Targeted Medical-Surgical
Spending adequate time with a client who is verbally abusive is an example of which ethical principle?
Justice
What foods can prevent flatus and odor for a client with a new colostomy?
Yogurt, crackers, and toast -can prevent flatus and stool odor
A nurse is providing teaching to a client who has a new diagnosis of multiple sclerosis (MS). The clients asks the nurse about the usual course MS. Which of the following responses should the nurse make
"Acute episodes are usually followed by remissions, which can vary in duration"
Patient is on rifampin for TB. What instruction should the nurse include?
"Expect your urine and other secretions to be orange while taking this medication"
Expected findings for appendicitis?
-Oral temperature 101.0 F -Nausea and vomiting -Right lower quadrant pain
What are some adverse effects of long-term corticosteroid therapy?
-Osteoporosis -Increased risk for infection -Moon-shaped face
A client comes in with BP of 254/139 mm Hg. The nurse knows that hypertensive crisis. Which of the following actions should the nurse take first?
Elevate the head of the client's bed -to promote oxygenation and reduce blood pressure
What intervention should the nurse identify as the priority for a mental health client on olanzapine?
Instruct the client to avoid driving during initial therapy -B/C of drowsiness or dizziness
A nurse is caring for a client following insertion of a permanent pacemaker. Which client statement indicates a potential complication of the insertion procedure?
"I can't get rid of these hiccups" -hiccups can indicate that the pacemaker is stimulation the chest wall or diaphragm, which can occur as a result of a lead wire perforation.
A client who has a new permanent pacemaker. What statement by the client indicates an understanding of the teaching?
"I should check my my heart rate at the same time each day"
A nurse is providing discharge teaching for a client who has chronic kidney disease (CKD). Which of the following statements should the nurse identify as an indication that the client understands the teaching?
"I will decrease my intake of foods that are high in phosphorus" -A client who has CKD should limit intake of foods that are high in phosphorus to prevent bone damage
A nurse is providing discharge teaching to a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching?
"I will need to take methotrexate even if I'm in remission"
Patient is prescribed montelukast. What indicates the patients understanding of the teaching?
"I will take this medication every night even if I don't have symptoms" -Montelukast is used for the prophylactic treatment of asthma and is taken on a daily basis in the evening.
To screen a client for pheochromocytoma, a nurse schedules a vanillylmandelic acid test. When teaching the client about this test, which of the following instructions should the nurse include?
"restrict coffee intake 2 to 3 days prior to the test" -The client should avoid coffee and tea (even if they are decaffeinated), bananas, chocolate, and vanilla for 2 to 3 days prior to the test.
A nurse is providing teaching for a client who is 2 days postoperative following a heart transplant. Which of the following statements should the nurse include in the teaching?
"you might no longer be able to feel chest pain." -Heart transplant client usually are no longer able to feel chest pain due to the denervation of the heart.
A nurse is providing teaching to a male client who has a continent internal ileal reservoir following surgery to treat bladder cancer. What statement should the nurse make?
"you must insert a catheter through your stoma to drain the urine"
Client asks how to prevent future uric acid stones. Which suggestions should the nurse make? (3)
-Take allopurinol as prescribed (antigout medication that reduces levels of uric acid) -Exercise several times a week (immobility is a risk factor for stone formation) -Limit intake of foods high in purine (purine increases the risk for uric acid stone formation)
A client with ulcerative colitis should do what to minimize the risk of further exacerbations?
-Use progressive relaxation techniques -Arrange activities to allow for daily rest periods -Restrict intake of carbonated beverages
Behaviors of left stroke?
-inability to read -aphasia -right-sided neglect
ammonia expected range?
10-80 mcg/dL
Glasgow Coma Scale normal range
3-15 -15 is good - 3- 8 is in a coma -above 8 might have a good chance to survive
Intracranial pressure normal range?
7-15 mm Hg
A nurse is planning care for a group of clients. Which of the following clients should the nurse plan to monitor for signs of nephrotoxicity?
A client who is receiving gentamicin for the treatment of a wound infection -aminoglycosie antibiotics can damage the cells of proximal renal tubules, causing scute tubular necrosis. The nurse should plan to monitor this client for nephrotoxicity and acute kidney injury.
