NCLEX Review (Peri-op, Endo, Renal, GI, Neuro)

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Hypothyroidism
S/S

Description: insufficient circulation of thyroid hormones resulting in a hypometabolic state.

S/S: fatigue, lethargy, personality and mental changes, mental dullness, decreased cardiac output, anemia, constipation, dry skin, cold intolerance, weight gain, menstrual problems- heavy menstruation

Hypothyroidism
Labs

History and PE
Thyroid function tests: elevated TSH, Low T3/T4
Thyroid scan
Radioactive Iodine Uptake test

Hypothyroidism
Nursing Interventions

LOOK AT S/S- then select appropriate action.
vital signs
warm environment
teach importance of lifelong Rx regiment

Hypothyroidism
Complications

Goiter
Decreased metabolic rate
Myxedema due to a deficiency of thyroid hormone (adult form)
--Myxedema Coma
Cretinism (infant form)
Atherosclerosis
Hyperthyroid (if too much Rx)
Hypoglycemia
Thyroiditis (Hashimoto's)

Hyperthyroidism
S/S

Weight loss with increased appetite
Exophthalmos (bulging eyes)
Heat intolerance
Menstrual problems- amenorrhea
Insomnia
hyperexcitable

Hyperthyroidism
Labs

...

Hyperthyroidism
Nursing Interventions

Vital signs including weight
Antithyroid meds
Thyroidectomy pt teaching
monitor for s/s of Thyroid Storm

Hyperthyroidism
Complications

Increased metabolic rate r/t increased circulating thyroid hormone
Thyroid Storm- may result in mania or heart failure

Common Preoperative Medications:

1) Benzodiazepines and barbiturates: for sedation and amnesia
2) Anticholinergics: to reduce secretions
3) Opioids: to decrease intraoperative anesthetic requirements and pain
4) Additional drugs include antiemetics, antibiotics, eye drops, and regular prescription drugs

Drug Use in Pre-Op setting:
Benzodiazepines and barbiturates

Drug used in pre-op setting for sedation and amnesia

Drug Use in Pre-Op setting:
Anticholinergics

Drug used in pre-op setting to reduce secretions.

Drug Use in Pre-Op setting:
Opioids

Drug used in pre-op setting to decrease intraoperative anesthetic requirements and pain.

Pre-Op patients should be screened for possible critical allergies?

Pre-Op pts should be screened for critical allergies:
Latex, Iodine, and allergies to anesthesia that may result in Malignant Hyperthermia.

In the surgical setting, where is the center of the sterile field?

The center of the sterile field is the site of the surgical incision.

Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks the nurse to get up to go to the bathroom to urinate. Which of the following is the most appropriate action for the nurse to take?

A.) Assist patient to bathroom and stay next to door to assist patient back to bed when done.
B. Allow patient to go to the bathroom since the onset of the medication will be more than 5 minutes.
C. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety.
D. Ask patient to hold the urine for a short period of time since a urinary catheter will be placed in the operating room.

C. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety.

The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance.

As the nurse is preparing a patient for surgery, the patient refuses to remove a wedding ring. Which of the following is the most appropriate action by the nurse?

A. Note the presence of the ring in the nurse's notes of the chart.
B. Insist the patient remove the ring.
C. Explain that the hospital will not be responsible for the ring.
D. Tape the ring securely to the finger.

C. Explain that the hospital will not be responsible for the ring.
It is customary policy to tape a patient's wedding band to the finger and make a notation on the preoperative checklist that the ring is taped in place.

While performing preoperative teaching, the patient asks when she needs to stop drinking water before the surgery. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, the nurse tells the patient that:

A. She must be NPO after breakfast.
B. She needs to be NPO after midnight.
C. She can drink clear liquids up to 2 hours before surgery.
D. She can drink clear liquids up until she is taken to the OR.

C. She can drink clear liquids up to 2 hours before surgery.
Practice guidelines for preoperative fasting state the minimum fasting period for clear liquids is 2 hours. Evidenced-based practice no longer supports the long-standing practice of requiring patients to be NPO after midnight.

The nurse is admitting a patient to the same day surgery unit. The patient tells the nurse that he was so nervous he had to take kava last evening to help him sleep. Which of the following nursing actions would be most appropriate?

A. Inform the anesthesiologist of the patient's ingestion of kava.
B. Tell the patient that using kava to help sleep was a good idea.
C. Tell the patient that the kava should continue to help him relax before surgery.
D. Inform the patient about the dangers of taking herbal medicines without consulting his health care provider.

A. Inform the anesthesiologist of the patient's ingestion of kava.
Kava may prolong the effects of certain anesthetics. Thus the anesthesiologist needs to be informed of recent ingestion of this herbal supplement.

The nurse would be alerted to the occurrence of malignant hyperthermia when the patient demonstrates:

A. Hypocapnia
B. Muscle rigidity
C. Decreased body temperature
D. Confusion upon arousal from anesthesia

B. Muscle rigidity
Malignant hyperthermia is a metabolic disease characterized by hyperthermia with rigidity of skeletal muscles occurring secondary to exposure to certain anesthetic agents in susceptible patients. Hypoxemia, hypercarbia, and dysrhythmias may also be seen with this disorder.

Before admitting a patient to the operating room, the nurse recognizes that which of the following must be attached to the chart of all patients?

