Client w/ Ulcerative colitis has an ileostomy. Which statement indicates PT needs more teaching

I will irrigate my ileostomy every morning

Its noninvasive, nothing will be inserted into the pt's body

Perfusion distal to the insertion site

Client w/ fractured hip is in Buck's traction is complaining of pain. Intervention?

Ensure the weigh's of the Buck's traction are off the floor

Which diagnostic data should be reported to the HCP IMMEDIATELY?

ph 7.11, PaCO2 45, HCO3 20, PaO2 98%, client w/ T1DM

Patient in ED: pale cool skin, sudden midsternal CP UNRELIEVED with rest, Hx of CAD

S. indicate acute cor episode and should be treated as such

84 year old client comes to clinic complaining of R lower abd pain. What ? is the MOST appropr?

Can you describe the type of pain?

Which client is most likely to have diverticulosis?

63 year old female w/ hemorrhoids

The nurse has received report on the following patients. Which should the nurse see first?

The elderly patient just admitted and reporting constipation

What are American cancer society recommendations for early detection of colon cancer?

Having a colonoscopy at 50, then once every 5-10 years.

Client diagnosed w Acute exacerbation of IBD. Which priority interv should the nurse implement?

Record frequency, amount, and color of stools

Pt's central venous pressure is 7 mmHg. What is the nurse's most appropriate action?

Assess the PT for fluid overload and inform physician

Pulmonary artery pressure monitoring

Which S/S indicates osteoporosis?

Client has lost 1 inch in height

Which data should the nurse report immediately of a client w/ fractured left tibia and fibula?

Dorsalis pedal pulse cannot be located w/ Doppler and ↑ pain

The nurse is teaching a pt about consequences of uncontrolled HPT. What are they?

Cerebrovascular accident and retinal hemorrhage

What is the most appropriate problem for a client w/ closed fracture of R arm?

Risk for complications R/T compromised neurovasc status

Client is prescribed a low residue diet. Which meal selection is appropriate?

Roast pork, white rice and plain custard

85 year old man asks a nurse "Why did I get colon cancer?" What is the best response?

Research shows a lack of fiber can cause colon cancer

Which assessment data supports that a client might be having peritonitis?

Hard, rigid abdomen and WBC count 22,000

Which data indicate the surgical Tx of hip replacement was effective?

Client ambulates to the bathroom

The patient is one day post major abdominal surgery. Which patient problem is the priority?

Fluid and electrolyte imbalance

The client who had abd surgery says: "I felt something give way in my stomach". Intervention?

Assess the abdominal wound incision

Nurse is assessing postop client on ortho floor. Which warrant immediate intervention?

Pain in the unaffected leg during dorsiflexion of the ankle

Which client should the nurse assess FIRST on an ortho floor?

64 yo female w/ L total knee replac who has confusion

What is the most appropriate outcome for a client w/ a fractured lower extremity?

Client will maintain function of the leg

It prevents some blockages that can cause CP or MI

Nurse is caring for a post op client. What should the nurse report to the surgeon?

Urinary output of 60 ml of clear yellow urine in 3hrs

Pt is undergoing exercise stress test. Prior to reaching the target, pt develops chest pain.

Stop the test and monitor the Pt closely

Client has crohn's disease. Which statement by the client supports this diagnosis?

My pain goes away when I have a bowel movement

The client has a nasogastric tube draining green liquid bile. Which should the nurse implement