What is an indication of breast cancer when doing a SBE?
A nontender, hard lump that is palpated in one breast
A client who is 48 hours postoperative following a total hip arthroplasty--- what is the client at greatest risk for?
A pulmonary embolism -due to decreased mobility of the affected extremity and an increased amount of blood clots form in the veins of the thigh following hip surgery. DVTs are most likely to occur 48-72 hours following the arthroplasty.
A nurse is monitoring a client following hemodialysis. The nurse should recognize that what places the client at risk for seizures?
A rapid decrease in fluid -A rapid decrease in fluid and electrolytes during hemodialysis can result in cerebral edema and increased intracranial pressure, placing the client at risk for seizures. This complication is called dialysis disequilibrium syndrome.
What does the adrenocorticotropic hormone (ACTH) stimulation test assess for?
Addison's disease -The nurse should instruct the client that the ACTH stimulation test is standard for Addison's disease. It measures the cortisol response to ACTH. The response is absent or very decreased in clients who have primary adrenal insufficiency.
A client is experiencing phantom limb pain after a leg amputation. What should the nurse do?
Administer an oral dose of gabapentin to the client. -A nonopioid medication to the client experiencing phantom limb pain. Gabapentin is an anti-epileptic medication and is effective for treatment of phantom limb pain.
A client has malignant hyperthermia in surgery. What should you give him?
Administer dantrolene -IV at 2-5 mg/kg to reverse the manifestations for a client who has malignant hyperthermia
What does continuous bubbling in a water chamber of a chest tube indicate?
Air leak -Requires notification of the provider. The nurse should check the system for external. correctable leaks while she is waiting for instructions from the provider.
TB is what precautions?
Airborne
What is a fast-acting bronchodilator?
Albuterol
What adverse effect should a nurse monitor for with metoclopramide?
Ataxia -monitor for extrapyramidal symptoms
A nurse is teaching a client who has a new diagnosis of acute pyelonephritis. Which of the following instructions should the nurse include in the teaching?
Avoid the use of NSAIDs for pain. -b/c they can cause further damage to the kidneys, causing papillary necrosis and reflux
A client with stomatitis should avoid using what when cleaning their mouths?
Avoid using lemon-glycerine swabs -because they cause drying and irritation of the mucous membranes
When taking out a chest tube the nurse should instruct the client to do what?
Instruct the client to perform the Valsalva maneuver during the removal -to maintain the appropriate amount of negative pressure in the chest to prevent air entry into the pleural space
Benztropine is to treat what?
Benztropine is used to treat Parkinsonism manifestations
Hep B is spread by
Blood or blood products sexual contact
A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report to the provider?
Bloody stools -The greatest risk to a client with cirrhosis of the liver is hemorrhagic shock due to bleeding in the esophageal varices.
Peritonitis what symptom should you expect?
Board-like abdomen -distended abdomen, accompanied by extreme pain and tenderness
A nurse is assessing a client who has adrenal insufficiency. Which lab should the nurse expect?
Calcium 12.8 mg/dL -A client who has adrenal insufficiency has a calcium level above the expected reference range.
A patient has extensive burns, including on her face. What assessments should the nurse perform first?
Characteristics of the cough and sputum -ABCs
Diabetes mellitus puts you at risk for the development of what urine/renal issue?
Chronic pyelonephritis -a client with DM is at risk for the development of chronic pyelonephritis due to the reduced bladder tone that results from diabetic neuropathy.
Any client with a chest tube the nurse should have what easily accessible?
Container of sterile water -Nurse should plan to place open end of the tubing into the sterile water if the tubing becomes disconnected in order to prevent a pneumothorax.
Hypoglycemic symptoms?
Cool, clammy skin, anxiety, nervousness, tachycardia, and confusion
A nurse is caring for a client who has an onset of chest pain 24 hours ago. The nurse should recognize that an increase in which of the following is diagnostic of a myocardial infarction?
Creatine kinase-MB -is the isoenzyme specific to the myocardium. Elevated creatine kinase-MB indicates myocardial muscle injury.
What should you expect with a client who has multiple sclerosis?
