N120: Week 2 Review

The nurse is aware of which factors are related to the development of gastroesophageal reflux disease (GERD): SATA

smoking obesity alcohol

After administering a dose of promethazine (Phenergan) to a patient with nausea and vomiting, which medication side effect does the nurse need to monitor when given it via IV route? A) Drowsiness B) Phlebitis C) Sensation of falling D) Photosensitivity

Phlebitis

A male patient with a history of peptic ulcer disease has presented to the ED with severe abdominal pain and a rigid, board-like abdomen. The health care provider suspects a perforated ulcer. Which interventions should the nurse anticipate?

Providing IV fluids and inserting a nasogastric tube

A male patient with no surgical history, reports pain in the inguinal area that occurs when he coughs. A bulge that can be pushed back into the abdomen is found in his inguinal area. What type of hernia does he have?

Reducible

The ED nurse assesses a 30 year old male patient with peritonitis. Which clinical manifestations would the nurse expect to find?

Tachycardia, distended abdomen, abdominal pain with rebound tenderness and hypovolemia.

A nurse is teaching a patient about magnesium hydroxide with aluminum hydroxide (Maalox). What instruction is most appropriate?

"Report diarrhea to your provider"

After hiatal hernia repair surgery, a young male patient is on intravenous pantoprazole (protonix). The patient asks the nurse why this medication is given since there is no history of ulcers. What is the response by the nurse best?

"it prevents stress-related ulcers"

A newly resident nurse is in training on the med-surg floor. which correct statement by the nurse differentiating Crohns disease (CD) from ulcerative colitis (UC)?

Patients with UC may experience hemorrhage.

A 39 year old pt is scheduled for an ileostomy. Which complication may occur would the nurse suspect after ileostomy?

Pernicious anemia

The med-surg floor nurse is caring for a 40 year old female patient who complains of abdominal pain and hematemesis. Which new assessment findings would indicate the patient is experiencing a decline in condition?

Pallor and clammy

The nurse finds a patient vomiting coffee-ground emesis. The patient has a blood pressure of 94/56 mm Hg on assessment, is acutely confused, and has a weak and thready pulse. Which intervention is the nurse's first priority?

Administering intravenous (IV) fluids.

A female patient is taking prednisone to prevent transplant rejection. What is instruction by the oncology nurse most important?

Avoid large crowds and people who are ill

The nursing student is learning about humoral-mediated immunity and understands that the cell with the most direct role int his process begins development in which tissue or organ?

Bone marrow

The following data relate to a male patient who is 2 hours postoperative after an appendectomy: Physical Assessment: Dry Skin Urine Output 20ml/hr NG tube patient with 100ml brown drainage/hr Restless Vital Signs: Pulse: 128 beats/min Blood pressure: 87/45 mm Hg Respiratory rate: 20 on a ventilator Oxygen saturation: 99% Physician Orders: Normal saline at 75 mL/hr Dilaudid 2 mg IV push every 1 PRN pain I/O every hour Vital signs every hour Vancomycin (Vancocin) 1g IV every 8 hr Which action is a priority by the nurse?

Consult the surgeon about increased IV fluids

A patient had a gastroduodenostomy (Billroth I operation) due to a worsening gastric ulcer. The patient reports generalized weakness, sweating, palpitations, and dizziness 15 to 30 minutes after eating. What long term complication does the nurse suspect is occurring?

Dumping syndrome

A male patient complaining of worsening nausea and vomiting receives a dose of metoclopramide (Reglan). Which potential adverse severe effect should the ED nurse monitor after giving this antiemetic medication?

Dyskinesias

The med-surg unit nurse is caring for a 50 year old pt with a history of peptic ulcer disease and who was recently diagnosed with gastric outlet obstruction. Which criteria findings would support the diagnosis of gastric outlet obstruction. SATA.

Edema Scar tissue formation Inflammation

The ED nurse assesses a female patient with ulcerative colitis and severe emesis. Which assessment would the nurse complete first?

Heart rate and rhythm

A male patient was brought into the ED with nausea, vomiting and diarrhea x 3 days. The patient has a BP of 81/56. Which action does the nurse take?

Infuse IV fluids.

A male patient was brought by ambulance to the ED due to worsening abdominal pain accompanied by nausea and vomiting. The ED nurse assesses a patient and suspects appendicitis based on which findings? SATA

Muscle guarding Anorexia The patient prefers to lie still, with the right leg flexed Pain at McBurney's Point

A female patient with osteoporosis is diagnosed with gastroesophageal reflux disease (GERD). Which over the counter medication to treat GERD should be used with caution?

Omeprazole

A male patient has gastroesophageal reflux disease (GERD). The attending physician prescribes a proton pump inhibitor. About what medication would the nurse anticipate teaching the patient?

Omeprazole (Prilosec)

In the oncology unit, a male patient receiving chemotherapy rings the call bell and reports the onset of nausea. The nurse should prepare an as-needed dose of which medication?

Ondansetron (Zofran)

A med-surg nurse assesses a male patient who is recovering from a descending colostomy placement. Which clinical manifestation would alert the nurse to urgently contact the health care provider?

Pale and bluish stoma