Document the findings as normal

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H&I Final

72 termsStudBud Administration23 plays

med surg cumulative final

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Questions 72

Answers

1
A patient is admitted to the ER with an acute abdomen. What intervention should be impl. first?
Assessm of the abdomen for distention, masses, bowel sounds
Assessment of pain onset, location, duration, etc.
Administration of pain meds
Measurement of VS
2
Client w/ Ulcerative colitis has an ileostomy. Which statement indicates PT needs more teaching
If i get a red bumpy, itchy rash, I will call my doctor
I will irrigate my ileostomy every morning
My stoma should be pink and moist
I will change my pouch (ew) if it starts leaking
3
Image
Pt will remain on bed rest for 1 to 2 hrs after the test
Pain will be managed aggressibvely during the procedure
Test will provide a detailed profile of hearts electr. activ
Its noninvasive, nothing will be inserted into the pt's body
4
Image
S/S of compartment syndrome
Fluctuations in core body temperature
S/S of esophageal varices
Perfusion distal to the insertion site
5
Client w/ fractured hip is in Buck's traction is complaining of pain. Intervention?
Ensure the weigh's of the Buck's traction are off the floor
Raise the head of the bed to 45 degrees and the foot to 15
Turn the client on the affected leg using pillows
Adjust the pt's controlled analgesia (PCA)
6
Which diagnostic data should be reported to the HCP IMMEDIATELY?
Pulse ox 93%, client w/ COPD
ph 7.11, PaCO2 45, HCO3 20, PaO2 98%, client w/ T1DM
Hg 9.4, hematocr: 29%, for a client who received blood
Na: 137, K: 4, glucose: 120, client w/ gastroenteritis
7
Afterload is increased when there is what?
Arterial vasoconstriction
Venous vasodilation
Arterial vasidialation
Venous vasoconstriction
8
Patient in ED: pale cool skin, sudden midsternal CP UNRELIEVED with rest, Hx of CAD
S. indicate acute cor episode and should be treated as such
Symptoms indicate a pulmonary etiology rather than a cardiac
Tx will determined pending the results of an exercise test
Symptoms indicate angina and should be treated as such
9
Pt is scheduled for CT with contrast. To prepare for test, what should the nurse perform?
Teach the Pt to perform incentive spirometry
Keep pt NPO for at least 6 hrs prior to testing
Establish IV access
Limit activity for 2 hrs before test
10
84 year old client comes to clinic complaining of R lower abd pain. What ? is the MOST appropr?
When was your last BM?
Did you have high-fat meal last night?
Have you been experiencing any gas?
Can you describe the type of pain?
11
Pt's BP is 161/101. Categorize it:
High normal
Hypertensive crisis
Stage 1 HPT
Stage 2 HPT
12
Which client is most likely to have diverticulosis?
60 year old male w/ a sedentary lifestyle
63 year old female w/ hemorrhoids
72 year old female w/ multiple child births
40 year old male w/ a family history of diverticulosis
13
The nurse has received report on the following patients. Which should the nurse see first?
Patient with Crohn's who had two semiformal stools
Pt reporting a spot of bright red blood on the toilet seat
The elderly patient just admitted and reporting constipation
Pt w AIDS who had 200 mL diarrhea with elastic skin turgor
14
Signs and Symptoms of Digoxin toxicity:
Numbness and tingling in the extremities
Confusion and bradycardia
Chest pain and SOB
Uncontrolled diuresis and tachycardia
15
Image
An increase in preload R/T ambulation
A pulse oximetry reading 94%
HR of 54 bpm
A change in position from standing to sitting
16
What are American cancer society recommendations for early detection of colon cancer?
Flexible sigmoidoscopy should be done yearly after 40.
Having a colonoscopy at 50, then once every 5-10 years.
At mid age, yearly fecal occult blood test should be done.
Starting at 60 digital rectal exam should be done annually.
17
On assessment the nurse finds a hard rigid abdomen and T 102F. Which should the nurse implement
continue to monitor the client closely
Notify health care provider
administer an antipyretic suppository
Prepare to administer enema
18
Image
A pt who has undergone valve relacement
An older adult
A 20-year old pt
A pt who takes a beta-adrenergic blocker
19
The nurse is calculating patients pulse pressure. If BP is 122/76 mmHg, what is pulse pressure?
99 mmHg
198 mmHg
76 mmHg
46 mmHg
20
Client diagnosed w Acute exacerbation of IBD. Which priority interv should the nurse implement?
Teach coping strategies such as dietary modifications
Monitor client's oral fluid intake q shift
Record frequency, amount, and color of stools
Weigh the client daily and document in the chart
21
Pt's central venous pressure is 7 mmHg. What is the nurse's most appropriate action?
Raise head of the bed, have pt perform deep breath exersice
Arrange for continuous cardiac monitoring and reposition Pt
Assess the PT for fluid overload and inform physician
Remove CVP catheter and apply an occlusive dressing
22
Image
Pulmonary artery pressure monitoring
Central venous pressure monitoring
Systemic arterial pressure monitoring
Arterial blood gasses
23
At which time should the nurse schedule the daily dose of iron supplement?
0900
1630
1000
1200
24
Which S/S indicates osteoporosis?
Client's hands are painful to the tough
Client's serum uric acid level is elevated
