Med-Surg Success 320 Final

The client two hours postoperative laparoscopic cholecystectomy is complaining of severe pain in the right shoulder. Which nursing intervention should the nurse implement? 1. Apply a heating pad to the abdomen for 15 to 20 minutes. 2. Administer morphine sulfate intravenously after diluting with saline. 3. Contact the surgeon for an order to x.ray the right shoulder. 4. Apply a sling to the right arm, which was injured during surgery.

1. (CORRECT) A heating pad should be applied for fifteen to twenty minutes to assist the migration of the CO2 used to insufflate the abdomen. Shoulder pin is an expected occurrence. 2. Morphine sulfate does not affect the etiology of the pain. 3. The surgeon would not order an x-ray for this condition 4. There is no indication an injury occurred during surgery. A sling would not benefit the migration of the CO2. Shoulder pain is expected.

Which statement indicates the client diagnosed with calcium phosphate renal calculi understands the discharge teaching for ways to prevent future calculi formation? 1. "I should increase my fluid intake, especially in warm weather." 2. "I should eat foods containing cocoa and chocolate." 3. "I will walk about a mile every week and not exercise often." 4. "I should take one vitamin a day with extra calcium."

1. (CORRECT) An increased fluid intake ensuring 2 to 3 L of urine a day prevents the stone forming salts from becoming concentrated enough to precipitate. 2. Cocoa and chocolate are high in calcium and should be avoided or the amount should be decreased to help prevent formation of calcium phosphate renal stones. 3. Physical activity prevents bone absorption and possible hypercalciuria; therefore, the nurse should instruct the client to walk daily to help retain calcium in bone. 4. The renal calculi are caused by calcium; therefore, the client should not increase calcium intake.

Which signs and symptoms should the nurse report to the health-care provider for the client recovering from an open cholecystectomy? Select all that apply. 1. Clay-colored stools. 2. Yellow-tinted sclera. 3. Amber-colored urine. 4. Wound approximated. 5. Abdominal pain.

1. (CORRECT) Clay-colored stools are caused by recurring stricture of the common bile duct, which is a sign of post-cholecystectomy syndrome. 2. (CORRECT) Yellow-tinted sclera and skin indicate residual effects of stricture of the common bile duct, which is a sign of post-cholecystectomy syndrome. 3. Amber-colored urine is a normal finding for a client recovering from an open cholecystectomy, so this does not warrant intervention by the nurse. 4. An approximated wound indicates the incision is intact and does not warrant intervention by the nurse. 5. (CORRECT) Abdominal pain indicates a residual effect of a stricture of the common bile duct, inflammation, or calculi, which is a sign of post-cholecystectomy syndrome.

The nurse writes the problem "imbalanced nutrition: less than body requirements" for the client diagnosed with hepatitis. Which intervention should the nurse include in the plan of care? 1. Provide a high-calorie intake diet. 2. Discuss total parenteral nutrition (TPN) 3. Instruct the client to decrease salt intake. 4. Encourage the client to increase water intake.

1. (CORRECT) Sufficient energy is required for healing. Adequate carbohydrate intake can spare protein. The client should eat approximately 16 carbohydrate kilocalories for each kilogram of ideal body weight daily. 2. TPN is not routinely prescribed for the client with hepatitis; the client must lose a large of amount of weight and be unable to eat anything for TPN to be ordered. 3. Salt intake does not affect the healing of the liver. 4. Water intake does not affect healing of the liver, and the client should not drink so much water as to decrease caloric food intake.

The client diagnosed with renal calculi is scheduled for a 24-hour urine specimen collection. Which interventions should the nurse implement? Select all that apply. 1. Check for the ordered diet and medication modifications. 2. Instruct the client to urinate, and discard this urine when starting collection. 3. Collect all urine during 24 hours and place in appropriate specimen container. 4. insert and indwelling catheter in client after having the client empty the bladder. 5. Instruct the UAP to notify the nurse when the client urinates.