A. A functional status evaluation
B. Renal and liver function tests
C. A physical examination report
D. An electrocardiogram

C. A physical examination report.
It is essential to have a physical examination report attached to the chart of a patient going for surgery. This document explains in detail the overall status of the patient for the surgeon and other members of the surgical team.

Which of the following nursing interventions should receive highest priority when a patient is admitted to the postanesthesia care unit?

A. Positioning the patient
B. Observing the operative site
C. Checking the postoperative orders
D. Receiving report from operating room personnel.

A. Positioning the patient.
A patient is received in the postanesthesia care unit on a bed or stretcher. Proper positioning is necessary to ensure airway patency in a sedated, unconscious, or semiconscious patient. Observation of the operative site, receiving report from operating room personnel, and checking postoperative orders are interventions made after proper positioning of the patient.

Which of the following may be left in place when a patient is sent to the operating room?

A. Wig
B. Hearing aid
C. Engagement ring
D. Well-fitting dentures

B. Hearing aid
If a patient is wearing a hearing aid, the perioperative nurse should be notified. Leaving the hearing aid in place enhances communication in the operating room. The nurse should make certain to record that the appliance is in place. Wigs, engagement rings, and dentures are not necessary items to facilitate quality patient care in the operating room.

In caring for a person receiving an opioid analgesic through an epidural catheter, the nursing responsibility of prime importance is

A. assessing for respiratory depression.
B. establishing a baseline laboratory profile.
C. inspecting the catheter insertion site hourly.
D. ensuring that the patient remains on strict bed rest.

A. assessing for respiratory depression.
Possible side effects of epidural opioids are pruritus, urinary retention, and delayed respiratory depression, occurring 4 to 12 hours after a dose. Establishing a baseline laboratory profile is outside the scope of practice for a nurse. Hourly inspection of the catheter insertion site is an unnecessary nursing intervention. In general, the site is assessed once a shift unless unexpected complications occur. Strict bed rest is not necessary for the patient with an epidural catheter; however, assistance with getting out of bed could be necessary related to effects of the opioid analgesic.

Which of the following is most appropriate after administration of preoperative medications?

A. Confirming that the patient has voided
B. Monitoring vital signs every 15 minutes
C. Placing the patient in bed with the rails up
D. Transporting the patient immediately to the operating room

C. Placing the patient in bed with the rails up.
After administration of preoperative medications, a nurse should instruct a patient not to get up without assistance because medications can cause drowsiness or dizziness. Confirming that the patient has recently voided should be done before preoperative medications are administered. Monitoring vital signs every 15 minutes is not a necessary intervention unless prescribed by the physician. Transporting the patient immediately to the operating room is not necessary unless the patient is called for.

Which of the following should be included in the plan of care for a patient who had spinal anesthesia?

A. Elevating the head of the bed to decrease nausea
B. Elevating the patient's feet to increase blood pressure
C. Instructing the patient to remain flat in bed for 6 hours
D. Administering oxygen to reduce hypoxia produced by spinal anesthesia

C. Instructing the patient to remain flat in bed for 6 hours.
In addition to interventions designed to replace fluids and indirectly replace lost spinal fluid after administration of spinal anesthesia, the patient is instructed to lie flat for 6 to 8 hours. Elevating the head of the bed after spinal anesthesia can precipitate "spinal headache" or nausea related to losses of cerebrospinal fluid or changes in ICP. Elevating the patient's feet or administering oxygen are not necessary interventions unless the patient becomes hypotensive or hypoxic.

A nurse has requested and gotten permission to observe a surgical procedure of interest in the hospital in which the nurse is employed. While the patient is being draped, the nurse notices that a break in sterile technique occurs. Which of the following actions on the nurse's part is most appropriate?

A. Tell the surgeon before an incision is made.
B. Tell the circulating nurse at the end of the surgery.
C. Say nothing because someone else is likely to notice also.
D. Point out the observation immediately to the personnel involved.

D. Point out the observation immediately to the personnel involved.
Any break in sterile technique in the operating room should be immediately pointed out and remedied.

In the operating room, a patient tells a circulating nurse that he is going to have the cataract in his left eye removed. If the nurse notes that the consent form indicates that surgery is to be performed on the right eye, what should be the nurse's first action?

A. Ask the patient his name.
B. Notify the surgeon and anesthesiologist.
C. Check to see whether the patient has received any preoperative medications.
D. Assume that the patient is a little confused because he is older and has received midazolam intramuscularly.

A. Ask the patient his name.
Ensuring proper identification of a patient is a responsibility of all members of the surgical team. In a specialty surgical setting where many patients undergo the same type of surgery each day, such as cataract removal, it is possible that the patient and the record do not match. Nurses do not assume in the care of their patients. The priority is with the nurse identifying the patient and the patient's consent form before the physicians are notified.

When administering low-molecular-weight heparin (LMWH) after an operation, a nurse should

A. explain that the drug will help prevent clot formation in the legs.
B. check the results of the partial thromboplastin time before administration.
C. administer the dose with meals to prevent GI irritation and bleeding.
D. inform the patient that blood will be drawn every 6 hours to monitor the prothrombin time.

