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After gastroscopy, an adaptation that indicates major complication would be:
Abdominal distension may be associated with pain, may indicate perforation, a complication that could lead to peritonitis.
Nurse Liza is assigned to care for a client who has returned to the nursing unit after left nephrectomy. Nurse Liza's highest priority would be...
After nephrectomy, it is necessary to measure urine output hourly. This is done to assess the effectiveness of the remaining kidney also to detect renal failure early.
Ryan has undergone subtotal gastrectomy. The nurse should expect that nasogastric tube drainage will be what color for about 12 to 24 hours after surgery?
12 to 24 hours after subtotal gastrectomy gastric drainage is normally brown, which indicates digested food.
Which of the following compilations should the nurse carefully monitors a client with acute pancreatitis.
A client with acute pancreatitis is prone to complications associated with respiratory system.
A newly admitted client is diagnosed with Hodgkin's disease undergoes an excisional cervical lymph node biopsy under local anesthesia. What does the nurse assess first after the procedure?
Assessing for an open airway is the priority. The procedure involves the neck, the anesthesia may have affected the swallowing reflex or the inflammation may have closed in on the airway leading to ineffective air exchange.
A client has Gastroesophageal Reflux Disease (GERD). The nurse should teach the client that after very meals, the client should...
Gravity speeds up digestion and prevents reflux of stomach contents into the esophagus.
A client who has undergone a cholecystectomy asks the nurse whether there are any dietary restrictions that must be followed. Nurse Hilary would recognize that the dietary teaching was well understood when the client tells a family member that:
It may take 4 to 6 months to eat anything, but most people can eat anything they want.
Mrs. Chua a 78 year old client is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear when listening to client'slungs indicative of chronic heart failure would be:
Left sided heart failure causes fluid accumulation in the capillary network of the lung. Fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration.
Nurse Perry is evaluating the renal function of a male client. After documenting urine volume and characteristics, Nurse Perry assesses which signs as the best indicator of renal function.
Perfusion can be best estimated by blood pressure, which is an indirect reflection of the adequacy of cardiac output.
Kate who has undergone mitral valve replacement suddenly experiences continuous bleeding from the surgical incision during postoperative period. Which of the following pharmaceutical agents should Nurse Aiza prepare to administer to Kate?
Protamine Sulfate is used to prevent continuous bleeding in client who has undergone open heart surgery.
Nurse Jenny is instilling an otic solution into an adult male client left ear. Nurse Jenny avoids doing which of the following as part of the procedure
The dropper should not touch any object or any part of the client's ear.
What would be the primary goal of therapy for a client with pulmonary edema and heart failure?
The primary goal of therapy for the client with pulmonary edema or heart failure is increasing cardiac output. Pulmonary edema is an acute medical emergency requiring immediate intervention.
In reducing the risk of endocarditis, good dental care is an important measure. To promote good dental care in client with mitral stenosis in teaching plan should include proper use of...
The use of electronic toothbrush, irrigation device or dental floss may cause bleeding of gums, allowing bacteria to enter and increasing the risk of endocarditis.
Nurse Jamie should explain to male client with diabetes that self-monitoring of blood glucose is preferred to urine glucose testing because...
Urine testing provides an indirect measure that maybe influenced by kidney function while blood glucose testing is a more direct and accurate measure.
Among the following signs and symptoms, which would most likely be present in a client with mitral gurgitation?
Weight gain due to retention of fluids and worsening heart failure causes exertional dyspnea in clients with mitral regurgitation
A client who has been diagnosed of hypertension is being taught to restrict intake of sodium. The nurse would know that the teachings are effective if the client states that...
Wheat cereal has a low sodium content.
Nurse Trisha teaches a client with heart failure to take oral Furosemide in the morning. The reason for this is to help
When diuretics are taken in the morning, client will void frequently during daytime and will not need to void frequently at night.
Smoking cessation is critical strategy for the client with Burgher's disease, Nurse Jasmin anticipates that the male client will go home with a prescription for which medication?