Intention tremors -Clients who have multiple sclerosis are at risk for motor dysfunction, such as intention tremors, poor coordination, and loss of balance.
A patient with acute respiratory distress syndrome (ARDS). Which finding should the nurse report to the provider?
Intercostal retractions -b/c this finding indicates increasing respiratory compromise in a client who has ARDs.
What color stoma should be reported to provider?
Dark purple stoma -indication of bowel ischemia
Glomerulonephritis what symptom may occur?
Dark-colored urine -Clients who have acute glomerulonephritis usually excrete urine that is a dark, reddish-brown color.
Client is experiencing alcohol withdrawal. What medication should the nurse administer?
Diazepam 5 mg IV bolus
A client is post Lobectomy and has two chest tubes put in. What is the reason for the lower chest tube?
Draining blood and fluid from the pleural space -Blood and fluids tend to accumulate in the bases and posterior areas of the pleural cavity following a lobectomy
A nurse is assessing a client who has borderline personality disorder. Which finding should the nurse expect?
Emotional liability -is the rapid transition form one emotion to another and is primary feature of borderline personality disorder.
A client is going through a sickle cell crisis. What intervention should the nurse include in the client's plan of care?
Encourage increased fluid intake -to promote hydration because dehydration increases the viscosity of the blood, which can increase sickling and client discomfort
A client is newly on Lactulose, what should they expect?
Expect to have two to three soft stools per day -lactulose promotes the excretion of ammonia in the stool
What manifestation should the nurse include for teaching of PTSD?
Experiences feelings of isolation -PTSD clients often feel estranged and detached from others.
What is a manifestation of Crohn's disease?
Fatty diarrheal stools -steatorrhea, or fatty stool, is an expected finding in a client who has Crohn's disease
A client has retinal detachment. What should the nurse expect the client to say they see?
Flashes of bright light -During retinal detachment, the client can experience flashes of bright light or floating dark spots in the affected eye as the retinal layers separate.
What lab value is elevated in a patient with Cushings disease?
Glucose is elevated
A nurse is reviewing the laboratory values of a client who has colorectal cancer. Which lab value should the nurse expect?
Hemoglobin 9.1% g/dL -is below the expected reference range. Decreases hemoglobin is an expected finding in a client who has colorectal cancer due to occult intestinal bleeding.
After surgery what can indicate abdominal distension?
Hiccups -can be caused by irritation of the phrenic nerve due to abdominal distension.
Valsalva Maneuver is?
Holding one's breath and tightening the abdominal muscles while pushing.
When would you take cyclosporine daily for life?
If you had a transplanted organ.
A nurse is assessing a client who has diabetes insipidus. The nurse should expect which of the following findings?
Increased hematocrit -is an expected finding resulting from dehydration
A patient has hyperkalemia what should you administer?
Infuse regular insulin in dextrose 10% in water. -to promote potassium movement from the extracellular fluid into the intracellular fluid.
A nurse should give IV heparin through what?
Infuse the heparin using an electronic IV pump -rather than by gravity, to prevent an accidental increase or change in the rate of infusion.
Greenstick fracture?
Injury causes the bone to fracture on one side and bend on the other side.
The nurse should use which of the following focused assessments to help differentiate between and arterial ulcer and a venous stasis ulcer?
Inquire about the presence or absence of claudication (cramping leg pain). -knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not.
A nurse is monitoring a client's status 24 hours after a total thyroidectomy. What finding should the nurse report to the provider?
Laryngeal stridor -is a harsh, high-pitched sound with inspiration that indicates respiratory obstruction. The nurse should take immediate action to preserve the client's airway.
LDL should be what?
Less than 130 mg/dL
A nurse is caring for a client who is being treated for heart failure and has a prescription for furosemide. The nurse should plan to monitor for which of the following as an adverse effect of this medication?
Lightheadedness -Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness or dizziness
A client who has Campylobacter enteritis. What prescription should the nurse clarify with the provider?
Magnesium hydroxide (milk of magnesia) -Nausea, vomiting, and diarrhea are manifestations of enteritis. -so the nurse should ask about this med since this medication increases gastrointestinal motility, which can increase the client's risk for electrolyte imbalance and contribute to dehydration.