1. (CORRECT) The health-care provider may order certain foods and medications when obtaining a 24-hour urine collection to evaluate for calcium oxalate or uric acid. 2. (CORRECT) When the collection begins, the client should completely empty the bladder and discard this urine. The test is started after the bladder is empty. 3. (CORRECT) All urine for 24 hours should be saved and put in a container with preservative, refrigerated, or placed on ice as indicated. Not following specific instructions will result in an inaccurate test result. 4. The urine is obtained in some type of urine collection device such as a bedpan, bedside commode, or commode hat. The client is not catheterized. 5. The nurse can delegate placing the urine output in the proper container to the UAP; therefore, the UAP does not need to notify the nurse when the client urinates.

The public health nurse is teaching day-care workers. Which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person? 1. Hepatitis A. 2. Hepatitis B. 3. Hepatitis C. 4. Hepatitis D.

1. (CORRECT) The hepatitis A virus is in the stool of infected people and takes up to two weeks before symptoms develop. 2. hepatitis B virus is spread through contact with infected blood and body fluids. 3. hepatitis C virus is transmitted through infected blood and body fluids. 4. hepatitis D virus only causes infection in people who are also infected with hepatitis B or C.

The charge nurse is monitoring client laboratory values. Which value is expected in the client with cholecystitis who has chronic inflammation? 1. An elevated white blood cell (WBC) count. 2. A decreased lactate dehydrogenase (LDH). 3. An elevated alkaline phosphatase. 4. A decreased direct bilirubin level.

1. (CORRECT) The white blood cell count should be elevated in client with chronic inflammation. 2. A decreased lactate dehydrogenase (LDH) indicates liver abnormalities. 3. An elevated alkaline phosphatase indicates liver abnormalities 4. A decreased bilirubin indicates an obstructive process

The public health nurse is discussing hepatitis B with a group in the community. Which health promotion activities should the nurse discuss with the group? Select all that apply. 1. Do not share needles or equipment. 2. use barrier protection during se. 3. Get the hepatitis B vaccine. 4. Obtain immune globulin injections. 5. Avoid any type of hepatotoxic medications.

1. (CORRECT) hepatitis B can be transmitted by sharing any type of needles, especially those used by drug abusers. 2. (CORRECT) Hepatitis B can be transmitted through sexual activity; therefore, the nurse should recommend abstinence, mutual monogamy, or barrier protection. 3. (CORRECT) Three doses of hepatitis B vaccine provide immunity in 90% of healthy adults. 4. Immune globulin injections are administered as post-exposure prophylaxis (after being exposed to hepatitis B), but encouraging these injections is not a health promotion activity. 5. Hepatotoxic medications should be avoided in clients who have hepatitis or who have had hepatitis. The health-care provider prescribes medications, and the layperson does not know which medications are hepatotoxic.

The client is four hours postoperative open cholecystectomy. Which data warrant immediate intervention by the nurse? 1. Absent bowel sounds in all four quadrants. 2. The T-tube has 60 mL of green drainage. 3. Urine output of 100 mL in the past three hours. 4. Refusal to turn, deep breathe, and cough.

1. After abdominal surgery, it is not uncommon for bowel sounds to be absent. 2. This is a normal amount and color of drainage. 3. The minimum urine output is 30 mL/hr 4. (CORRECT) Refusing to turn, deep breath, and cough places the client at risk for pneumonia. This client needs immediate intervention to prevent complications

Which type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses? 1. Airborne Precautions 2. Standard Precautions. 3. Droplet Precautions 4. Exposure Precautions

1. Airborne precautions are required for transmission occurring by dissemination of either airborne droplet nuclei or dust particles containing the infectious agent. 2. (CORRECT) Standard precautions apply to blood, all body fluids, secretions, and excretions, except sweat, regardless of whether they contain visible blood. 3. Droplet transmission involves contact of the conjunctivae of the eyes or mucous membranes of the nose or mouth with large particle droplets generated during coughing, sneezing, talking, or suctioning. 4. Exposure precautions is not a designated isolation category

Which problem is highest priority for the nurse to identify in the client who had an open cholecystectomy surgery? 1. Alteration in nutrition. 2. Alteration in skin integrity. 3. Alteration in urinary pattern. 4. Alteration in comfort.