A. explain that the drug will help prevent clot formation in the legs.
Unfractionated heparin or LMWH is given as a prophylactic measure for venous thrombosis and pulmonary embolism. These anticoagulants work by inhibiting thrombin-mediated conversion of fibrinogen to fibrin. LMWH is injected subcutaneously with no relationship to meals. It has a more predictable dose response and less risk of bleeding complications. It does not require anticoagulant monitoring and dosage adjustments.

A physician is performing a sterile procedure at a patient's bedside. Near the end of the procedure, the nurse thinks that the physician has contaminated a sterile glove and the sterile field. The nurse should

A. report the physician for violating surgical asepsis and endangering the patient.
B. not say anything, because the nurse is not sure that the gloves and field were contaminated.
C. ask the physician whether the contaminated glove and the sterile field have been contaminated.
D. point out the possible break in surgical asepsis and provide another set of sterile gloves and fresh sterile field.

D. point out the possible break in surgical asepsis and provide another set of sterile gloves and fresh sterile field.
It is the responsibility of the nurse to point out any possible break in surgical asepsis when others are unaware that they have contaminated the field. Reporting the physician is not indicated, nor does it protect the patient. Asking the physician may lead to infection if the physician is unaware of the break in technique that the nurse believes may have happened. Saying nothing does not protect the patient and is negligence on the part of the nurse.

Which of the following preoperative assessment findings should be reported to a surgeon for preoperative treatment?

A. Serum sodium level of 140 mEq/L
B. Serum potassium level of 3 mEq/L
C. Hb concentration of 13.5 mg/dl
D. Partial thromboplastin time of 25 seconds

B. Serum potassium level of 3 mEq/L.
Electrolyte imbalances increase operative risk. Preoperative laboratory results should be checked to see whether they are within the normal range. The normal potassium level is 3.5 to 5.0 mEq/L. A low serum potassium level puts the patient at risk for cardiac dysrhythmias. A serum sodium level of 140 mEq/L is considered a normal value. An Hb concentration of 13.5 mg/dl is considered a normal value by most laboratory standards and does not interfere with operative decisions. A partial thromboplastin time of 25 seconds is a normal value and conducive to proceeding with a surgical procedure.

Which of the following is most likely to be effective in meeting a patient's teaching/learning needs preoperatively?

A. Teaching only the patient
B. Teaching the patient and family
C. Using brief verbal instructions
D. Using only written instructions

B. Teaching the patient and family.
A nurse should determine learning needs preoperatively and teach both the patient and the family before surgery. Using only written instructions does not provide the opportunity for evaluation for learning. Brief verbal instructions are often forgotten. Teaching only the patient limits learning preoperatively because the patient can be anxious and not receptive to new information.

Which of the following preoperative assessment findings should be reported to a surgeon for preoperative treatment?

A. Excessive thirst
B. Gradual weight gain
C. Overwhelming fatigue
D. Recurrent blurred vision

A. Excessive thirst.
The classic clinical manifestations of diabetes mellitus are increased frequency of urination (polyuria); increased thirst and fluid intake (polydipsia); and as the disease progresses, weight loss despite increased hunger and food intake (polyphagia). Weakness, fatigue, and recurrent blurred vision are associated with diabetes mellitus but are not considered priority manifestations because of the generalization of these complaints being applied to other disease processes. Weight loss is the cardinal sign related to the depletion of water, glycogen, and triglyceride stores.

What would be the most effective way for a nurse to validate "informed consent"?

A. Ask the family whether the patient understands the procedure.
B. Check the chart for a completed and signed consent form.
C. Ask the patient what he or she understands regarding the procedure.
D. Determine from the physician what was discussed with the patient.

C. Ask the patient what he or she understands regarding the procedure.
Informed consent in the health care setting is a process whereby a patient is informed of the risks, benefits, and alternatives of a certain procedure, and then gives consent for it to be done. The piece of paper is simply evidence that the informed consent process has been done.

If a 77-year-old patient who is NPO after surgery has dry oral mucous membranes, which of the following is the most appropriate nursing intervention?

A. Increase oral fluid intake.
B. Perform oral hygiene frequently.
C. Swab the inside of the mouth with petroleum.
D. Increase the rate of IV fluid administration.

B. Perform oral hygiene frequently.
Frequent oral hygiene will help alleviate discomfort for a patient who is NPO. IV fluid rate is prescribed by the physician. Petroleum is always inappropriate intraorally. Oral fluid intake is contraindicated in a patient who is NPO.

While a nurse is caring for a patient who is scheduled to have surgery in 2 hours, the patient states, "My doctor was here and told me a lot of stuff I didn't understand and then I signed a paper for her." To fulfill the role of advocate, what is the best nursing action?

A. Reassure the patient that the surgery will go as planned.
B. Explain the surgery and possible outcomes to the patient.
C. Complete her first priority, the preoperative teaching plan.
D. Call the physician to return and clarify information for the patient.

D. Call the physician to return and clarify information for the patient.
Examples of nursing advocacy include questioning doctors' orders, promoting patient comfort, and supporting patient decisions regarding health care choices.

A patient is scheduled for a hemorrhoidectomy at an ambulatory day-surgery center. An advantage of performing surgery at an ambulatory center is a decreased need for

A. laboratory tests and perioperative medications.
B. preoperative and postoperative teaching by the nurse.
C. psychologic support to alleviate fears of pain and discomfort.
D. preoperative nursing assessment related to possible risks and complications.