A client with cirrhosis and ascites. Which assessment should the nurse do daily?
Measure the client's abdominal girth daily. -assess breath sounds 4-8 hours -check mental status 4-8 hours
A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority?
Monitor pulse oximetry findings. -The greatest risk to the client is respiratory compromise due to progressive paralysis of respiratory muscles.
A nurse is caring for a client who is in respiratory distress. What low-flow delivery device should the nurse use to provide the client with the highest level of oxygen?
Nonrebreather mask -made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. -Delivers greater than 90% FiO2
A client with endocarditis should notify the doctor before having what type of procedure?
Notify the doctor before having any dental procedures. -to decrease the risk of recurrence of infective endocarditis.
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. What intervention should the nurse include?
Offer the client high-calorie finger foods frequently -While client is on the go b/c a client in mania might be unable to sit down for meals and can experience weight loss and dehydration
A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue?
Older children who are responsible for their younger siblings -This is an example of enmeshed boundaries in which there are no distinctions between the roles of family members.
Isoniazid should be taken when?
On an empty stomach -to improve absorption of the medication -- 1 hour before or 2 hours after a meal
A client reports sudden, severe eye pain with blurred vision. The provider determines the client has primary angle-closure glaucoma. What medication should the nurse administer?
Osmotic diuretics via IV bolus -to rapidly reduce intraocular pressure and prevent damage to the eye
During brachytherapy for cancer the patient should be doing what?
Patient should lie still in bed during brachytherapy treatment -limited movement while radioactive implant is in place to prevent dislodgment
A nurse is assessing a client who has COPD. What finding should the nurse report to the provider?
Productive cough with green sputum.
What diet should a COPD patient be on?
Provide a diet that is high in calories and protein. -high in calories and protein and low in carbohydrates
what is a finding that indicates a UTI?
Pyuria -the nurse should identify pyuria, or white blood cells in the urine, as a common manifestation of a UTI.
A nurse is providing teaching for a client who is prescribed alendronate for osteoporosis. Which of the following information should the nurse include in the teaching?
Remain upright for 30 min after taking this medication -to prevent esophagitis or esophageal ulcers that can result from alendronate therapy
A nurse is planning care for a preschool-age child who has ADHD. Which of the following interventions should the nurse identify as the priority?
Remove unnecessary equipment from the child's surroundings. -The greatest risk to the child who has ADHD is injury from impulsive behavior and the decreased ability to perceive self-harm.
A nurse is caring for a client who has type 2 diabetes mellitus and has hyperglycemic-hyperosmolar state (HHS). What laboratory findings should the nurse expect?
Serum pH of 7.45 -A client who has HHS produces enough insulin to prevent ketosis, but not enough to prevent hyperglycemia. Therefore, the serum pH is within the expected reference range. Glucose levels will be about 600 mg/dL.
A client has schizophrenia and was prescribed a conventional antipsychotic medication yesterday. What finding means the nurse should administer benztropine?
Shuffling gait
A nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). What finding should the nurse report to the provider?
Sodium 110 mEq/L -A client who has SIADH retains fluids, which causes dilutional hyponatremia.
A client taking paroxetine for depression reports that he also takes herbal supplements. Which supplement interacts adversely with paroxetine?
St. John's wort -is an herbal preparation that decreases the reuptake of serotonin. Which places the client at risk for serotonin syndrome.
A nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition?
Stroke the client's inner thigh -The nurse can stimulate micturition by stroking the client's inner thigh
Methylphenidate can cause what adverse effect?
Tachycardia
A nurse is caring for a client who has asthma and is receiving albuterol. For which of the following adverse effects should the nurse monitor the client?
Tachycardia -common adverse effect of this medication, especially if the client uses albuterol on a regular basis.
What wave is ventricular repolarization on a ECG strip?
The T wave (Last wave)
What is a factor that places the client at an increased risk for depression?
The client has COPD -Clients who have a medical illness are at an increased risk for the development of depression.
A surgical nurse enters a surgical suite to ensure surgical asepsis is maintained. Which of the following findings requires intervention by the nurse?