1. Alteration in nutrition may be an appropriate client problem, but it is not priority. 2. Alteration in skin integrity may be an appropriate client problem but is not priority 3. Alteration in urinary elimination may be an appropriate client problem but is not priority 4. (CORRECT) Acute pain management is the highest priority client problem after surgery because pain may indicate a life-threatening problem

Which assessment data indicate to the nurse the client recovering from an open cholecystectomy may require pain medication? 1. The client's pulse is 65 beats per minute. 2. The client has shallow respirations. 3. The client's bowel sounds are 20 per minute. 4. The client uses a pillow to splint when coughing.

1. An increased pulse is expected in the client who is in acute pain. 2. (CORRECT) An open cholecystectomy requires a large incision under the diaphragm. Deep breathing places pressure on the diaphragm and the incision, causing pain. Shallow respirations indicate inadequate pain control, and the nurse should intervene. 3. Twenty bowel sounds a minute is normal data and does not require further action. 4. Splinting the abdomen allows the client to increase the strength of the cough by increasing comfort and does not indicate a need for pain medication.

The client with possible renal calculi is scheduled for a renal ultrasound. Which intervention should the nurse implement for this procedure? 1. Ask if the client is allergic to shellfish or iodine. 2. Keep the client NPO eight hours prior to the ultrasound. 3. Ensure the client has a signed informed consent form.. 4. Explain the rest is noninvasive and there is no discomfort.

1. An ultrasound does not require administration of contrast dye. 2. Foods, fluids, and ordered medication are not restricted prior to this test. 3. This is not an invasive procedure, so a signed consent is not required. 4. (CORRECT) No special preparation is needed for this noninvasive, non painful test. A conductive gel is applied to the back or flank and then a transducer is applied, which produces sound waves, resulting in a picture.

Which intervention is most important for the nurse is implement for the client diagnosed with rule-out renal calculi? 1. Assess the client's neurological status every two hours. 2. Strain all urine and send any sediment to the laboratory. 3. Monitor the client's creatinine and BUN levels. 4. Take a 24-hour dietary recall during the client interview.

1. Assessment is important, but the neurological system is not priority for a client with a urinary problem. 2. (CORRECT) Passing a renal stone may negate the need for the client to have lithotripsy or a surgical procedure. Therefore, all urine must be strained, and a stone, if found, should be sent to the laboratory to determine what caused the stone. 3. These are laboratory studies evaluating kidney function, but they are not pertinent when passing a renal stone. These values do not elevate until at least half the kidney function is lost. 4. A dietary recall can be done to determine what types of foods the client is eating that may contribute to the stone formation, but it is not the most important intervention.

The client is diagnosed with a uric acid stone. Which food should the client eliminate from the diet to help prevent reoccurrence? 1. Beer and colas. 2. Asparagus and cabbage. 3. Venison and sardines. 4. Cheese and eggs.

1. Beer and colas are foods high in oxalate, which can cause calcium oxalate stones. 2. Asparagus and cabbage are foods high in oxalate, which can cause calcium oxalate stones. 3. (CORRECT) Venison, sardines, goose, organ meats, and herring are high-purine foods, which should be eliminated fro the diet to help prevent uric acid stones. 4. Cheese and eggs are foods that help acidify the urine and do not cause the development of uric acid stones.

Which clinical manifestations should the nurse expect to assess for the client diagnosed with a ureteral renal stone? 1. Dull, aching flank pain and microscopic hematuria. 2. Nausea; vomiting; pallor; and cool, clammy, skin. 3. Gross hematuria and dull suprapubic pain with voiding. 4. The client will be asymptomatic.

