Which client is most likely to have diverticulosis?

63 year old female w/ hemorrhoids

Which statement about care of a new colostomy indicates the need for further teaching?

Drink only liquids until the colostomy starts to work

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?

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

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 diagnostic data should be reported to the HCP IMMEDIATELY?

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

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

Assess the abdominal wound incision

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

Roast pork, white rice and plain custard

This is an accurate indicator of MI

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

What aspect of pain would be most suggestive of angina as the cause?

Pain occurs immediately following physical exertion

Nurse is preparing to admin. Warfarin for a client w/ DVT. Which lab value ind therap. level?

International normalized ratio (INR) between 2 and 3

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

Pain in the unaffected leg during dorsiflexion of the ankle

Which S/S indicates osteoporosis?

Client has lost 1 inch in height

It is done to assess how blocked/open pts coronary art. are

Client diagnosed w/ IBD prescribed TPN which intervention should the nurse implement.

Check the client's glucose level

Nurse is preparing a presentation about prevention colon cancer. Which info should be included

Eat several servings of cruciferous vegetables daily

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

Document the findings as normal

What is the relationship between BP and age?

Struct.+funct. changes in CV system contrib. to ↑ in BP

What assessment ? most directly addresses the possibility of worsening HPT?

Do you ever see spots in front of your eyes?

It prevents some blockages that can cause CP or MI

Pt w/ renal insufficiency is on Heparin. How will pt's renal status affect Heparin therapy?

Lower doses of Heparin are required for this Pt

What should the nurse implement FIRST for an 88-year old client is admitted w/ fractured pelvis

Assess the abdomen for bowel sounds

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

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

Client w/ iron def anemia is prescribed ferrous gluconate orally. Which should the nurse teach?

The stools may be very dark, and this can mask blood

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

My pain goes away when I have a bowel movement

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

I will irrigate my ileostomy every morning

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

Risk for complications R/T compromised neurovasc status

Pt is scheduled for cardiac surgery. What should the nurse include in preop care?

With the Pt, clarify surg procedure that will be performed

Which instruction should the nurse include when teaching the client about diverticulitis?

Explain the need to have daily bowel movements

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

The elderly patient just admitted and reporting constipation

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

Perfusion distal to the insertion site

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

Hard, rigid abdomen and WBC count 22,000

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

Cerebrovascular accident and retinal hemorrhage

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

Record frequency, amount, and color of stools

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H&I Final

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med surg cumulative final

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Questions 72

Answers

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

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