The scrub technologist is wearing a watch under his scrubs -finger and wrist jewelry are likely contaminated with microorganisms and bacteria.
A nurse is providing teaching to a client who has a histoy of tonic-clonic seizures and is scheduled for a standard electroencephalogram (EEG). What instruction should the nurse include in the teaching?
Thoroughly shampoo hair prior to the EEG -because hairsprays, oils, and other hair preparations interfere with recording results of the EEG
After spinal anesthesia what is the first sensation the nurse should expect the client to feel?
Touch
Which finding indicates to the nurse the client is possibly experiencing a tension pneumothorax?
Tracheal deviation to the unaffected side -A tension pneumothorax results from free air filling the chest cavity, causing lung to collapse and forcing the trachea to deviate to the unaffected side.
A client is getting intermittent peritoneal dialysis. The nurse observes that the peritoneal fluid is not adequately draining. What should the nurse do with the client to help?
Turn the client from side to side -to facilitate removal of peritoneal drainage.
A nurse is providing teaching to a client who is to begin undergoing light therapy at home to treat seasonal affective disorder. What should the nurse include in the teaching?
Wear sunglasses when outdoors. -Light therapy, or phototherapy, can cause eye strain and sensitivity to light.
A nurse is caring for a client who is taking propylthiouracil. The nurse should identify that the client has met the treatment goals when she reports an increase in which of the following manifestations?
Weight -Propylthiouracil suppresses the production of the thyroid hormones and, therefore, allows for weight gain. However, excessive weight gain could indicate that the dose of propylthiouracil is too high.
Amyotrophic later sclerosis
a progressive degeneration of the motor neurons of the central nervous system, leading to wasting of the muscles and paralysis.
Diabetic ketoacidosis (DKA) glucose levels?
above 300 mg/dL
HDL should be what for men?
above 45 mg/dL men
HDL should be what for women?
above 55 mg/dL women
Hyperglycemic-hyperosmolar state glucose levels?
above 600 mg/dL
72 hours post operative of an above-the knee amputation what should the nurse do every 4 hours?
assist the client to a prone position every 4 hours -assist client to prone position for 20-30 mins every 3-4 hours following an amputation because it reduces the risk of flexion contractures.
When should you take famotidine?
at bedtime -to inhibit the action of histamine at the H2-receptor site in the stomach.
Hep C is spread by?
blood
A client who had a mastectomy with reconstructive surgery can do what after the provider removes the drain?
can shower after the doctor removes the drain
Hyperglycemic symptoms?
dehydration, hypotension, rapid, deep respirations, abdominal cramping
Hep A is spread by?
fecal-oral route
After an abdominal surgery what should the patient increase intake of?
foods that are high in protein and vitamin C during their recovery -to promote wound healing
Spiral fracture?
fracture twist around the shaft of the bone
A nurse is reviewing the laboratory results of a client who has acute pancreatitis. Which lab should the nurse expect?
increased serum amylase -levels are increased in a client who has acute pancreatitis due to pancreatic cell injury.
Client has a NG tube in and starts to have Gastric distension. What does that indicate?
indication that the NG tube is not patent. The nurse should check the tubing for kinks, blockages, and loose connections.
Comminuted fracture is?
injury causes the bone to fragment into several pieces.
Famotidine does what?
is a H2-receptor antagonist that is prescribed for the treatment of peptic ulcer disease to inhibit the secretion of gastric acid.
NSAIDs are metabolized where?
kidneys
expected reference range of cholesterol is
less than 200 mg/dL
A client with viral meningitis you should check what every 4 hours?
monitor capillary refill at least every 4 hours -the nurse should perform a complete vascular assessment at least every 4 hours to monitor for vascular compromise.
Teaching plan for a client who has Meniere's disease.
move head slowly to decrease vertigo
What does epistaxis mean?
nose bleed
what is an adverse effect of prednisone that should be reported to the provider?
sore throat -Glucocorticoids depress the immune system and increase the client's risk for infection. The nurse should recognize a sore throat as an indication of infection and report this finding to the provider.
What wave is atrial depolarization on a ECG strip?
the P wave (first one)
What wave is ventricular depolarization on a ECG strip?
the QRS complex (middle)
A client with dependent personality disorder would have what type of behavior?
the client need excessive external input to make everyday decisions.
