med surg 2 exam 2

The nurse recognizes that teaching a patient following a laparoscopic cholecystectomy has been effective when the patient makes which statement? "I can take a shower and walk around the house tomorrow." "I need to limit my activities and not return to work for 4 weeks." "I can expect yellowish drainage from the incision for a few days." "I will follow a low-fat diet for life because I do not have a gallbladder."

A After a laparoscopic cholecystectomy, patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a lifelong requirement.

A young woman with Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? Fistulas can form between the bowel and bladder. Bacteria in the perianal area can enter the urethra. Drink adequate fluids to maintain normal hydration. Empty the bladder before and after sexual intercourse.

A Fistulas between the bowel and bladder occur in Crohn's disease and can lead to UTI. Teaching for UTI prevention in general includes good hygiene, adequate fluid intake, and voiding before and after intercourse.

A patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate? Schedule the patient for HCV genotype testing. Administer the HCV vaccine and immune globulin. Teach the patient about ribavirin (Rebetol) treatment. Explain that the infection will resolve over a few months.

A Genotyping of HCV has an important role in managing treatment and is done before drug therapy is initiated. Because most patients with acute HCV infection convert to the chronic state, the nurse should not teach the patient that the HCV will resolve in a few months. Immune globulin or vaccine is not available for HCV. Ribavirin is used for chronic HCV infection.

Which laboratory test result will the nurse monitor to evaluate the effects of therapy for a patient who has acute pancreatitis? a. Lipase b. Calcium c. Bilirubin d. Potassium

A Lipase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be useful in evaluating whether the prescribed therapies have been effective.

A patient in the urology clinic is diagnosed with monilial urethritis. Which action will the nurse include in the plan of care? Teach the patient about the use of antifungal medications. Tell the patient to avoid tub baths until the symptoms resolve. Instruct the patient to refer recent sexual partners for treatment. Tell the patient to avoid nonsteroidal antiinflammatory drugs (NSAIDs).

A Monilial urethritis is caused by a fungus and antifungal medications such as nystatin or fluconazole are usually used as treatment. Because monilial urethritis is not sexually transmitted, there is no need to refer sexual partners. Warm baths and NSAIDS may be used to treat symptoms.

After having frequent diarrhea and a weight loss of 10 lb (4.5 kg) over 2 months, a patient has a new diagnosis of Crohn's disease. What should the nurse plan to teach the patient? Medication use Fluid restriction Enteral nutrition Activity restrictions

A Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings.

After an unimmunized person is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take? (Select all that apply.) a Administer hepatitis B vaccine. b Test for antibodies to hepatitis c Teach about -interferon therapy. d Give hepatitis B immune globulin. e Explain options for oral antiviral therapy.

A, B, D The recommendations for hepatitis B exposure include both vaccination and immune globulin administration. In addition, baseline testing for hepatitis B antibodies will be needed. Interferon and oral antivirals are not used for hepatitis B prophylaxis.

Which nursing action will the nurse include in the plan of care for a patient admitted with an exacerbation of inflammatory bowel disease (IBD)? Restrict oral fluid intake. Monitor stools for blood. Ambulate six times daily. Increase dietary fiber intake.

B Because anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Dietary fiber may increase gastrointestinal motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.

A 46-yr-old female patient returns to the clinic with continued dysuria after being treated with trimethoprim and sulfamethoxazole for 3 days. Which action will the nurse plan to take? Remind the patient about the need to drink 1000 mL of fluids daily. Obtain a midstream urine specimen for culture and sensitivity testing. Suggest that the patient use acetaminophen (Tylenol) to relieve symptoms. Tell the patient to take the trimethoprim and sulfamethoxazole for 3 more days.

B Because uncomplicated urinary tract infections (UTIs) are usually successfully treated with 3 days of antibiotic therapy, this patient will need a urine culture and sensitivity to determine appropriate antibiotic therapy. Acetaminophen would not be as effective as other over-the-counter medications such as phenazopyridine in treating dysuria. The fluid intake should be increased to at least 1800 mL/day. Because the UTI has persisted after treatment with trimethoprim and sulfamethoxazole, the patient is likely to need a different antibiotic.

A patient seen in the clinic for a bladder infection describes the following symptoms. Which information is most important for the nurse to report to the health care provider? Urinary urgency Left-sided flank pain Intermittent hematuria Burning with urination

B Flank pain indicates that the patient may have developed pyelonephritis as a complication of the bladder infection. The other clinical manifestations are consistent with a lower urinary tract infection.

which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis? Restrict fluid intake to prevent constant liquid drainage from the stoma. Use care when eating high-fiber foods to avoid obstruction of the ileum. Irrigate the ileostomy daily to avoid having to wear a drainage appliance. Change the pouch every day to prevent leakage of contents onto the skin.

B High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control by irrigation is not possible.

What topic should the nurse plan to teach the patient diagnosed with acute hepatitis B? Administering a-interferon c. Side effects of nucleotide analogs b. Measures for improving appetite d. Ways to increase activity and exercise

B Maintaining adequate nutritional intake is important for regeneration of hepatocytes. Interferon and antivirals may be used for chronic hepatitis B, but they are not prescribed for acute hepatitis B infection. Rest is recommended.

To prevent recurrence of uric acid kidney stones, the nurse teaches the patient to avoid eating: milk and cheese. sardines and liver. spinach and chocolate. legumes and dried fruit.

B Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones.

A patient had a cystectomy with an ileal conduit yesterday. Which new assessment data is most important for the nurse to communicate to the health care provider? Cloudy appearing urine Heart rate 102 beats/min Hypoactive bowel sounds Continuous stoma drainage

B Tachycardia may indicate infection, hemorrhage, or hypovolemia, which are all serious complications of this surgery. The urine from an ileal conduit normally contains mucus and is cloudy. Hypoactive bowel sounds are expected after bowel surgery. Continuous drainage of urine from the stoma is normal.

A patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care? Instruct the patient to cough every hour. Monitor the patient for shortness of breath. Verify the position of the balloon every 4 hours. Deflate the gastric balloon if the patient reports nausea.

B The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. Balloons may be deflated briefly every 8 to 12 hours to avoid tissue necrosis, but if only the gastric balloon is deflated, the esophageal balloon may occlude the airway. Balloons are not deflated for nausea.

The nurse evaluates that administration of hepatitis B vaccine to a healthy patient has been effective when the patient's blood specimen reveals: HBsAg. anti-HBs. c. anti-HBc IgG. d. anti-HBc IgM.

B The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine. The other laboratory values indicate current infection with HBV.

What is most important for the nurse to monitor to detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices? Bilirubin levels Ammonia levels Potassium levels Prothrombin time

B The protein in the blood in the gastrointestinal tract will be absorbed and may result in an increase in the ammonia level because the liver cannot metabolize protein very well. The prothrombin time, bilirubin, and potassium levels should also be monitored, but they will not be affected by the bleeding episode.

A patient has been diagnosed with urinary tract stones that are high in uric acid. Which foods will the nurse teach the patient to avoid? (Select all that apply.) Milk b. Liver c. Spinach d. Chicken e. Cabbage f. Chocolate

B, D Meats contain purines, which are metabolized to uric acid. The other foods might be restricted in patients who have calcium or oxalate stones.

A patient in the emergency department has just been diagnosed with peritonitis from a ruptured diverticulum. Which prescribed intervention will the nurse implement first? Send the patient for a CT scan. Insert a urinary catheter to drainage. Infuse metronidazole (Flagyl) 500 mg IV. Place a nasogastric tube to intermittent low suction.

C Because peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated.

The nurse is caring for a patient with pancreatic cancer. Which nursing action is the highest priority? Offer psychologic support for depression. Offer high-calorie, high-protein dietary choices. Administer prescribed opioids to relieve pain as needed.d. Teach about the need to avoid scratching any pruritic areas.

C Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to teaching, or manage anxiety or depression.

The nurse assesses a patient with pernicious anemia. Which finding would the nurse expect? Yellow-tinged sclerae Shiny, smooth tongue Tender, bleeding gums Numbness of extremities

C Extremity numbness is associated with cobalamin (vitamin B12) deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia.

A 68-yr-old patient admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action should be included in the plan of care? Restrict fluids between meals and after the evening meal. Insert an indwelling catheter until the symptoms have resolved. Assist the patient to the bathroom every 2 hours during the day. Apply absorbent adult incontinence diapers and pads over the bed linens.

C In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for urinary tract infection. Incontinent pads and diapers increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration.

A patient admitted to the hospital with pneumonia has a history of functional urinary incontinence. Which nursing action will be included in the plan of care? Demonstrate the use of the Credé maneuver. Teach exercises to strengthen the pelvic floor. Place a bedside commode close to the patient's bed. Use an ultrasound scanner to check postvoiding residuals.

C Modifications in the environment make it easier to avoid functional incontinence. Checking for residual urine and performing the Credé maneuver are interventions for overflow incontinence. Kegel exercises are useful for stress incontinence.

The nurse observes unlicensed assistive personnel (UAP) taking the following actions when caring for a female patient with a urethral catheter. Which action requires that the nurse intervene? Securing the catheter to the patient's upper inner thigh Cleaning around the patient's urinary meatus with soap and water Disconnecting the catheter from the drainage tube to obtain a specimen Using an alcohol-based gel hand cleaner before performing catheter care

C The catheter should not be disconnected from the drainage tube because this increases the risk for urinary tract infection. The other actions are appropriate and do not require any intervention.

How should the nurse prepare a patient with ascites for paracentesis? Place the patient on NPO status. Assist the patient to lie flat in bed. Ask the patient to empty the bladder. Position the patient on the right side.

C The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. Because no sedation is required for paracentesis, the patient does not need to be NPO.

Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes for the first 4 hours. Which nursing action is the priority? Encourage the patient to drink more fluids. Plan to monitor the patient's intake and output. Use an ultrasound scanner to check the postvoiding residual volume. Reassure the patient that urinary problems are common after rectal surgery.

C The patient's history and clinical manifestations are consistent with overflow incontinence, so an ultrasound scanner can be used to check for residual urine after the patient voids. The other interventions may also be useNful,RbutItheGpriBor.ityCpaMtient problem is the potentially overfilled bladder.

A patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies, but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is appropriate? "Have you taken corticosteroids?" "Do you have a history of IV drug use?" "Do you use any over-the-counter drugs?" "Have you recently traveled to another country?"

C The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.

A patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102° F (38.3° C), pulse 120 beats/min, respirations 32 breaths/min, and blood pressure (BP) 82/54 mm Hg. Which prescribed intervention should the nurse implement first? Administer IV ketorolac 15 mg for pain relief. Send a blood sample for a complete blood count (CBC). Infuse a liter of lactated Ringer's solution over 30 minutes. Send the patient for an (CT) scan

C The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion.

Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago? Dry palpebral and oral mucosa Crackles at bilateral lung bases Temperature 100.8° F (38.2° C) No bowel movement for 4 days

C The risk of infection is high in the first few months after liver transplant, and fever is frequently the only sign of infection. The other patient data indicate the need for further assessment or nursing actions and might be communicated to the health care provider, but they do not indicate a need for urgent action.

Which assessment finding is of most concern for a patient with acute pancreatitis? Absent bowel sounds Abdominal tenderness Left upper quadrant pain Palpable abdominal mass

D A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common in acute pancreatitis and do not require rapid action to prevent further complications.

What risk factor will the nurse specifically ask about when a patient is being admitted with acute pancreatitis? Diabetes Alcohol use High-protein diet Cigarette smoking

D Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking, diabetes, and high-protein diets are not risk factors.

Which assessment finding is most important to report to the health care provider regarding a patient who has had left-sided extracorporeal shock wave lithotripsy? Blood in urine Left flank bruising Left flank discomfort d. Decreased urine output

D Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to report a drop in urine output. Left flank pain, bruising, and hematuria are common after lithotripsy.

What should the nurse plan to teach about to a patient with Crohn's disease who has megaloblastic anemia? Iron dextran infusions Oral ferrous sulfate tablets Routine blood transfusions Cobalamin (B12) supplements

D Crohn's disease frequently affects the ileum, where absorption of cobalamin occurs. Cobalamin must be administered regularly by nasal spray or IM to correct the anemia. Iron deficiency does not cause megaloblastic anemia. The patient may need occasional transfusions but not regularly scheduled transfusions.

A young adult contracts hepatitis from contaminated food. What should the nurse expect serologic testing to reveal during the acute (icteric) phase of the patient's illness? Antibody to hepatitis D (anti-HDV) Hepatitis B surface antigen (HBsAg) Anti-hepatitis A virus immunoglobulin G (anti-HAV IgG) Anti-hepatitis A virus immunoglobulin M (anti-HAV IgM)

D Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen for hepatitis B or antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong immunity.

A patient with acute pancreatitis is NPO and has a nasogastric (NG) tube to suction. Which information obtained by the nurse indicates that these therapies have been effective? Bowel sounds are present. Grey Turner sign resolves. Electrolyte levels are normal. Abdominal pain is decreased.

D NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds doNes nRot inIdicGateBth.atCtreaMtment with NG suction and NPO status USNT O has been effective. Electrolyte levels may be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this to occur to determine whether treatment was effective.

Which question from the nurse would help determine if a patient's abdominal pain might indicate irritable bowel syndrome (IBS) Have you been passing a lot of gas?" "What foods affect your bowel patterns?" "Do you have any abdominal distention?" "How long have you had abdominal pain?"

D One criterion for the diagnosis of irritable bowel syndrome is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance are associated with IBS but are not diagnostic criteria.

Which assessment data reported by a patient is consistent with a lower urinary tract infection (UTI)? Low urine output Bilateral flank pain Nausea and vomiting Burning on urination

D Pain with urination is a common symptom of a lower UTI. Urine output does not decrease, but frequency may occur. Flank pain and nausea are associated with an upper UTI.

Which focused data should the nurse assess after identifying 4+ pitting edema on a patient who has cirrhosis? Hemoglobin Temperature Activity level Albumin level

D The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. The other parameters are not directly associated with the patient's edema.

A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care? Restrict daily dietary protein intake. Reposition the patient every 4 hours. Perform passive range of motion twice daily. Place the patient on a pressure-relief mattress.

D The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein intake is necessary in patients with ascites to improve oncotic pressure. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity.PassiverangeofmNotioRnwIillnGottaBk.eCtheMpressureoffareassuchasthesacrumthat are vulnerable to breakdown. U S

A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. What action should the nurse take? Place ice packs around the stoma. Notify the surgeon about the stoma. Monitor the stoma every 30 minutes. Document stoma assessment findings.

D The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery. An ice pack is not needed.

Which statement by a 22-yr-old female patient with cystitis indicates to the nurse that instruction regarding prevention of future urinary tract infections (UTIs) has been effective? a. "I can use vaginal antiseptic sprays to reduce bacteria." N R I G B.C Mb. "I will drink a quart of watUer oSr othNer fTluids evOery day." c. "I will wash with soap and water before sexual intercourse." d. "I will empty my bladder every 3 to 4 hours during the day."

D Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary to prevent UTI. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI.

he nurse is assessing a patient with abdominal pain. How will the nurse document ecchymosis around the area of umbilicus? Cullen sign Rovsing sign McBurney sign Grey-Turner's sign

a Cullen sign is ecchymosis around the umbilicus. Rovsing sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. Grey Turner's sign is bruising over the flanks. Deep tenderness at McBurney's point (halfway between the umbilicus and the right iliac crest), known as McBurney's sign, is a sign of acute appendicitis.

A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 bloody stools a day. What should the nurse include in the plan of care? Administer IV metoclopramide (Reglan). Discontinue the patient's oral food intake. Administer cobalamin (vitamin B12) injections. Teach the patient about total colectomy surgery.

b An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Metoclopramide increases peristalsis and will worsen symptoms. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate.

After change-of-shift report, which patient should the nurse assess first? Patient who has cloudy urine after bladder reconstruction. Patient with a urethral stricture who has not voided for 12 hours. Patient who voided bright red urine after returning from lithotripsy. Patient with polycystic kidney disease whose blood pressure is 186/98 mm Hg.

b Not voiding for 12 hours suggests acute urinary retention, which is a medical emergency. The nurse will need to assess the patient and consider whether to insert a retention catheter. The other patients will be assessed, but their findings are consistent with their diagnoses and do not require immediate assessment or intervention.

A 22-yr-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective? The patient uses incontinence briefs to contain loose stools. The patient uses witch hazel compresses to soothe irritation. The patient asks for antidiarrheal medication after each stool. The patient cleans the perianal area with soap after each stool.

b Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown. Antidiarrheal medications are not given 15 to 20 times a day. The perianal area should be washed with plain water or pH balanced cleanser after each stool.

Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine? Take phenazopyridine for at least 7 days. Phenazopyridine may cause photosensitivity. Phenazopyridine may change the urine color. Take phenazopyridine before sexual intercourse.

c Patients should be taught that phenazopyridine will color the urine deep orange. Urinary analgesics should be needed for only a few days until the prescribed antibiotics decrease the bacterial count. Phenazopyridine does not cause photosensitivity. Taking phenazopyridine before intercourse will not be helpful in reducing the risk for UTI.