Nicotine (Nicotrol) is given in controlled and decreasing doses for the management of nicotine withdrawal syndrome.
Jessie weighed 210 pounds on admission to the hospital. After 2 days of diuretic therapy, Jessie weighs 205.5 pounds. The nurse could estimate the amount of fluid Jessie has lost...
One liter of fluid approximately weighs 2.2 pounds. A 4.5 pound weight loss equals to approximately 2L.
Dr. Marquez orders a continuous intravenous nitroglycerin infusion for the client suffering from myocardial infarction. Which of the following is the most essential nursing action?
Administration of Intravenous Nitroglycerin infusion requires pump for accurate control of medication.
Nurse Lucy is planning to give pre operative teaching to a client who will be undergoing rhinoplasty. Which of the following should be included?
Aspirin containing medications should not be taken 14 days before surgery to decrease the risk of bleeding.
Dr. Marquez tells a client that an increase intake of foods that are rich in Vitamin E and beta-carotene are important for healthier skin. The nurse teaches the client that excellent food sources of both of these substances are:
Beta-carotene and Vitamin E are antioxidants which help to inhibit oxidation. Vitamin E is found in the following foods: wheat germ, corn, nuts, seeds, olives,spinach, asparagus and other green leafy vegetables. Food sources of beta-carotene include dark green vegetables, carrots,mangoes and tomatoes.
During the first several hours after a cardiac catheterization, it would be most essential for nurse Cherry to...
Blood pressure is monitored to detect hypotension which may indicate shock or hemorrhage. Apical pulse is taken to detect dysrhythmias related to cardiac irritability.
During the second day of hospitalization of the client after a Myocardial Infarction. Which of the following is an expected outcome?
By the 2nd day of hospitalization after suffering a Myocardial Infarction, Clients are able to perform care without chest pain
Nurse Rachel teaches a client who has been recently diagnosed with hepatitis A about untoward signs and symptoms related to Hepatitis that may develop. The one that should be reported immediately to the physician is:
Clay colored stools are indicative of hepatic obstruction
A client suffered from a lower leg injury and seeks treatment in the emergency room. There is a prominent deformity to the lower aspect of the leg, and the injured leg appears shorter that the other leg. The affected leg is painful, swollen and beginning to become ecchymotic. The nurse interprets that the client is experiencing:
Common signs and symptoms of fracture include pain, deformity, shortening of the extremity, crepitus and swelling.
Jerry has diagnosed with appendicitis. He develops a fever, hypotension and tachycardia. The nurse suspects which of the following complications?
Complications of acute appendicitis are peritonitis, perforation and abscess development.
Which of the following statements should the nurse teach the neutropenic client and his family to avoid?
Neutropenic client is at risk for infection especially bacterial infection of the gastrointestinal and respiratory tract.
Nurse Linda is caring for a client with head injury and monitoring the client with decerebrate posturing. Which of the following is a characteristic of this type of posturing?
Decerebrate posturing is the extension of the extremities after a stimulus which may occur with upper brain stem injury.
Kris with a history of chronic infection of the urinary system complains of urinary frequency and burning sensation. To figure out whether the current problem is in renal origin, the nurse should assess whether the client has discomfort or pain in the
Discomfort or pain is a problem that originates in the kidney. It is felt at the costovertebral angle on the affected side.
A male client with a history of cirrhosis and alcoholism is admitted with severe dyspnea resulted to ascites. The nurse should be aware that the ascites is most likely the result of increased...
Enlarged cirrhotic liver impinges the portal system causing increased hydrostatic pressure resulting to ascites.
George who has undergone thoracic surgery has chest tube connected to a water-seal drainage system attached to suction. Presence of excessive bubbling is identified in water-seal chamber, the nurse should...
Excessive bubbling indicates an air leak which must be eliminated to permit lung expansion.
Myrna a 52 year old client with a fractured left tibia has a long leg cast and she is using crutches to ambulate. Nurse Joy assesses for which sign and symptom that indicates complication associated with crutch walking?
Forearm muscle weakness is a probable sign of radial nerve injury caused by crutch pressure on the axillae.