A. laboratory tests and perioperative medications.
Ambulatory surgery is usually less expensive and more convenient, generally involving fewer laboratory tests, fewer preoperative and postoperative medications, less psychological stress, and less susceptibility to hospital-acquired infections. However, the nurse is still responsible for assessing, supporting, and teaching the patient undergoing surgery, regardless of where the surgery is performed.

A patient has the following preoperative medication order: morphine 10 mg with atropine 0.4 mg IM. The nurse informs the patient that this injection will

A. decrease nausea and vomiting during and after surgery.
B. decrease oral and respiratory secretions, thereby drying the mouth.
C. decrease anxiety and produce amnesia of the preoperative period.
D. induce sleep, so the patient will not be aware during transport to the operating room.

B. decrease oral and respiratory secretions, thereby drying the mouth.
Atropine, an anticholinergic medication, is frequently used preoperatively to decrease oral and respiratory secretions during surgery, and the addition of morphine will help to relieve discomfort during the preoperative procedures. Antiemetics decrease nausea and vomiting during and after surgery, and scopolamine and some benzodiazepines induce amnesia. An actual sleep state is rarely induced by preoperative medications unless an anesthetic agent is administered before the patient is transported to the operating room.

The primary goal of the circulating nurse during preparation of the operating room, transferring and positioning the patient, and assisting the anesthesia team is

A. avoiding any type of injury to the patient.
B. maintaining a clean environment for the patient.
C. providing for patient comfort and sense of well-being.
D. preventing breaks in aseptic technique by the sterile members of the team.

A. avoiding any type of injury to the patient.
The protection of the patient from injury in the operating room environment is maintained by the circulating nurse by ensuring functioning equipment, preventing falls and injury during transport and transfer, monitoring asepsis, and being with the patient during anesthesia induction.

Conscious sedation is being considered for a patient undergoing a cervical dilation and endometrial biopsy in the health care provider's office. The patient asks the nurse, "What is this conscious sedation?" The nurse's response is based on the knowledge that conscious sedation

A. can be administered only by anesthesiologists or nurse anesthetists.
B. enables the patient to respond to commands and accept painful procedures.
C. is so safe that it can be administered by nurses with direction from health care providers.
D. should never be used outside of the OR because of the risk of serious complications.

B. enables the patient to respond to commands and accept painful procedures.
Conscious sedation is a moderate sedation that allows the patient to manage his or her own airway and respond to commands, and yet the patient can emotionally and physically accept painful procedures. Drugs are used to provide analgesia, relieve anxiety and/or provide amnesia. It can be administered by personnel other than anesthesiologists, but nurses should be specially trained in the techniques of conscious sedation to carry out this procedure because of the high risk of complications resulting in clinical emergencies.

To prevent airway obstruction in the postoperative patient who is unconscious or semiconscious, the nurse

A. encourages deep breathing.
B. elevates the head of the bed.
C. administers oxygen per mask.
D. positions the patient in a side-lying position.

D. positions the patient in a side-lying position.
An unconscious or semiconscious patient should be placed in a lateral position to protect the airway from obstruction by the tongue. Deep breathing and elevation of the head of the bed are implemented to facilitate gas exchange when the patient is responsive. Oxygen administration is often used, but the patient must first have a patent airway.

In the absence of postoperative vomiting, GI suctioning, and wound drainage, the physiologic responses to the stress of surgery are most likely to cause

A. diuresis.
B. hyperkalemia.
C. fluid overload.
D. impaired blood coagulation.

C. fluid overload.
Secretion and release of aldosterone and cortisol from the adrenal gland and ADH from the posterior pituitary as a result of the stress response cause fluid retention during the first 2 to 5 days postoperatively, and fluid overload is possible during this time. Aldosterone causes renal potassium loss with possible hypokalemia, and blood coagulation is enhanced by cortisol.

Select all that apply.
Which of the following best describes a consent form?

A. May be signed by an emancipated minor.
B. Protects the health care facility but not the physician
C. Signifies that the patient understands all aspects of the procedure.
D. Signifies that the patient and family have been told about the procedure
E. Must be signed by the patient or responsible party at the health care facility, and that consent may not be obtained by phone or fax

A. May be signed by an emancipated minor. (&)
C. Signifies that the patient understands all aspects of the procedure.
A consent form may be signed by an emancipated minor, and consent may be obtained by fax or phone with appropriate witnesses. Only in the cases of underage children or unconscious or mentally incompetent people must a family member be aware of the procedure. The document protects the surgeon and the health care facility in that it indicates that the patient knows and understands all aspects of the procedure.

Select all that apply.
Advantages of laser surgery include diminished

A. bleeding.
B. swelling.
C. tissue damage.
D. postoperative pain.
E. postoperative infection.

A, B, C, D, & E
(All of the above)
Laser surgery offers the benefits of diminished bleeding, swelling, tissue damage, and postoperative pain and infection.

Select all that apply.
A nurse is caring for a surgical patient in the preoperative area. The nurse obtains the patient's informed consent for the surgical procedure. Which statements are true regarding informed consent?

A. Informed consent must be signed while the patient is free from mind-altering medications.
B. Informed consent must be witnessed.
C. Informed consent may be withdrawn at any time.
D. Informed consent must be signed by patients age 16 and older.
E. Informed consent must be obtained by the physician.
F. Informed consent must be obtained from the family even in a life-threatening emergency.

