Medsurg CAQ #2

The nurse is taking care of a client with cirrhosis of the liver and ascites. Which lunch is the best choice for a client with this disorder?

Penne pasta, spinach, banana, and decaffeinated iced tea

A client with an acute attack of cholecystitis has a cholecystectomy with a choledochostomy. The client returns from surgery with a T-tube connected to a drainage bag. What does the nurse conclude is the purpose of the T-tube?

Permit drainage of bile

A nurse is reviewing preoperative instructions with a client who is scheduled for orthopedic surgery at 8:00 AM the next day. What advice does the nurse give the client?

"Consume a light evening meal tonight and then no food or fluids after midnight."

A client recovering from hepatitis A asks the nurse about returning to work. Which is the best response by the nurse?

"Gradually increase your activities because relapses may occur in those who return to full activity too soon."

A healthcare provider explains a cystectomy and an ileal conduit for a client with invasive carcinoma of the bladder. Later the client expresses concerns about the possibility of offensive odors associated with this procedure. What is the best response by the nurse?

"Tell me more about what you are thinking."

A client is admitted to the hospital with ascites. The client reports drinking a quart (liter) of vodka mixed in orange juice every day for the past three months. To assess the potential for withdrawal symptoms, which question would be appropriate for the nurse to ask the client?

"When was your last drink of vodka?"

A high cleansing enema is prescribed for a client. What is the maximum height at which the container of fluid should be held by the nurse when administering this enema?

37 cm (15 inches)

A nurse reviews the laboratory results of a client with acute pancreatitis. Which test is most significant in determining the client's response to treatment?

Amylase level

A nurse is teaching a group of adults about the signs and symptoms of colorectal cancer. Which common clinical manifestations should the nurse include in the teaching program? Select all that apply

Anemia Rectal bleeding Change in bowel habits

A client has an adenocarcinoma of the colon. It is suspected that the cancer has metastasized, and a liver computed tomography (CT) scan with contrast medium has been prescribed. What would be appropriate for the nurse to include in the client's instructions?

Before the procedure, the client will be given an intravenous (IV) infusion, and the client must lie as still as possible for a period of time.

A nurse is assessing a client with Crohn disease who is to have an upper gastrointestinal series. Which condition necessitates the cancellation of the upper gastrointestinal series?

Colon perforation

A nurse is caring for a client on the second day after an abdominoperineal resection. Which finding does the nurse document as normal in the stoma?

Moist, red, and raised above the skin surface

On the second day after an abdominoperineal resection, the nurse anticipates that the colostomy stoma will have what appearance?

Moist, red, and raised above the skin surface

A client is diagnosed with cancer of the pancreas and is apprehensive and restless. Which nursing action should be included in the plan of care?

Encouraging expression of concerns

A nurse is caring for a client who has surgery for cancer of the pancreas. Which nutrients will the nurse most closely observe after surgery?

Fats and carbohydrates

When an intestinal obstruction is suspected, a client has a nasogastric tube inserted and attached to suction. What response should the nurse critically assess on this client?

Fluid deficit

An active adolescent is admitted to the hospital for surgery for an ileostomy. When planning a teaching session about self-care, the nurse includes sports that should be avoided by a client with an ileostomy. Which should be included on the list of sports to avoid? Select all that apply

Football Ice hockey

A client with dementia and a percutaneous endoscopic gastrostomy (PEG) tube is being cared for at home. Which action provides evidence that a family member is effectively managing the client's care?

Head of the bed remains elevated after the feeding

During a client's paracentesis, 1500 mL of fluid is removed. The nurse monitors the client for which sign of a potentially severe response?

Heart rate increases from 80 to 135

A nurse is reviewing a list of current medications with a client who has developed gastrointestinal bleeding. Which medication prescription should the nurse discuss with the primary healthcare provider?

Ibuprofen

A nurse is caring for a client who just had surgery for a parotid tumor. Which nursing intervention is the priority in the immediate postoperative period?

Keeping the client's respiratory passages patent

A client with cirrhosis of the liver has a prolonged prothrombin time and a low platelet count. A regular diet is prescribed. What should the nurse instruct the client to do considering the client's condition?

Report signs of bleeding no matter how slight

An older client with a history of chronic constipation develops acute appendicitis. Prior to arrival at the hospital, the client attempted self-care at home. Which self-care measures could potentially lead to rupture of the appendix?

Self-administering a small volume enema

What is most important for a nurse to monitor after a client has an endarterectomy in a lower extremity?

Skin color