Which of the following symptoms during the icteric phase of viral hepatitis should the nurse expect the client to inhibit?
Liver inflammation and obstruction block the normal flow of bile. Excess bilirubin turns the skin and sclera yellow and the urine dark and frothy.
Paul is admitted to the hospital due to metabolic acidosis caused by Diabetic ketoacidosis (DKA). The nurse prepares which of the following medications as an initial treatment for this problem?
Metabolic acidosis is anaerobic metabolism caused by lack of ability of the body to use circulating glucose. Administration of insulin corrects this problem.
Patrick who is hospitalized following a myocardial infarction asks the nurse why he is taking morphine. The nurse explains that morphine:
Morphine is a central nervous system depressant used to relieve the pain associated with myocardial infarction, it also decreases apprehension and prevents cardiogenic shock.
The client asks Nurse Annie the causes of peptic ulcer. Nurse Annie responds that recent research indicates that peptic ulcers are the result of which of the following:
Most peptic ulcer is caused by Helicopter pylori which is a gram negative bacterium.
John suddenly experiences a seizure, and Nurse Gina notice that John exhibits uncontrollable jerking movements. Nurse Gina documents that John experienced which type of seizure?
Myoclonic seizure is characterized by sudden uncontrollable jerking movements of a single or multiple muscle group.
Nurse Donna is aware that the shift of body fluids associated with Intravenous administration of albumin occurs in the process of:
Osmosis. (the movement of fluid from an area of lesser solute concentration to an area of greater solute concentration.)
Nurse Lilly has been assigned to a client with Raynaud's disease. Nurse Lilly realizes that the etiology of the disease is unknown but it is characterized by:
Raynaud's disease is characterized by vasospasms of the small cutaneous arteries that involves fingers and toes.
Which of the following should the nurse teach the client about the signs of digitalis toxicity?
Seeing yellow spots and colored vision are common symptoms of digitalis toxicity
A female client is experiencing painful and rigid abdomen and is diagnosed with perforated peptic ulcer. A surgery has been scheduled and a nasogastric tube is inserted. The nurse should place the client before surgery in
Semi-fowlers position will localize the spilled stomach contents in the lower part of the abdominal cavity.
Which of the following antituberculosis drugs can damage the 8th cranial nerve?
Streptomycin is an aminoglycoside and damage on the 8th cranial nerve (ototoxicity) is a common side effect of aminoglycosides.
Nurse Bea should instruct the male client with an ileostomy to report immediately which of the following symptom?
Sudden decrease in drainage or onset of severe abdominal pain should be reported immediately to the physician because it could mean that obstruction has been developed.
A 68 year old client is diagnosed with a right-sided brain attack and is admitted to the hospital. In caring for this client, the nurse should plan to:
The left side of the body will be affected in a right-sided brain attack.
A 64 year old male client with a long history of cardiovascular problem including hypertension and angina is to be scheduled for cardiac catheterization. During pre cardiac catheterization teaching, Nurse Cherry should inform the client that the primary purpose of the procedure is
The lumen of the arteries can be assessed by cardiac catheterization. Angina is usually caused by narrowing of the coronary arteries.
A client has 15% blood loss. Which of the following nursing assessment findings indicates hypovolemic shock?
Typical signs and symptoms of hypovolemic shock includes systolic blood pressure of less than 90 mm Hg.
Nurse Joan is assigned to come for client who has just undergone eye surgery. Nurse Joan plans to teach the client activities that are permitted during the post operative period. Which of the following is best recommended for the client?
Watching TV is permissible because the eye does not need to move rapidly with this activity, and it does not increase intraocular pressure.
A female client is taking Cascara Sagrada. Nurse Betty informs the client that the following maybe experienced as side effects of this medication:
most frequent side effects of Cascara Sagrada (Laxative) is abdominal cramps and nausea.
Which nursing intervention ensures adequate ventilating exchange after surgery?
the client laterally with the neck extended does not obstruct the airway so that rainage of secretions and oxygen and carbon dioxide exchange can occur.