A. Informed consent must be signed while the patient is free from mind-altering medications.
B. Informed consent must be witnessed.

An informed consent must be signed while the patient is free from mind-altering medications and must be witnessed after it has been determined that the patient has received all of the necessary information needed to make an informed decision. An informed consent may be withdrawn at any time before the procedure and must be signed by patients age 18 and older. A parent or guardian's signature is required for minors. The informed consent may be obtained by the physician or the nurse and is not required in the event of a life-threatening emergency.

Select all that apply.
A nurse is caring for patients on a medical-surgical unit. The nurse plans the patients' care and instructs the nursing assistant to assist in repositioning patients every 2 hours. Which patients are at the greatest risk for complications if not repositioned properly?

A. A 20-year-old unconscious patient
B. A 90-year-old frail patient
C. A 65-year-old patient who is visually impaired
D. A 40-year-old patient who has paraplegia

A. A 20-year-old unconscious patient
B. A 90-year-old frail patient (&)
D. A 40-year-old patient who has paraplegia

Patients who are at the greatest risk for complications if not properly repositioned are those who are unconscious, frail, or paralyzed.

What are some common Nursing Interventions to reduce risk/avoid post-op complications?

1. Turn & reposition the pt to promote circulation and reduce the risk of skin breakdown, especially over boney prominences.
Initially position pt in a Lateral recumbant position until arousal from anesthesia, then position pt in Semi or Fowler position to reduce breathing effort.
2. Encourage coughing & deep breathing.
This helps clear anestetics from the body, lowers risk of pulmonary/fat emboli, and hypostatic pneumonia associated with secretion buildup in the airways.
3. Encourage use of Incentive Spirometer.
4. Monitor In's and Out's.
Hydration and protein rich nutrition promotes healing and provides energy to meet the needs of the pts increased metabolism associated with surgery.
5. Promote early ambulation.
Early post-op exercise and ambulation significantly reduce the risk of thromboembolism.

Definition:
Atelectasis

Respiratory complication when the alveoli within the lung becomes deflated, resulting in a complete or partial collapse of a lung.

Common causes/ risk factors:
Atelectasis

Respiratory complication that may be the result of a blocked airway, diminished surfactant, or mucus plug.
Recent general anesthesia, shallow breathing, respiratory muscle weakness and immobility are common risk factors.

The reason pts are sent to a PACU after surgery is:

A. to be monitored while recovering from anesthesia.
B. to remain near the surgeon immediately after surgery.
C. to allow the medical-surgical unit time to prepare for transfer.
D. to provide time for the pt to cope with the effects of surgery.

A.
Pts are sent to a PACU to be monitored while they're recovering from anesthesia.

Which statement should be stressed while giving instructions after adrenalectomy?

A. Stop taking medication when pts physical appearance improves.
B. Pt should take steroids on an empty stomach.
C. Pt should take the prescribed medication as directed.

C.
The pt should take prescribed medication as directed. Sudden withdrawl of steroids can precipitate adrenal crisis.

An adrenal crisis is characterized by all of the signs and symptoms except:

A. weakness and fatigue
B. nausea & vomiting
C. hypotension
D. sodium & fluid retention

D.
Sodium and fluid retention are characteristics of Cushing's Syndrome.
Adrenal crisis causes decreased sodium levels and hypotension.

Which statement about diabetes mellitus is false?

A. Type 2 diabetes commonly occurs in adults <40 yr. old.
B. Type 1 diabetes usually occurs before age 30.
C. Type 1 diabetes is treatable with exercise, meal planning, and antidiabetic drugs.
D. An increasing number of adolescents are being diagnosed with type 2 diabetes.

C.
Type 1 diabetes is treated with insulin and dietary management.

Patients may experience which problem 24-48 hrs post-op as a result of anesthetics?

A. colitis
B. Stomatitis
C. Paralytic ileus
D. Gastrocolic reflux

C.
After surgery, pts are clients are at risk for paralytic ileus as a result of anesthesia.

What are some common RN interventions to prevent/ minimize paralytic ileus?

The nurse can prevent/minimize paralytic ileus after surgery with pt positioning and early ambulation.
Evidence of bowel function returning to normal includes auscultation of bowel sounds and passing of flatus and stool.

A pt has returned from surgery with a tracheostomy tube in place. After about 10 minutes in postoperative recovery, the pt begins to have noisy, increased respirations and an elevated heart rate. What action should the RN take immediately?

A. Suction the tracheostomy.
B. Readjust the tracheostomy tube and tighten the ties.
C. Preform a complete respiratory assessment.

A.
Noisy, increased respiration & increased pulse are signs that the pt needs immediate suctioning to clear the airway of secretions. A complete respiratory assessment may then be completed.

A nurse is assessing a pt with a closed chest tube drainage system connected to suction. Which finding would require additional evaluation in the post-operative period?

A. 75ml of bright red drainage in the system.
B. A column of water 20cm high in the suction control chamber.
C. Constant bubbling in the water seal chamber.

D.
Constant bubbling in the water seal chamber is indicative of an air leak. The nurse should assess the entire system to the pt to find the sourse of he leak. The leak may be with in the pts chest or at the insertion site. If it is, notify physician. This could cause the lung to collapse due to a buildup of air pressure within the plural cavity.