Open fracture?
there is damage involving the skin or mucous membranes. Went through skin.
Carbidopa-levodopa can do what to your pee?
turn urine a darker color -secretions such as saliva, urine, and sweat can darken in color when taking this med
A client has a Penrose drain. How should the nurse clean it?
use sterile technique -should change the Penrose drain dressing using the surgical aseptic technique
Hypoglycemia manifestations?
weakness hunger diaphoresis nausea shakiness confusion
What is an indication of a basilar skull fracture?
Clear fluid coming from the nares
A nurse is developing a teaching plan for a client who has a thyroidectomy and takes a thyroid hormone replacement. Which of the following instructions should the nurse plan to include?
"take this medication on an empty stomach" -To promote proper absorption, the client should take the medication on an empty stomach and not eat or drink anything for 30-60 min after taking it.
Before hanging packed RBCs for a client what should the nurse do?
-Assess and document client's vital signs -Client has a 20-gauge or larger needle for administration -Verify with another nurse the blood type and Rh of the packed RBCs -Hang a bag of 0.9% sodium chloride IV solution for administration with the packed RBCs. -Change IV tubing to set that has a filter
Expected findings for emphysema?
-Barrel-shaped chest -Rhonchi on inspiration -Diminished breath sounds
A client has osteoarthritis. What should the nurse expect?
-Crepitus with joint movement -Decreased ROM of the affected joint -Joint pain that resolves with rest
Behaviors of right stroke?
-Impulsive behavior -left-sided neglect
A nurse is caring for a client who has encephalitis due to West Nile virus. Which actions should the nurse take?
-Monitor vital signs every 2 hours -Assess neurological status every 4 hours -Keep the client's room darkened
Peritoneal dialysis treatment. What finding should the nurse report to the provider?
Cloudy dialysate effluent -Cloudy or opaque drainage is an early manifestation of peritonitis.
Clozapine can cause what with a lab value?
Clozapine can cause agranulocytosis, which can be fatal due to overwhelming infection. Example... WBC 2500/mm3 = do not give drug
Bradydydysrhythmias can cause what symptom?
Confusion
A nurse is reviewing labs for a client with hepatic cirrhosis. Which lab should the nurse report to the provider?
Ammonia 180 mcg/dL -increased and should be reported because it can indicate portal-systemic encephalopathy
What is Meniere's disease?
An inner ear disorder that causes episodes of vertigo (spinning).
A nurse is caring for a client who has thrombocytopenia and develops epistaxis. What action should the nurse take?
Apply lateral pressure to the client's nose for 10 mins -to control epistaxis.
A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take?
Apply pressure to the puncta after instilling the medication.
What can cause a low pressure alarm to sound for a patient receiving mechanical ventilation?
Artificial airway cuff leak -interferes with oxygenation and causes the low pressure alarm to sound.
A nurse is managing the care of a client who is postoperative and has acute adrenal insufficiency. What action should the nurse take?
Asminister IV hydrocortisone sodium -Hydrocortisone sodium is necessary to replace the cortisol deficiency that occurs with adrenal insufficiency
A client who has myasthenia gravis, reports recent increasing muscle weakness and the nurse suspects the client is experiencing a myasthenic crisis. What action is the nurse's priority?
Assist with Tensilon test -Assess the client. The tenilon test will determine if the client is experiencing a myasthenic crisis or a cholinergic crisis.
A nurse is planning care for a client with a closed-wound drainage system in place. What should the nurse do after emptying it?
Cleanse the drain plug with alcohol after emptying
A client with a basilar skull fracture following a fall from a ladder, what assessment finding should the nurse report
Clear drainage from nose -indicates cerebral spinal fluid is leaking from the skull fracture.
Teaching a client with emphysema about improving gas exchange. What should the nurse teach the client?
Use pursed-lip breathing during periods of dyspnea -to slow expiration, increase airway pressure, and facilitate effective gas exchange
Hypocalcemia can cause?
ECG changes, bradycardia, or tachycardia Muscle spasms
What is a hallmark manifestation of delirium?
Easily distracted
A patient with diverticulitis should eat what?