Client has lost 1 inch in height
Client has lost 12 lbs in the last year
25
Which data should the nurse report immediately of a client w/ fractured left tibia and fibula?
Localized edema and discoloration occuring hrs after injury
Generalized weakness and increasing sensitivity to touch
Pain relieved after taking 4mg hydromorphone
Dorsalis pedal pulse cannot be located w/ Doppler and ↑ pain
26
Image
Development of an atrial-septal defect
Release of potassium ions from cells
Formation of a pulmonary embolism
Myocardial ischemia
27
The nurse is teaching a pt about consequences of uncontrolled HPT. What are they?
Cerebrovascular accident and venous insufficiency
Cerebrovascular accident and retinal hemorrhage
Venous insufficiency and Stroke
Transient ischemic attack and R ventricular hypertropy
28
What is the most appropriate problem for a client w/ closed fracture of R arm?
Risk for infection R/T exposed bone
Risk for ineff coping skills R/T the inability to perf ADLs
Risk for compartment syndrome R/T injured muscle tissue
Risk for complications R/T compromised neurovasc status
29
Client is prescribed a low residue diet. Which meal selection is appropriate?
Grilled hamburger on a wheat bun and fried potatoes
A chicken salad sandwich w/ lettuce and tomato salad.
Roast pork, white rice and plain custard
Fried fish, whole grain pasta, and fruit salad
30
What assessment finding is most consistent with R-sided HF?
Dry cough
Distended neck veins
Pulmonary edema
Orthopnea
31
85 year old man asks a nurse "Why did I get colon cancer?" What is the best response?
It is not common to get colon cancer at your age
Research shows a lack of fiber can cause colon cancer
No one knows why anyone gets cancer. It just happens
Women usually get colon cancer more often then men.
32
Which assessment data supports that a client might be having peritonitis?
Abdominal cramping and hemoglobin of 14
Hard, rigid abdomen and WBC count 22,000
Profuse diarrhea and stool specimen shows Campylobacter
Absent bowel sounds and potassium level of 3.9
33
Which data indicate the surgical Tx of hip replacement was effective?
Client's L leg is shorter than the R leg
Client ambulates to the bathroom
Client states pain is "3" on a 1-10 scale
The client has a limited ability to ambulate
34
Image
Inflammation
Immunosuppression
Infection
Hemostasis
35
The patient is one day post major abdominal surgery. Which patient problem is the priority?
Fluid and electrolyte imbalance
Pain
Impaired skin integrity
Altered bowel elimination
36
The client who had abd surgery says: "I felt something give way in my stomach". Intervention?
Instruct the client to splint the incision
Administer prescribed PRN pain medication
Notify the surgeon immediately
Assess the abdominal wound incision
37
Nurse is assessing postop client on ortho floor. Which warrant immediate intervention?
Bowel sounds heard intermittently in 4 quadrants
T 99F, HR 80, RR 20, BP 128/76
Diffuse, crampy abdominal pain
Pain in the unaffected leg during dorsiflexion of the ankle
38
Most common cause of angina
Infarction of the myocardium
Coronary atherosclerosis
Decreased cardiac contractility
Decreased Cardiac Output
39
Which client should the nurse assess FIRST on an ortho floor?
64 yo female w/ L total knee replac who has confusion
84 yo female w/ fractured R femoral neck in Buck's traction
88 yo male post-R total hip repl w/ an abduction pillow
50 yo postop client w/ a continuous passive motion device
40
What is the most appropriate outcome for a client w/ a fractured lower extremity?
Client will maintain function of the leg
Client will be turned every 2 hours
Client will ambulate w/ assistance
Client will have no infection
41
Image
It prevents some blockages that can cause CP or MI
It is simple way to make your blood penetrate heart freely
It helps your blood to carry more O2
Its an easy way to help restore normal function of the heart
42
Image
Valve dysfunction
HF
Pleurisy
Cardiomyopathy
43
Which sign/symptom should the nurse expect to find in a patient diagnosed with UC?
Oral temp at 102 F
Hard, rigid abdomen
Urinary stress incontinence
Twenty bloody stools a day
44
Image
Possible MI
Aortic valve regurgitation
Possible hypovolemia
Left-sided HF
45
Which diagnostic test is the MOST accurate when diagnosing osteoporosis?
Serum alkaline phosphate
Serum bone Gla-protein test
DEXA
X-ray of the femur
46
Nurse is caring for a post op client. What should the nurse report to the surgeon?
Cool toes, distal pulses palpable, and pale nailbeds
A total of 100 ml of red drainage in the drainage system
Pain relief using PCA pump
Urinary output of 60 ml of clear yellow urine in 3hrs
47
Pt has a productive cough with mucoid sputum, SOB, cyanotic hands, rapid breathing. Problem?
Cardiomyopathy
Pericarditis
Right ventricular hypertropy
Pulmonary edema
48
Commonly used vessel as a source for a CABG is:
Brachial vein
Femoral artery
Great saphenous vein
Brachial artery
49
Pt is undergoing exercise stress test. Prior to reaching the target, pt develops chest pain.
Administer analgesia and slow the test
Initiate cardiopulmonary resuscitation
Administer sublingual nitroglycerin to finish the test
Stop the test and monitor the Pt closely
50
Client has crohn's disease. Which statement by the client supports this diagnosis?
My abdomen is hard and rigid and I have a fever