A pediatric nurse is preparing a child for cleft palate repair surgery. The nurse recognizes that this type of surgery is categorized as:

A. Transplantation surgery
B. Constructive surgery
C. Palliative surgery
D. Reconstructive surgery

B) Cleft palate repair considered constructive surgery because the goal is to restore function in congenital anomalies. Reconstructive surgery serves to restore function to traumatized or malfunctioning tissues and includes plastic surgery or skin grafting. Transplant surgery replaces organs or structures that are diseased or malfunctioning, such as a liver or kidney transplant. Palliative surgery is not a curative and seeks to relieve or reduce the intensity of an illness, such as debridement or necrotic tissue.

Upon assessment, a patient reports that he drinks 5-6 bottles of beer every evening after work. Based upon this information, the nurse is aware that the patient may require:

A. Larger doses of anesthetic agents and larger doses of postoperative analgesics.
B. Larger doses of anesthetic agents and lower doses of postoperative analgesics.
C. Lower doses of anesthetic agents and larger doses of postoperative analgesics.
D. Lower doses of anesthetics agents and lower doses of postoperative analgesics.

A) Patients with a larger habitual intake of alcohol require larger doses of anesthetic agents and postoperative analgesics, increasing the risk for drug-related complications.

The nurse is providing teaching to a patient regarding pain control after surgery. The nurse informs the patient that the best time to request pain medication is:

A. Before the pain becomes severe.
B. When the patient experiences a pain rating of 10 on a 1-to-10 pain scale.
C. After the pain becomes severe and relaxation techniques have failed.
D. When there is no pain, but it is time for the medication to be administered.

A) The question states that the patient is being instructed on when to "request" pain medication. If a pain medication is ordered PRN, the patient should be instructed to ask for the medication before the pain becomes severe.

The nurse is preparing to send a patient to the operating room for an exploratory laparoscopy. The nurse recognizes that there is no informed consent for the procedure on the patient's chart. The nurse informs the physician who is performing the procedure. The physician asks the nurse to obtain the informed consent signature from the patient. The nurse's best action to the physician's request is to:

A. Inform the physician that is his responsibility to obtain the signature.
B. Obtain the signature and ask another nurse to co-sign the signature.
C. Inform the physician that the nurse manager will need to obtain the signature.

A) The responsibility for securing informed consent from the patient lies with the person who will perform the procedure. The nurse's best action is to inform the physician that it is his responsibility to obtain the signature.

The PACU has received a semiconscious patient from the operating room and reviews the chart for orders related to positioning of the patient. There are no specific orders on the chart related to specific orders for the patient's position. In this situation, in what position will the nurse place the patient?

A. Trendelenburg position
B. Prone position
C. Side-lying position
D. Supine position

C) If the patient is not fully conscious, place the patient in the side-lying position, unless there is an ordered position on the patient's chart.

The nurse is preparing a patient for a colonoscopy. The nurse is familiar with the colonoscopy procedures at the hospital and is aware that which type of anesthesia os commonly used for his procedure?

A. Spinal anesthesia
B. Nerve block
C. Conscious sedation
D. Epidural anesthesia

C) Moderate sedation/analgesia is also known as conscious sedation or procedural sedation and is used for short-term and minimally invasive procedures such as a colonoscopy.

The telemetry unit nurse is reviewing laboratory results for a patient who is scheduled for an operative procedure later in the day. The nurse notes on the laboratory report that the patient has a serum potassium level of 6.5 mEq/L, indicative of hyperkalemia. The nurse informs the physician of this laboratory result because the nurse recognizes hyperkalemia increases the patient's operative risk for:

A. Cardiac problems
B. Bleeding with anemia
C. Fluid imbalances
D. Infection

A) Hyper/hypokalemia increases the patient's risk for cardiac problems. A decrease in the hematocrit and hemoglobin level may indicate the presence of anemia or bleeding. An elevated WBC occurs in the presence of infection. Abnormal urine constituents may indicate infection or fluid imbalances.

Upon admission for an appendectomy, the patient provides the nurse with a document that specifies instructions his healthcare team should follow in the event he is unable to communicate these wishes postoperatively. This document is best known as:

A. An informed consent
B. An insurance card
C. A Patient's Bill of Rights
D. An advance directive

D) An advance directive, a legal document, allows the patient to specify instructions for his or her healthcare treatment should he or she be unable to communicate these wishes postoperatively. The advance directive allows the patient to discuss his or her wishes with the family members in advance of the surgery. Two common forms of advance directives include living wills and durable powers of attorney for healthcare.

A patient returning to the floor after orthopedic surgery is complaining of nausea. The nurse is aware that an appropriate intervention is to:

A. Hold all medications.
B. Avoid strong smelling foods.
C. Avoid oral hygiene until the nausea subsides.
D. Provide clear liquids with a straw.

B)Nursing care for a patient with nausea includes avoiding strong smelling foods. Providing oral hygiene, administering prescribed medications (especially if medications ordered are anti-nausea/antiemetics), and avoid the use of a straw.

The operating room is aware that which of the following patients are at a greater risk related to a surgical procedure?

A. 34 yr old female
B. 83 yr old female
C. 48 yr old male
D. 8 yr old male

B)Infants and older adults are at greatest risk from surgery than are children and young or middle-aged adults. Physiologic changes associated with aging increase the surgical risk for older patients.

