Med Surg
A patient receives a diagnosis of Crohn disease and states, "I don't understand anything about this disease." Which information provided by the nurse is most helpful at this time?
Treatment will focus on symptom management and medications.
Thoracentesis What Position you going to place them in?
Upright leaning over table to increase lung expansion
Bronchoscopy
After procedure keep the patient NPO until gag reflux returns.
The nurse provides care to a patient who is lethargic and unable to tolerate standing for long periods. The patient experiences dyspnea on exertion. Which type of bath is best for the nurse to implement with this patient?
Bed bath
What test do you use to verify pulmonary embolus?
CT scan
A patient with pneumonia has a nursing diagnosis pf ineffective airway clearance related to pain, fatigue, and thick secretions. An appropriate nursing intervention for the patient is to
Encourage fluid intake of 3L/day
are short high pitched sounds made on expiratory
Wheezing
On examining a patient 8 hours after formation of a colostomy, the nurse would expect to find
a brick-red, puffy stoma that oozes blood.
nurse brings a dinner tray to a client who is blind which intervention will the nurse implement
compare food on plate with face clock
nurse plan care for an 80 yo client in long term facility which food items meet the clients need
grilled chicken with a fresh fruit salad
pt having severe anxiety attack has an arterial blood gas showing respiratory alkalosis which is best nursing action
have pt breath in paper bag
client is prescribed "clear liquids, advance as tolerated." which finding indicates the clients diet should not be advanced select all
hypoactive bowel nausea and vomiting reports of indigestion
physician orders clear liquid advance as tolerated which factor indicates to the nurse the advancement of clients diet should be delayed
hypoactive bowel report of feeling full nausea and vomiting
client newly diagnosed with hypertension about dietary disease restriction which statements states the client understands?
i will give my canned goods to the food pantry
nurse cares for a client after surgery client ask why do i need to increase the amount of protein i eat how will the nurse respond
increase dietary protein is essential for wound healing
nurse prepares to administer an intradermal injection which action is correct?
insert the needle with the bevel up
client complains of joint pain and stiffness what approach to health care is the primary health care provider practicing
integrative
ileostomy is located
into the ileum or small intestine
urostomy is located
into the urinary system on ureter
2 body systems responsible for control of acid base balance
kidneys and lungs
INH
latent TB and treat 6 to 9 months.
Coarse Crackles
long duration, discontinuous, low pitched sounds caused by air passing through airway intermittently occluded by mucus, unstable bronchial wall, or fold of mucosa; evident with inspiration. COPD, heart failure, and pneumonia.
A patient is admitted to the emergency department with acute abdominal pain. The nursing intervention that should be implemented first is
measurement of vital signs
nurse assesses client who had a stroke client can swallow but has difficulties chewing which nutritional support will the nurse recommend
mechanical soft diet
Following a Billroth II procedure, a patient develops dumping syndrome. The nurse explains that the symptoms associated with this problem are caused by
movement of fluid into the small bowel because concentrated food and fluids move rapidly into the intestine.
colostomy is located
on colon or large intestine
nurse assesses client who has been npo for a prolonged periodwhich finding indicates pt has protein and calorie malnutrition
poor wound healing
assessment findings does the nurse evaluate in a patient with chronic bronchitis
productive cough
pt w/ end stage obstructive lung disease has diagnosis of impaired gas exchange which finding by nurse shows additional interventions are needed
pt has a resp rate of 28
nurse caring for group which pt is highest risk for developing metabolic alkalosis
pt vomiting for last 48 hr
A client asks why the shoulder is hurting when the problem is in the abdomen. Which type of pain should the nurse explain this client is experiencing?
referred
while inserting a nasogastric tube a nurse notes that the client becomes cyanotic cough incessantly and is unable to speak what action will the nurse take first
remove the tube completely
ph 7.46, pco2 34, hco3 28, pao2 88
respiratory alkalosis
Before administering a bolus of intermittent tube feeding to a patient with percutaneous endoscopic gastrostomy (PEG), the nurse aspirates 220mL of gastric contents. The nurse should
return the aspirate to the stomach and continue with the tube feeding as planned.