My pain goes away when I have a bowel movement
I have episodes of diarrhea and constipation
I have bright red blood in my stool all the time.
51
The client has a nasogastric tube draining green liquid bile. Which should the nurse implement
determine the clients last Bowel movement
Document the findings as normal
assess the clients bowel sounds
insert the NG tube at least two more inches
52
What assessment ? most directly addresses the possibility of worsening HPT?
Are you eating salt in your diet?
Do you ever see spots in front of your eyes?
How is your energy these days?
Do you ever get chest pain when you exercise?
53
Client diagnosed w IBD has serum K of 3.4. Which action should the nurse impl FIRST?
Request telemetry for the client
Prepare to administer IV Potassium
Notify HCP
Assess the client for muscle weakness
54
Which statement about care of a new colostomy indicates the need for further teaching?
I should not drive or lift more then 5 lbs.
Drink only liquids until the colostomy starts to work
If I notice any skin breakdown, I will call the doctor
I should not take a tub bath until the doctor okay's it
55
What is the relationship between BP and age?
Reduced muscle tone in blood vessels, causes BP to go down
Decrease in strength of arteries, venous insuff. lead to HPT
Neurologic system of elderly is less effic. in monitoring BP
Struct.+funct. changes in CV system contrib. to ↑ in BP
56
Client w/ iron def anemia is prescribed ferrous gluconate orally. Which should the nurse teach?
Take an OCT antidiarrheal when having diarrhea
Eat only red meats and organ meats for proyein
The stools may be very dark, and this can mask blood
Limit exercise for several wks until a tolerance is achieved
57
Client diagnosed w/ IBD prescribed TPN which intervention should the nurse implement.
Check the client's glucose level
Administer oral hypoglycemic
Access peripheral IV site
Monitor client's oral fluid intake
58
Client w/ ulcerative colitis is scheduled for an ileostomy. Where will the stoma be located?
LLQ
RLQ
RUQ
LUQ
59
The nurse obtained a pt's BP reading of 122/84 and 130/88, respectively. Categorize this pts BP
Normal
Prehypertensive
Stage 2 hypertensive
Stage 1 hypertensive
60
Nurse is preparing to admin. Warfarin for a client w/ DVT. Which lab value ind therap. level?
Hematocrit of 32%
Partial thromboplastin time (PTT) within normal range
Prothrombin time (PT) eitgh to ten times the control
International normalized ratio (INR) between 2 and 3
61
Image
It is done to assess how blocked/open pts coronary art. are
Done to detect how efficiently heart muscle contracts
To eval cardiac electrical activity
To eval cardiovascular response to stress
62
Image
This is an accurate indicator of MI
It is a poor indicator of MI
It is an accurate indicator when it reaches its peak in 24h
It indicates muscle injury, but doesn't specify the source
63
Which instruction should the nurse include when teaching the client about diverticulitis?
Instruct to excercise at least 3 times a week.
Teach about eating a low residue diet
Explain the need to have daily bowel movements
Discuss the importance of drinking 1000ml of water daily.
64
Nurse is preping a Pt for transesophageal echocardiography. What action should the nurse perf?
Instruct Pt to drink 1 L of water before the test
Administer IV benzodiazepines and opioids
Inform that access line will be initiated in femoral artery
Inform the Pt she will remain on bed rest following proced.
65
What should the nurse implement FIRST for an 88-year old client is admitted w/ fractured pelvis
Apply Buck's traction
Administer a Fleet's enema
Insert an indwelling catheter
Assess the abdomen for bowel sounds
66
Image >>
Visceral pericardium
Endocardium
Myocardium
Pericardium
67
Nurse is preparing a presentation about prevention colon cancer. Which info should be included
Take a multi vitamin daily
Do not engage in high risk sexual behaviors
Eat several servings of cruciferous vegetables daily
Wear a high filtration mask when around chemicals
68
Before administering Nitroglycerin, the nurse should inform the Pt about which potential AE?
Drowsiness or blurred vision
Tinnitus or diplopia
Nervousness or paresthesia
Throbbing H/A or dizziness
69
What aspect of pain would be most suggestive of angina as the cause?
Pain occurs immediately following physical exertion
Pain is worse when coughing
Pain is worse when inhaling deeply
Pain is most severe when moving upper body
70
Pt is scheduled for cardiac surgery. What should the nurse include in preop care?
With the Pt, clarify surg procedure that will be performed
Withhold pt's scheduled meds for at least 12 hrs
Avoid discussing pt's fears as not to exacerbate them
Inform Pt that health teaching will begin asap after surgery
71
Pt w/ renal insufficiency is on Heparin. How will pt's renal status affect Heparin therapy?
Heparin may be administered subQ, nut not IV
Coumadin will be substituted for Heparin
Heparin is contraind. in the Tx of this Pt
Lower doses of Heparin are required for this Pt
72
Client is taking to the ED w/ injury to L arm. Which should the nurse implement FIRST?
Prepare the client for the application of the cast
Call radiology for a STAT x-ray of the arm
Remove the client's clothing from the arm
Assess the nailbeds for cap refill time

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