A client who is started on metformin and glyburide would have initially present with with symptoms?

A. Polydipsia, polyuria, and weight loss
B. Weight gain, tiredness, and bradycardia
C. irritability, diaphoresis and tachycardia
D. Diarrhea, abdominal pain and weight loss

A) symptoms of hyperglycemia included polydispia, polyuria, and weightloss. Metformin and sulfonylureas are commonly ordered medications. Weight gain, tiredness, and bradycardia are symptoms of hypothyroidism. Irritability, diaphoresis, and tachycardia are symptoms of hypoglycemia. Symptoms of Crohn's disease include diarrhea, abdominal pain, and weight loss.

A client admitted for acute pyelonephritis is about to start antibiotic therapy. Which symptom would be expected in this client?
1) Hypertension
2) Flank pain on the affected side
3) Pain that radiates toward the unaffected side
4) No tenderness with deep palpation over the
CVA

RATIONAL: 2) The client may complain of pain on the affected side because the kidney is enlarged and might have formed an abscess.
Hypertension is associated with chronic pyelonephritis. Pain may radiate down the ureters or to the epigastrium. The client would have tenderness with deep palpation over the CVA.

Discharge instructions for a client treated for acute pyelonephritis should include which statement?
- 1. Avoid taking any dairy products.
- 2. Return for follow-up urine cultures.
- 3. Stop taking the prescribed antibiotics when the symptoms subside.
- 4. Recurrence is unlikely because you&#039;ve been treated with antibiotics.

RATIONALE: 2) The client needs to return for follow-up urine cultures because bacteriuria may be present but asymptomatic. Intake of dairy products won't contribute to pyelonephritis. Antibiotics need to be taken for the full course of therapy regardless of the symptoms. Pyelonephritis typically recurs as a relapse or new infection and frequently recurs within 2 weeks of completing therapy.

A client is complaining of severe flank and abdominal pain. A flat plate of the abdomen shows urolithiasis. Which intervention is important?
- 1. Strain all urine
- 2. Limit fluid intake
- 3. Enforce strict bed rest.
- 4. Encourage a high-calcium diet

RATIONALE: 1) Urine should be strained for calculi and sent to the laboratory for analysis. Fluid intake of 3 to 4 qt. 3 to 4 L/day is encouraged to flush the urinary tract and prevent further calculi formation. Ambulation is encouraged to help pass the calculi through gravity. A low-calcium formation of calcium calculi.

A client is diagnosed with cystitis. Client teaching aimed at preventing a recurrence should include which instruction?
- 1. Bathe in a tub.
- 2. Wear cotton underwear.
- 3. Use a feminine hygiene spray.
- 4. Limit your intake of cranberry juice.

RATIONALE: 2) Cotton underwear prevents infection because it allows for air to flow to the perineum. Women should shower instead of taking a tub bath to prevent infection. Feminine hygiene spray can act as an irritant. Cranberry juice helps prevent cystitis because it increases urine acidity; alkaline urine supports bacterial growth, so cranberry juice intake should be increased, not limited.

When performing a physical assessment, the nurse discovers a client&#039;s urinary drainage bag lying next to him. Based on this finding, the nurse identifies which priority nursing diagnosis?
- 1. Risk for infection
- 2. Reflex urinary incontinence
- 3. Impaired comfort
- 4. Risk for compromised human dignity

RATIONALE: 1) The drainage bag shouldn't be placed alongside the client or on the floor because of the increased risk of infection caused by microorganisms. It should hang on the bed in a dependent position. The other nursing diagnoses are not appropriate for this assessment finding.

Which method should be used to collect a specimen for urine culture?
- 1. Have the client void in a clean container.
- 2. Clean the foreskin of the penis of uncircumcised men before specimen collection.
- 3. Have the client void into a urinal, and then pour the urine into the specimen container.
- 4. Have the client begin the stream of urine in the toilet and catch the urine in a sterile container midstream.

RATIONALE: 4) Catching urine midstream reduces the amount of contamination by microorganisms at the meatus. Voiding in a clean container is done for a random specimen, not a clean-catch specimen for urine culture. When cleaning an uncircumcised male, the foreskin should be retracted and the glands penis should be cleaned to prevent specimen contamination. Voiding in a specimen because the urinal isn't sterile.

A client with renal insufficiency is admitted with a diagnosis of pneumonia. He&#039;s being treated with IV antibiotics, which can be nephrotoxic. Which laboratory value(s) should be monitored closely?
- 1. Blood Urea Nitrogen (BUN) and creatinine levels.
- 2. Arterial Blood Gas (ABG) levels
- 3. Platelet count
- 4. Potassium level

RATIONALE: 1) BUN and creatinine levels should be monitored closely to detect elevations due to nephrotoxicity. ABG determinations are inappropriate for this situation. Platelets and potassium levels should be monitored according to routine.

During a health history, which statement by a client indicates a risk of renal calculi?
- 1. &quot;I&#039;ve been drinking a lot of cola soft drinks lately.&quot;
- 2. &quot;I&#039;ve been jogging more than usual.&quot;
- 3. &quot;I&#039;ve had more stress since we adopted a child last year.&quot;
- 4. &quot;I&#039;m a vegetarian and eat cheese two or three times each day.&quot;

RATIONALE: 4) Renal calculi are commonly composed of calcium. Diets high in calcium may predispose a person to renal calculi. Milk and milk products are high in calcium. Cola soft drinks don't contain ingredients that would increase the risk of renal calculi. Jogging and increased stress aren't considered risk factors for renal calculi formation.