1. Dull flank pain and microscopic hematuria are manifestations of a renal stone in the kidney 2. (CORRECT) The severe flank pain associated with a stone in the ureter often causes a sympathetic response with associated nausea; vomiting; pallor; and cool, clammy skin. 3. Gross hematuria and suprapubic pain when voiding are manifestations of a stone in the bladder. 4. Kidney stones and bladder stones may produce no signs/symptoms, but a ureteral stone always causes pain on the affected side because a ureteral spasm occurs when the stone obstructs the ureter.

The school nurse is discussing methods to prevent an outbreak of hepatitis A with a group of high school teachers. Which action is the most important to teach the high school teachers? 1. Do not allow students to eat or drink after each other. 2. Drink bottled water as much as possible. 3. Encourage protected sexual activity. 4. Sing the happy birthday song while washing hands.

1. Eating after each other should be discouraged, but it is not the most important intervention. 2. Only bottled water should be consumed in third world countries, but this precaution is not necessary in American High Schools. 3. hepatitis B and C, not hepatitis A, are transmitted by sexual activity. 4. (CORRECT) Hepatitis A is transmitted via the fecal oral route. Good hand washing helps to prevent its spread. Singing the happy birthday song takes approximately 30 seconds, which is how long an individual should wash his or her hands.

The nurse assess a large amount of red drainage on the dressing of a client who is six hours postoperative open cholecystectomy. Which intervention should the nurse implement? 1. Measure the abdominal girth. 2. Palpate the lower abdomen for a mass. 3. Turn client onto side to assess for further drainage. 4. Remove the dressing to determine the source.

1. Measuring the abdominal girth helps further assess internal bleeding, not external bleeding. 2. Palpating the lower abdomen assesses the bladder, not bleeding. 3. (CORRECT) Turning the client to the side to assess the amount of drainage and possible bleeding is important prior to contacting the surgeon. 4. The first dressing change is usually done by the surgeon; the nurse can reinforce the dressing.

The client with a history of renal calculi calls the clinic and reports having burning on urination, chills, and an elevated temperature. Which instruction should the nurse discuss with the client? 1. Increase water intake for the next 24 hours. 2. Take two Tylenol to help decrease the temperature. 3. Come to the clinic and provide a urinalysis specimen. 4. Use a sterile 4 X 4 gauze to strain the client's urine.

1. The client needs to be evaluated for a possible urinary tract infection, which may accompany renal calculi. Therefore, the clinic nurse should not give advice without knowing what is wrong with the client. 2. The nurse should not recommend any medication (even Tylenol) unless the nurse is absolutely sure what is wrong with the client. 3. (CORRECT) A urinalysis can assess for hematuria, the presence of white blood cells, crystal fragments, or all three, which can determine if the client has a urinary tract infection or possibly a renal stone, with accompanying signs.symptoms of UTI. 4. The client needs to strain the urine if there is a possibility of renal calculi, which these signs/symptoms do not support. Further diagnostic testing is needed to determine the presence of renal calculi.

Which statement by the client diagnosed with hepatitis warrants immediate intervention by the clinic nurse? 1. "I will not drink any type of beer or mixed drink." 2. "I will get adequate rest so I don't get exhausted." 3. "I had a big hearty breakfast this morning." 4. "I took some cough syrup for this nasty head cold."

1. The client should avoid alcohol to prevent further liver damage and promote healing. 2. Rest is needed for healing of the liver and to promote optimum immune function. 3. Clients with hepatitis need increased caloric intake, so this is a good statement. 4. (CORRECT) The client needs to understand some types of cough syrup have alcohol and all alcohol must be avoided to prevent further injury to the liver; therefore, this statement requires intervention.

The client is diagnosed with an acute episode of ureteral calculi. Which client problem is priority when caring for this client? 1. Fluid volume loss. 2. Knowledge deficit. 3. Impaired urinary elimination. 4. Alteration in comfort.

1. The client's fluid volume is increased and there is usually not a fluid volume loss. 2. Knowledge deficit is important to help prevent future renal calculi, but this is not priority when the client is in pain, which will occur with an acute episode. 3. Impaired urinary elimination may occur, but it is not priority for the client with an acute episode of calculi. 4. (CORRECT) Pain is priority. The pain can be so severe a sympathetic response may occur, causing nausea; vomiting, pallor; and cool, clammy skin.

The client diagnosed with renal calculi is admitted to the medical unit. which intervention should the nurse implement first? 1. Monitor the client's urinary output. 2. Assess the client's pain and rule out complications. 3. Increase the client's oral fluid intake. 4. Use a safety gait belt when ambulating the client.

1. The client's urinary output should be monitored, but it is not the first nursing intervention. 2. (CORRECT) Assessment is the first part of the nursing process and is priority. The renal colic pain can be so intense it can cause a vasovagal response, with resulting hypotension and syncope. 3. Increased fluid increases urinary output, which will facilitate movement of the renal stone through the ureter and help decrease pain, but it is not the first intervention. 4. Ambulation will help facilitate movement of the renal stone through the ureter and safety is important, but it is not the first intervention.

Which outcome should the nurse identify for the client scheduled to have a cholecystectomy? 1. Decreased pain management. 2. Ambulate first day postoperative 3. No break in skin integrity. 4. Knowledge of postoperative care.

1. The expected outcome is pain control for both preoperative and postoperative care. 2. Postoperative care includes ambulation. 3. prevention of an additional impaired skin integrity is a desired postoperative outcome. The incision would be break in skin integrity. 4. (CORRECT) This would be an expected outcome for the client scheduled for surgery. This indicates preoperative teaching has been effective.

Which task is to appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Draw the serum liver function test. 2. Evaluate the client's intake and output. 3. Perform the bedside glucometer check. 4. Help the ward clerk transcribe orders.

1. The laboratory technician draws serum blood studies, not the UAP. 2. The UAP can obtain the intake and output, but the nurse must evaluate the data to determine if the results are normal for the client's disease process or condition. 3. (CORRECT) The UAP can perform a bedside glucometer check, but the nurse must evaluate the result and determine any action needed. 4. The ward clerk has specific training that allows the transcribing of health-care provider orders.

The female nurse sticks herself with a contaminated needle. Which action should the nurse implement first? 1. Notify the infection control nurse. 2. Cleanse the area with soap and water. 3. Request postexposure prophylaxis. 4. Check the hepatitis status of the client.

1. The nurse must notify the infection control nurse as soon as possible so treatment an start if needed, but this is not the first intervention. 2. (CORRECT) The nurse should first clean the needle stick with soap and water and attempt stick bleed to help remove any virus injected into the skin. 3. Post exposure prophylaxis may be needed, but this is not the first action. 4. The infection control/employee health nurse will check the status of the client whom the needle was used on before the nurse stuck herself.

The client diagnosed with liver problems asks the nurse, "Why are my stools clay-colored?" On which scientific rationale should the nurse base the response? 1. There is an increase in serum ammonia level. 2. The liver is unable to excrete bilirubin. 3. The liver is unable to metabolize fatty foods. 4. A damaged liver cannot detoxify vitamins

1. The serum ammonia level is increased in liver failure, but it is not the cause of clay-colored stools. 2. (CORRECT) Bilirubin, the by-product of red blood cell destruction, is metabolized in the liver and excreted via the feces, which causes the feces to be brown in color. If the liver is damaged, the bilirubin is excreted via the urine and skin. 3. The liver excretes bile into the gallbladder and the body uses the bile to digest fat, but is does not affect the feces. 4. Vitamin deficiency, resulting from the liver's inability to detoxify vitamins, may cause steatorrhea, but it does not cause clay-colored stool.

The client diagnosed with renal calculi is scheduled for lithotripsy. Which post procedure nursing task is the most appropriate to delegate to the UAP? 1. Monitor the amount, color, and consistency of urine output. 2. Teach the client about care of the indwelling Foley catheter. 3. Assist the client to the car when being discharged home. 4. Take the client's post-procedural vital signs.

1. The urine must be assessed for bleeding and cloudiness. Initially the urine is bright red, but the color soon diminishes and cloudiness may indicate an infection. This assessment should not be delegated to a UAP. 2. Teaching cannot be delegated to a UAP. The nurse should teach and evaluate the effectiveness of the teaching. 3. (CORRECT) The UAP could assist the client to the car once the discharge has been completed. 4. The kidney is highly vascular. Hemorrhaging and resulting shock are potential complications of lithotripsy, so the nurse should not delegate vital signs post procedure.

The client with hepatitis asks the nurse, "I went to an herbalist, who recommended I take milk thistle. What do you thin about the herb?" Which statement is the nurse's best response? 1. "You are concerned about taking an herb." 2. "The herb has been used to treat liver disease." 3. "I would not take anything that is not prescribed." 4. "Why would you want to take any herbs?"

1. This is a therapeutic response, and the nurse should provide factual information. 2. Milk thistle has an active ingredient, silymarin, which has been used to treat liver disease for more than 2,000 years. It is a powerful oxidant and promotes liver cell growth. 3. The nurse should not discourage complementary therapies. 4. This is a judgmental statement, and the nurse should encourage the client to ask questions.

The laboratory data reveal a calcium phosphate renal stone for a client diagnosed with renal calculi. Which discharge teaching intervention should the nurse implement? 1. encourage the client to eat a low-purine diet and limit foods such as organ meats. 2. Explain the importance of not drinking water two hours before bedtime. 3. Discuss the importance of limiting Vitamin D-enriched foods. 4. Prepare the client for extracorporeal shock wave lithotripsy (ESWL).

1. This is appropriate for the client who has uric acid stones. 2. The nurse should recommend drinking one to two glasses of water at night to prevent concentration of urine during sleep. 3. (CORRECT) Dietary changes for preventing renal stones include reducing the intake fo the primary substance forming the calculi. In this case, limiting vitamin D will inhibit the absorption of calcium from the gastrointestinal tract. 4. This is a treatment for an existing renal stone, not a discharge teaching intervention for a client who has successfully passed a renal calculus.

The nurse is caring for the immediate postoperative client who had a laparoscopic cholecystectomy. Which task could the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Check the abdominal dressings for bleeding. 2. Increase the IV fluid if the blood pressure is low. 3. Ambulate the client to the bathroom. 4. Auscultate the breath sounds in all lobes.

1. This is assessment and cannot be delegated. 2. This intervention would require nursing judgment, and increasing IV fluid is medication administration; neither task can be delegated. 3. (CORRECT) A day surgery client can be ambulated to the bathroom, so this task can be delegated to the UAP. 4. This would require assessment and cannot be delegated.

The client had surgery to remove a kidney stone. Which laboratory assessment data warrant immediate intervention by the nurse? 1. A serum potassium level of 3.8 mEq/L. 2. A urinalysis shows microscopic hematuria. 3. A creatinine level of 0.8 mg/100 mL. 4. A white blood cell count of 14,000/mm3.

1. This potassium level is within normal limits, (3-5-5.5 mEq/L). 2. Hematuria is not uncommon after removal of a kidney stone. 3. A normal creatinine level is 0.8 to 1.2 mg/100mL 4. (CORRECT) The white blood cell count is elevated; normal is 5,000 to 10,000/mm3

The nurse is teaching a client recovering from a laparoscopic cholecystectomy. Which statement indicate the discharge teaching is effective? 1. "I will take my lipid-lowering medicine at the same time each night." 2. "I may experience some discomfort when I eat a high-fat meal." 3. "I need someone to stay with me for about a week after surgery." 4. "I should not splint my incision when I deep breathe and cough."

1. This surgery does not require lipid-lowering medications, but eating high-fat meals may cause discomfort. 2. (CORRECT) After removal of the gallbladder, some clients experience abdominal discomfort when eating fatty foods. 3. Laparoscopic cholecystectomy surgeries are performed in day surgery, and clients usually do not need assistance for a week. 4. Using a pillow to splint the abdomen provides support for the incision and should be continued after discharge.