Eat foods that are low in fiber -follow a low-fiber diet. When the inflammation subsides, the client should consume foods that are high in fiber.
A client is having increased sedation caused form a benzodiazepine. What medication should the nurse give?
Flumazenil -a benzo agonist, to reverse the sedative effects of the medication.
A client with chronic pancreatitis should stay away from what food?
High fat foods -low-fat food options are what they should eat (Ex: bananas)
A nurse is assessing a client who has a new diagnosis of Cushing's disease. Which of the following findings should the nurse expect?
Hirsutism -Increased hair growth, or hirsutism, is an expected finding of Cushing's disease due to increased androgen production.
A nurse is assessing a client who has upper gastrointestinal bleeding. What finding should the nurse expect?
Hypotension -upper GI bleed is at risk for hemorrhagic shock. Hypotension is a manifestation of hemorrhagic shock
Lithium food teaching?
I should eat a regular diet with normal amounts of salt and fluids. -If sodium levels are low, the body compensates by decreasing lithium excretion, which can lead to toxicity. (increase in lithium)
A nurse is caring for a client who is 2 days postop following a cholecystectomy. Client is vomiting for past 24 hours and reports a pain level of 8 on a scale from 0-10. The nurse notes hard, distended abdomen and absent bowel sounds. After conferring with the provider, which action should the nurse take?
Insert anNG tube -Client is at greatest risk for fluid and electrolyte imbalance as a result of accumulated fluid and gas in the GI tract.
recombinant tissue plasminogen activator is for what?
Is a thrombolytic administered to dissolve the blood clot that caused the stroke. (Ex: Embolic stroke)
What is an expected finding for someone with acute hepatitis B?
Joint Pain
Herpes zoster is not contagious to who?
People who have had chickenpox -Varicella zoster is the causative agent of both chickenpox and herpes zoster. This virus is contagious to people who have not had chickenpox or have not received vaccination for varicella
What adverse effect from a ACE inhibitor for hypertension should the client notify his provider about?
Persistent cough
A nurse is caring for a client who is 1 our postoperative following a thoracentesis. Which of the following is the priority assessment finding?
Persistent cough -this indicates a tension pneumothorax, which is a medical emergency.
A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan?
Renew the prescription for the client every 4 hours
A nurse is preparing a teaching plan for a client who has diabetes insipidus and required intranasal desmopressin. Which of the following information should the nurse include in the teaching plan?
Report nocturia because it requires a dosage adjustment. -The client should receive the initial dose of desmopressin in the evening; the provider will increase the dosage until the client no longer has nocturia.
A nurse is reviewing the chart of a client who has dissociative amnesia. Which of the following findings should the nurse expect?
The client was seriously injured while under the influence of alcohol. -A traumatic event that causes severe stress is a trigger for dissociative amnesia.
A nurse is assessing a client who has rheumatoid arthritis. Which assessment finding should the nurse expect?
Ulnar deviation -the inflammation that occurs in the hand joints can make them susceptible to deformity from daily use. Ulnar deviation, or lateral deviation of the fingers, can occur from opening jars and other similar motions
A client is 2 hours postoperative following an appendectomy. What finding should the nurse report to the provider?
Urine output of 20 mL/hr -The nurse should notify the provider if the client's urine output is less than 30 mL/hr. Decreased output can indicate hypovolemia and decreased perfusion of the kidneys
What is a finding that can indicate shock and should be reported to the provider?
Urine output of 20 mL/hr -urine output less than 30 mL/hr is a manifestation of shock. Urine output is decreased due to a compensatory decreased blood flow to the kidneys, hypovolemia, or graft thrombosis or rupture.
A nurse is monitoring a client's ECG monitor and notes the client's rhythm has changed form normal sinus rhythm to supraventricular tachycardia. The nurse should prepare to assist with which of the following interventions?
Vagal stimulation -might temporarily convert the clients heart rate to normal sinus rhythm.
What are some manifestations of hypothyroidism?
Weight gain cold intolerance cool, dry skin hair loss Hypotension bradypnea dysrhythmias
After a craniotomy the nurse should report what drainage?
drainage greater than 50 mL/8 hr