A client has a percutaneous endoscopic gastrostomy tube inserted for tube feedings. Before starting a continuous feeding, the nurse should place the client in which position? A. Semi-Fowlers B. Supine C. Reverse Trendelenburg D. High Fowler's
semi fowlers
Fine Crackles
short-duration, discontinuous, high pitched sounds heard just before the end of inspiration. In pneumonia or heart failure.
To prepare the patient for a thoracentesis, the nurse positions the patient
sitting upright with the elbows on an over-the-bed table.
nurse assists client with food selection for breakfast the client is on low cholesterol diet which is most important?
skim milk, oatmeal, banana, orange juice
nurse providing care for a client w/ PH 7.5which assessment finding will nurse identify as a compensatory response to clients condition
slow deep respiration
clients feet has 3+ pitting edema review of clients past medical history reveals history of cardiac problems which diet does the nurse expect the provider to order
sodium restricted diet
The nurse evaluates that patient teaching about a high-calorie, high protein diet has been effective when the patient selects for breakfast from the hospital menu
two poached eggs, hash brown potatoes, and whole milk
nurse assists client with asthma which requires immediate action by nurse
use of accessory muscles to breathe
a nurse cares for a client who has chronic bronchitis client states I have trouble eating because i get short of breath how should the nurse respond
use your bronchodilator inhaler about 30 min before you plan to eat.
Abnormal Breathe sounds
used to describe bronchial or bronchovesicular sounds heard in the peripheral lung fields.
a nurse prepares to administer an intramuscular medication. which action is essential when withdrawing the medication from an ampule?
using a filtered needle
Where is a double barrel stoma usually placed
from the traverse colon, this is the one that is usually temporary
The nurse is caring for a male client who has a new order for the insertion of an indwelling urinary catheter. What is the most important question to ask the client prior to performing this task?
"Do you have a latex allergy?"
The staff nurse tells the night shift nurse "Your patient refused her bath today." When assessing the patient, the patient tells the nurse she is too tired to bathe and wants to be left alone. What is the nurse's best response?
"Go ahead and rest, I'll come back in an hour to help you bathe."
The nurse working in a clinic is interviewing a patient complaining of a new skin infection. Which question by the nurse will provide the best information related to the "O" in OLDCARTS?
"How long have you had the rash?"
The nurse instructs a patient prescribed omeprazole for peptic ulcer disease about the use of the medication. Which patient statements indicate understanding of the instructions? (Select all that apply.)
"I will take the capsule before eating a meal in the morning." "I will report any abdominal pain, diarrhea, or bleeding that occurs."
The nurse is providing education to a female client with urinary stress incontinence. Which statement by the client indicates the teaching has been effective?
"Kegel exercises will help strengthen the muscles that control the release of urine and I should do them regularly."
A client expresses understanding about the role dietary fiber has in the prevention of constipation. Which other reasons should the nurse present about the importance of fiber in the diet?
- dietary fiber will decrease the LDL cholesterol level - adequate dietary fiber increases the absorption of minerals- fiber support normal flora in the GI tract by providing a food source- adequate intake of dietary fiber will contribute to weight loss
What is updated on the new Nutrition Facts Label:
- larger serving - new added sugars - serving size updated - change in nutrients
The area around the stoma site should be
1/16 to 1/8 inches
The nurse is completing the placement of a nasogastric (NG) tube. Which is the most reliable way for the nurse to initially confirm the placement of the tube?
After placement of a radiopaque tube confirm the location of the tube by x-ray.
When should you change the colostomy bag
2-4 hours after meals or in the morning when the bowel is likely less active
Place the following steps for withdrawing medication from a vial in the correct order.
6 wash hands 4 pull plunger back 1 pierce rubber stopper 3 inject air 2 invert the vial 5 withdraw the appropriate amount
which serum ph can the nurse expect to see in a pt w/ COPD
7.33
nurse asses several clients who is at highest risk for hypertension
75 yo African American man w/ cataracts
A nurse correctly recognizes that administration of medication via the rectal route is appropriate for which client?
A 2 year old child who does not like the taste of orally administered medication
The nurse is caring for multiple clients with a variety of bowel conditions. Which client does the nurse consider at greatest risk for surgery to place a colostomy?
A client with a portion of bowel without circulation
The nurse is collecting data for a postoperative patient. Which of the following findings would the nurse recognize as being the most significant sign indicating acute kidney injury has occurred?
A decrease in urine output
The nurse works in a clinic that specializes in the care of patients diagnosed with psoriasis. Which patient does the nurse identify as being the greatest challenge for management of the disease?
A school-age patient who frequently has strep throat
The nurse is preparing to assess the leg of a client who states he has a new mole. What characteristics would the nurse assess for in melanoma?
A-asymmetry, B=irregular boarders, C=different colors, D=diameter >pencil eraser, E=evolution or change in appearance
The nurse is caring for a patient who has developed esophagitis from gastroesophageal reflux disease (GERD). For which additional complication should the nurse anticipate providing care to this patient?
Barrett's esophagus
The nurse is caring for a client who crushes medications and administers them via a gastrostomy tube. Which medication could safely be included in the client's plan of care?
Chewable antacids
A female client has been admitted with ulcerative colitis. Which appearance of the client's stools will the nurse expect with the exacerbation of this condition?
Contain pus, mucus, and blood
The nursing diagnosis of Excess Fluid Volume is made for a patient with Chronic Kidney Injury. Which of the follow data is most important for the nurse to collect for this patient based on the nursing diagnosis?
Daily Weight
What will the nurse teach a patient with pneumonia?
Deep breathing and coughing
The nurse is caring for a patient admitted with a possible bowel obstruction. Which patient symptom should cause the nurse the most concern?
Fecal vomiting
The nurse is caring for a patient receiving 1000mL of PN solution over 24 hours. When it is time to change the solution, 150mL remain in the bottle. The most appropriate action by the nurse is to
Hang a new solution and discard the unused solution.
term refers to the relationship among all living things
Holism
A patient treated for vomiting for several days from an unknown cause is admitted to the hospital. The nurse anticipates collaborative care to include
IV replacement of fluid and electrolytes.
BCG or Bacille Calmette-Guerin
Immigrants have been vaccinate in parts of the world with high TB. Do not give TB test only chest x-ray.
Metabolic Acidosis Respirations
Kussmaul respirations
The nurse is assessing the client's skin while performing a bed bath. The nurse observes an area of skin in the perianal region that appears lighter in color and feels softened from urinary incontinence. Which term does the nurse use when documenting this skin finding?
Maceration
Nursing management of the patient with chronic gastritis includes teaching the patient to
Maintain a non irritating diet with six small meals a day
St. John's Wort
May prolong the effects of anesthetic agents. Increases the waking time after surgery.
The nurse is providing care for a patient who underwent a Billroth I surgery for stomach cancer. Which nursing care is most important during the postoperative period for this patient?
Medicating for pain to promote coughing and deep breathing
A patient is admitted to the hospital for evaluation and treatment of thrombocytopenia. Which of the following actions is most important for the nurse to implement?
Monitoring the patient for headaches, vertigo, or confusion
A client recovering from an amputation asks why the foot that was removed is still causing pain. Which type of pain should the nurse explain that the client is experiencing?
Neuropathic
Under the supervision of a registered nurse (RN), the LVN is providing parents with instructions for administering eye drops to their young child, who has been diagnosed with pink eye. Which of the following statements would the LVN be correct in telling the parents?
Place the drop in the middle part of the space created when you pull down the lower lid."
The nurse is participating in a unit program aimed at preventing pressure injuries to residents in a long-term care facility. Which intervention does the nurse anticipate will be least effective?
Position patients at a 45-degree angle when on their side.
The nurse is reinforcing teaching to a patient newly diagnosed with ulcerative colitis about triggers for exacerbation of the disease. Which recommendation does the nurse make to the patient to prevent a future exacerbation? (Select all that apply.)
Read food labels to avoid food additives. Avoid ingesting foods sprayed with pesticides. Do not use tobacco. Reduce exposure to stress.
The nurse teaches the patient with a hiatal hernia or GERD to control symptoms by
Sleeping with the head of the bed elevated on 4 to 6 inch blocks
Which of the following symptoms would the nurse most likely be told was the first symptom that cause a patient with rheumatoid arthritis to seek health care?
Stiff, sore joints
While receiving a unit of packed RBCs, the patient develops chills and a temperature of 102.2 F. The priority action for the nurse to take is
Stop the transfusion and removes the IV catheter
A patient who had extensive gastric surgery for stomach cancer reports feeling sick and diaphoretic with abdominal cramping about 20 minutes after eating. The nurse is providing information about dumping syndrome. Which information is correct? (Select all that apply.)
The patient is experiencing one of the most common complications. Food enters the jejunum without adequate amounts of digestive juices. High concentrations of electrolytes and sugar draws fluid into the bowel. The patient will need to eat some candy or drink juice containing sugar.
A patient with severe right flank pain, general weakness, and fever is hospitalized. The patient has a history of recurrent urinary tract infection, and renal calculi are suspected. On the second hospital day, the patient's urine output drops to 300ml/24 hours, and the patient has distention and pain in the suprapubic area. The nurse would suspect which of the following to be the most likely cause for this sudden change?
Urinary tract obstruction
A patient sustains a closed fracture of the right tibia and is placed in a long-leg plaster cast, which is still damp. Which of the following methods should the nurse use to move the cast to prevent complications?
Use palms to move the cast
A nurse assesses a client who has asthma and and a baseline peak expiratory flow rate of 400 liters per minute. the clients peak expiratory flow rate is 260 liters per minute. which action will the nurse take?
administer the prescribed bronchodilator
nurse cares for a client who is diagnosed with peripheral artery disease. which intervention is implemented?
allow client to dangle one leg at a time off the side of the bed
nurse assists a clients blood pressure which action will the nurse take
allow pt to sit quietly for 5 minutes position pt arm and cuff to heart level asked if pt smoked in last 30 minutes use the appropriate size cuff
which client is the nurse most likely to screen for an amino acid deficiency
an adult client who is a strict life long vegetarian
Adventitous sounds
are extra breath sounds that are abnormal.
nurse prepares a subcutaneous injection in the medication room and use the one handed scoop method. what is the purpose of this method?
avoid needle stick
elderly patient admitted to hospital w/ increasing confusion and has become combative. nurse assess pt to have mild circumoral cyanosis. how will the nurse document this finding
blue discoloration around the mouth
nurse notes venous ulcer on clients left ankle which further finding does the nurse expect
brownish discoloration of the lower extremity
nurse inserts nasogastric tube for enteral nutrition what actions will the nurse take prior to feeding?
check placement(xray) pt in semi fowler confirm feeding solution type and rate
nurse cares for client who has COPD client is routinely cared for by spouse who states it takes forever to do all morning routine which suggestion will nurse make to client
decide together if some activities can be done later in day
pt with uncontrolled diabetes mellitus develops metabolic acidosis which finding indicates pt compensatory mechanism are working
deep rapid breathing
while assessing a client the nurse notes large number of dental caries and numerous missing teeth what concerns does this cause for the nurse about the clients nutritional status
digestion begins in the mouth with the process of chewing
a critically ill client may have difficulty in getting the restorative sleep necessary for healing. Which action should the nurse take to help this client?
dim the lights and close the door
nurse assists with the development of dietary plan for a client who is prescribed a high protein diet which items will you find on the clients tray
egg salad sandwich
nurse cares for client diagnosed with viral rhinitis which action will nurse take
encourage client to drink fluids
A ostomy bag should be changed
every 3-5 days
