-controlled analgesia is assessment of what system?

osmotic pressure exerted by proteins.

Oncotic pressure refers to the

Gabapentin

The advance nurse practitioner, who is treating a client diagnosed with neuropathic pain, decides to start adjuvant analgesic agent therapy. Which medication is appropriate for the nurse practitioner to prescribe?

Assess the client's stool for color

The client takes naproxen for arthritic pain and is now prescribed warfarin for persistent atrial fibrillation. Due to the interactions of the medications, what is the nurse's best response?

Remove the heating pad present on the chest area.

The nurse is visiting a client at home with intractable cancer pain. The client has a transdermal fentanyl patch on her right chest area. It is most important for the nurse to

Bicarbonate

The emergency department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG?

Pink to red and soft, bleeding easily

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue?

Acute

The nurse has assessed a client's pain subsequent to a broken ankle. How would the nurse categorize and document the client's pain?

Position the client for comfort.

The nurse has given an older adult an oral opioid for postoperative pain. What should the nurse do first to make the pain medication more effective?

The pain medication will be administered before the pain is experienced.

The nurse informs the patient that a preventive approach for pain relief will be used, involving nonsteroidal anti-inflammatory drugs. What will this mean for the patient?

Older people are more sensitive to drugs.

The nurse is administering an analgesic to an older adult patient. Why is it important for the nurse to assess the patient carefully?

diaphoresis

The nurse is assessing a patient complaining of severe pain. What physiologic indicator does the nurse recognize as significant of acute pain?

Bradypnea

The nurse is assisting the anesthesiologist with the insertion of an epidural catheter and the administration of an epidural opioid for pain control. What adverse effect of epidural opioids should the nurse monitor for?

Urine retention

The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?

Elevated blood pressure

The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process?

Discontinue the intravenous lactated Ringer solution.

The nurse is caring for a client with a serum potassium concentration of 6.0 mEq/L (6.0 mmol/L). The client is ordered to receive oral sodium polystyrene sulfonate and furosemide. What other order should the nurse anticipate giving?

Confusion

The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition?

Metabolic acidosis

The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for?

Position the client to maintain a patent airway.

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?

Active transport

The nurse is correct to state that a client's body needs to have adequate nutrition to maintain energy. Which type of transport of dissolved substances requires adenosine triphosphate (ATP)?

"I will not salt my food; instead I'll use salt substitute."

The nurse is instructing a client with recurrent hyperkalemia about following a potassium-restricted diet. Which statement by the client indicates the need for additional instruction?

7

The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room?

Central venous pressure

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function?

Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia.

The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan?