med surg

A client with end-stage renal disease (ESRD) has the problem of ineffective coping. Which nursing intervention would be potentially unsafe in working with this client? Assess the client and family's coping patterns. Explore the meaning of the illness with the client. Set limits on mood swings and expressions of hostility. Give the client information when the client is ready to listen.

Set limits on mood swings and expressions of hostility.

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? Out-of-bed activities Bathroom privileges Immobilization of the affected leg Placing the affected leg in a dependent position

Immobilization of the affected leg Rationale: Autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3 to 7 days. This period of immobilization allows the autograft time to adhere to the wound bed

The nurse is performing a neurovascular assessment on a client with a cast on the left lower leg. The nurse notes the presence of edema in the foot below the cast. The nurse should make which interpretation about this finding? Arterial insufficiency Impaired venous return Impaired arterial circulation The presence of an infection

Impaired venous return

The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse expects to note? Select all that apply. Increased heart rate Decline in visual acuity Decreased respiratory rate Decline in long-term memory Increased susceptibility to urinary tract infections Increased incidence of awakening after sleep onset

Decline in visual acuity Increased susceptibility to urinary tract infections Increased incidence of awakening after sleep onset

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings would the nurse expect to note as confirming this diagnosis? Select all that apply. Increase in pH Comatose state Deep, rapid breathing Decreased urine output Elevated blood glucose level Low plasma bicarbonate level

Deep, rapid breathing Elevated blood glucose level Low plasma bicarbonate level

The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care? "I change my pouch every week." "I change the appliance in the morning." "I empty the urinary collection bag when it is two-thirds full." "When I'm in the shower I direct the flow of water away from my stoma."

"I empty the urinary collection bag when it is two-thirds full."

A client with renal cancer is being treated preoperatively with radiation therapy. What statement by the client demonstrates understanding of proper care of the skin over the treatment field? "I need to avoid skin exposure to direct sunlight and chlorinated water." "I need to use lanolin-based cream on the affected skin on a daily basis." "I need to use the hottest water possible to wash the treatment site twice daily." "I need to remove the lines or ink marks using a gentle soap after each treatment."

"I need to avoid skin exposure to direct sunlight and chlorinated water."

The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? "I need to stop my insulin." "I need to increase my fluid intake." "I need to monitor my blood glucose every 3 to 4 hours." "I need to call the health care provider (HCP) because of these symptoms."

"I need to stop my insulin." Rationale: When a client with diabetes mellitus is unable to eat normally because of illness, the client still should take the prescribed insulin or oral medication. The client should consume additional fluids and should notify the HCP. The client should monitor the blood glucose level every 3 to 4 hours. The client should also monitor the urine for ketones.

The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period? 1 minute 5 seconds 10 seconds 30 seconds

10 seconds

The nurse is reviewing the electrocardiogram (ECG) rhythm strip obtained on a client with a diagnosis of myocardial infarction. The nurse notes that the PR interval is 0.20 second. The nurse should make which interpretation about this finding? A normal finding Indicative of atrial flutter Indicative of atrial fibrillation Indicative of impending reinfarction

A normal finding

The nurse is performing an assessment on a client who has returned from the postanesthesia care unit after a cystoscopy. Which assessment finding indicates a need to notify the health care provider (HCP)? A temperature of 99.4° F Grossly bloody urine with clots A bluish or green tinge to the urine A blood pressure of 120/82 mm Hg

A bluish or green tinge to the urine Rationale: Grossly bloody urine with clots following cystoscopy is always an abnormal finding and should be reported to the HCP immediately. The client may have clear or blood-tinged urine after cystoscopy. If a contrast agent such as methylene blue is used, the urine may have an unusual bluish or green tinge. A blood pressure of 120/82 mm Hg and a temperature of 99.4° F are not abnormal findings at this time.

The community health nurse is conducting an educational session with community members regarding the symptoms associated with tuberculosis. Which is one of the first manifestations associated with tuberculosis? Dyspnea Chest pain A bloody, productive cough A cough with the expectoration of mucoid sputum

A cough with the expectoration of mucoid sputum

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which finding would the nurse expect to note on assessment of this client? Select all that apply. Hypocapnia A hyperinflated chest noted on the chest x-ray Decreased oxygen saturation with mild exercise A widened diaphragm noted on the chest x-ray Pulmonary function tests that demonstrate increased vital capacity

A hyperinflated chest noted on the chest x-ray Decreased oxygen saturation with mild exercise A widened diaphragm noted on the chest x-ray Rationale: Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.

A client who is to have a cystectomy with creation of an ileal conduit asks the nurse why the bowel needs to be cleansed before surgery if the bladder is being removed. The nurse would give the best response using which piece of information? All clients undergo bowel preparation with major surgery. This will decrease the chance of postoperative paralytic ileus. A portion of the bowel will be used to create the conduit for urinary diversion. This will reduce the chance that the surgeon will nick the bowel during surgery.

A portion of the bowel will be used to create the conduit for urinary diversion. Rationale: The client scheduled for surgical creation of either an ileal conduit or a reservoir undergoes bowel preparation the night before the procedure. Preparation can include intake of copious clear liquids, laxatives, enemas, and antibiotics, depending on health care provider preference. This is done primarily to prevent infection because a loop of bowel will be used to create the urinary diversion.

A client is being evaluated as a potential kidney donor for a family member. The client asks the nurse why separate teams are evaluating donor and recipient. In formulating a response, what should the nurse understand about this approach? Helps reduce the cost of the preoperative workup Saves the client and the recipient valuable preoperative time Avoids a conflict of interest between the team evaluating the recipient and those evaluating the donor Provides for a sufficient number of persons reviewing the case so that no information is overlooked

Avoids a conflict of interest between the team evaluating the recipient and those evaluating the donor

The nurse in the neurological unit is monitoring a client for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item? Blood pressure Motor response Pupillary response Level of consciousness

Blood pressure Rationale: Cushing's reflex is a late sign of increased ICP and consists of a widening pulse pressure (systolic pressure rises faster than diastolic pressure) and bradycardia.

A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item? Sensation of palpitations Causative factors, such as caffeine Precipitating factors, such as infection Blood pressure and oxygen saturation

Blood pressure and oxygen saturation Rationale: Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders, states of hypoxemia, or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by intake of caffeine, nicotine, or alcohol.

The nurse has administered a dose of meperidine hydrochloride (Demerol), 100 mg, to a client with renal colic as treatment for pain. The nurse carefully monitors this client for which side effect of this medication? Bradycardia Hypertension Urinary retention Increased respirations

Bradycardia Meperidine hydrochloride is an opioid analgesic. Side effects of meperidine hydrochloride include respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urinary retention.

A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? Folate deficiency Malabsorption of fat Intestinal obstruction Fluid and electrolyte imbalance

Fluid and electrolyte imbalance Rationale: A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client? Coma Flushing Dizziness Tachycardia

Flushing

The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the health care provider's prescriptions and should plan to question which prescription? Gastric lavage Intravenous (IV) fluid therapy Nothing by mouth (NPO) status Preparation for laboratory studies

Gastric lavage Rationale: The client who has sustained chemical burns to the esophagus is placed on NPO status, is given IV fluids for replacement and treatment of possible shock, and is prepared for esophagoscopy and barium swallow to determine the extent of damage. Laboratory studies also may be prescribed. A nasogastric tube may be inserted, but gastric lavage and emesis are avoided to prevent further erosion of the mucosa by the irritating substances that these treatments involve.

The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places highest priority on which client problem? Lack of knowledge Inadequate fluid volume Compromised family coping Inadequate consumption of nutrients

Inadequate fluid volume Rationale: An increased blood glucose level will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe.

A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? Lying recumbent following meals Consuming small, frequent, bland meals Raising the head of the bed on 6-inch blocks Taking H2-receptor antagonist medication

Lying recumbent following meals

A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? Regular insulin Glipizide (Glucotrol) Repaglinide (Prandin) Metformin (Glucophage)

Metformin (Glucophage) Metformin (Glucophage) needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system, the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld 24 hours before and 48 hours after cardiac catheterization.

A client who is intubated and receiving mechanical ventilation has a problem of risk for infection. The nurse should include which measures in the care of this client? Select all that apply. Monitor the client's temperature. Use sterile technique when suctioning. Use the closed-system method of suctioning. Monitor sputum characteristics and amounts. Drain water from the ventilator tubing into the humidifier bottle.

Monitor the client's temperature. Use sterile technique when suctioning. Use the closed-system method of suctioning. Monitor sputum characteristics and amounts. Rationale: Monitoring temperature and sputum production is indicated in the care of the client. A closed-system method of suctioning and sterile technique decrease the risk of infection associated with suctioning. Water in the ventilator tubing should be emptied, not drained back into the humidifier bottle. This puts the client at risk of acquiring infection, especially Pseudomonas

The nurse caring for a client with a head injury is monitoring for signs of increased intracranial pressure. The nurse reviews the record and notes that the intracranial pressure (cerebrospinal fluid) is averaging 8 mm Hg. The nurse plans care, knowing that these results are indicative of which condition? Normal condition Increased pressure Borderline situation Compensating condition

Normal condition Rationale: The normal intracranial pressure is 5 to 10 mm Hg. A pressure of 8 mm Hg is within normal range.

A health care provider (HCP) tells the nurse that a client's chest tube is to be removed. The nurse should bring which dressing materials to the bedside for the HCP's use? Telfa dressing and Neosporin ointment Petrolatum gauze and sterile 4 × 4 gauze Benzoin spray and a hydrocolloid dressing Sterile 4 × 4 gauze, Neosporin ointment, and tape

Petrolatum gauze and sterile 4 × 4 gauze Rationale: On removal of the chest tube, a sterile petrolatum gauze and a sterile 4 × 4 gauze is placed at the insertion site. The entire dressing is securely taped to make sure it is occlusive.

The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign, if exhibited in the client, would indicate hyperglycemia? Polyuria Diaphoresis Hypertension Increased pulse rate

Polyuria Rationale: Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Diaphoresis may occur in hypoglycemia. Options 2, 3, and 4 are not signs of hyperglycemia

The nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which interventions should the nurse take when performing the irrigation? Select all that apply. Apply some force when instilling the irrigation solution. Position the client with the affected side down after the irrigation. Warm the irrigating solution to a temperature that is close to body temperature. Position the client to turn the head so that the ear to be irrigated is facing upward. Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal.

Position the client with the affected side down after the irrigation. Warm the irrigating solution to a temperature that is close to body temperature. Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal.

The nurse is assessing for stoma prolapse in a client with a colostomy. What should the nurse observe if stoma prolapse occurs? Protruding stoma Sunken and hidden stoma Narrowed and flattened stoma Dark- and bluish-colored stoma

Protruding stoma Rationale: A prolapsed stoma is one in which the bowel protrudes through the stoma.

A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the health care provider will request which prescriptions? Select all that apply. Radiation Chemotherapy Increased fluid intake Decreased oral sodium intake Serum sodium level determination Medication that is antagonistic to antidiuretic hormone

Radiation Chemotherapy Serum sodium level determination Medication that is antagonistic to antidiuretic hormone

The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply. Polyuria Shakiness Palpitations Blurred vision Lightheadedness Fruity breath odor

Shakiness Palpitations Lightheadedness Rationale: Shakiness, palpitations, and lightheadedness are signs of hypoglycemia and would indicate the need for food or glucose. Polyuria, blurred vision, and a fruity breath odor are signs of hyperglycemia

A client is diagnosed with epididymitis. The nurse checks the health care provider's prescriptions and expects that which options will be prescribed? Select all that apply. Sitz bath Antibiotics Scrotal elevation Use of a heating pad Bed rest with bathroom privileges

Sitz bath Antibiotics Scrotal elevation Bed rest with bathroom privileges

The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis? Chest x-ray Bronchoscopy Sputum culture Tuberculin skin test

Sputum culture Rationale: Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.

A client who has undergone radical neck dissection for a tumor has a potential problem of obstruction related to postoperative edema, drainage, and secretions. To promote adequate respiratory function in this client, the nurse should implement which activities? Select all that apply. Suctioning the client as needed Encouraging coughing every 2 hours Placing the bed in low Fowler's position Supporting the neck incision when the client coughs Monitoring the respiratory status frequently as prescribed

Suctioning the client as needed Encouraging coughing every 2 hours Supporting the neck incision when the client coughs Monitoring the respiratory status frequently as prescribed

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? Sweating and pallor Bradycardia and indigestion Double vision and chest pain Abdominal cramping and pain

Sweating and pallor Rationale: Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

The nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which assessment finding would the nurse note as an early sign of hepatic encephalopathy? Restlessness Complaints of fatigue The presence of asterixis Decreased serum ammonia levels

The presence of asterixis

A client with renal cancer is to undergo preoperative renal artery embolization. What should the nurse tell the client regarding the primary benefit of this procedure? This will reduce the time needed for surgery by at least half because it provides hemostasis. This will cause the tumor to become tougher and easier to resect in surgery with the scalpel. This will prevent the risk of pulmonary embolism by occluding the renal artery and its branches. This will decrease the size of the tumor because its blood supply will be removed after placement of an absorbable gelatin sponge.

This will decrease the size of the tumor because its blood supply will be removed after placement of an absorbable gelatin sponge. Rationale: Renal artery embolization may be done instead of radiation therapy to shrink the kidney tumor by cutting off its blood supply and impairing its overall vascularity. A secondary benefit is that it reduces the risk of hemorrhage during surgery. This procedure can be accomplished in a number of ways, including placement of an absorbable gelatin sponge (Gelfoam), a balloon, a metal coil, or any of various other substances