The nurse is assessing a client who reports painful urination during and after voiding. The nurse suspects the client may have a problem with which area of the client&#039;s urinary system?
- 1. Bladder
- 2. Kidneys
- 3. Ureters
- 4. Urethra

RATIONALE: 1) Pain during or after voiding indicates a bladder problems, usually infection. Kidney and ureter pain would be in the flank area, and problems or the urethra would cause pain at the external orifice that's commonly felt at the start of voiding.

A nurse is instructing a client with oxalate renal calculi. What foods should the nurse urge the client to eliminate from his diet?
1) Citrus fruits, molasses, and dried apricots
2) Milk, cheese, and ice cream
3) Sardines, liver and kidney
4) Spinach rhubarb and asparagus

RATIONALE: 4) To reduce the formation of oxalate calculi, urge the client to avoid foods high in oxalate, such as spinach, rhubarb, and asparagus. Other oxalate- rich foods to avoid include tomatoes, beets, chocolate, cocoa, celery, and parsley.
Citrus fruits, molasses, dried apricots, milk, cheese, ice cream, sardines and organ meats do NOT produce oxalate and do NOT need to be omitted from the client's diet.

A nurse is assessing a client diagnosed with acute pyelonephritis. Which of the following symptoms does the nurse expect to see?
1) Jaundice and flank pain
2) Costovertebral angle tenderness and chills
3) Burning sensation on urination
4) Polyuria and nocturia

RATIONALE: 2) Costovertebral angle tenderness and chills are symptoms of acute pyelonephritis (inflammation of the kidney and renal pelvis).
Jaundice indicates gallbladder or liver obstruction.
A burning sensation on urination is a sign of lower urinary tract infection (UTI).
Nocturia is associated with a lower UTI or benign prostatic hyperplasia.
Polyuria is seen with diabetes mellitus, diabetes insipidus, or the use of diuretics.

A nurse is caring for a client who has undergone surgery to create an ileal conduit. Which expected outcome statement is appropriate for this client?
1) The client uses sterile gloves when changing the appliance.
2) The client demonstrates the ability to irrigate the stoma correctly.
3) The client expresses understanding and acceptance of the fact that he can no longer engage in sexual relations.
4) The stoma remains pink and moist.

RATIONALE: 4) A healthy stoma is pink and moist.
Sterile gloves aren't necessary when changing the appliance.
The stoma isn't to be irrigated.
There's no physiologic reason why the client can't engage in sexual relations.

A client is admitted with dark urine, fever, and flank pain and is diagnosed with acute glomerulonephritis. What finding is the nurse most likely to find in the client's history?
1) Renal calculi
2) Renal trauma
3) Recent sore throat
4) Family history of acute glomerulonephritis

RATIONALE: 3) Recent sore throat. Typically, acute glomerulonephritis occurs 2 to 3 weeks after a strep throat infection. The Most Common form of acute glomerulonephritis is caused by group A beta-hemolytic streptococcal infection elsewhere in the body.
Renal calculi and renal trauma aren't known to cause acute glomerulonephritis.
A family history isn't associated with the development of acute glomerulonephritis.

A nurse is assessing a client who might have a UTI. What statement by the client suggests that a UTI is likely?
1) I urinate large amounts.
2) It burns when I urinate.
3) I go for hours without the urge to urinate.
4) My urine has a sweet smell.

RATIONALE: 2) Dysuria (painful urination) is a common symptom of a UTI.
Voiding large amounts of urine isn't associated with UTI's; clients with UTI's commonly report frequent voiding of small amounts of urine.
A client with a UTI is unlikely to be able to go for hours without urinating because UTI's increase feelings of urgency to void.
Urine with a sweet acetone odor is associated with diabetic ketoacidosis.
Foul-smelling urine may be a sign of infection.

While undergoing hemodialysis, a client complains of muscle cramps. What intervention is effective in relieving muscle cramps?
1) Encourage active ROM exercises.
2) Administer a 5% dextrose solution.
3) Infuse normal saline solution.
4) Increase the rate of dialysis.

RATIONALE: 3) Because muscle cramps can occur when sodium and water are removed too quickly during dialysis, treatment includes administering normal saline or hypertonic normal saline solution.
ROM exercises and an infusion of 5% dextrose solution wouldn't reduce muscle cramps.
Reducing, not increasing, the rate of dialysis may also alleviate muscle cramps.

A nurse is instructing a client how to obtain an accurate clean-catch urine specimen for a urine culture. She should include what instruction?
1) Clean the perineal area well.
2) Wash the inside of the container.
3) Void to fill the container.
4) Leave the container open to the air.

RATIONALE: 1) when obtaining a clean-catch urine specimen, the perineal area should be thoroughly cleaned.
The inside of the container is already sterile, so washing it would only contaminate it.
Only a small specimen of urine is needed, so it isn't necessary to completely fill the container.
The container should be closed as soon as the urine is collected to prevent contamination

Which client is at greatest risk for developing a UTI?
1) A 35 year old woman with an arm fracture.
2) An 18 year old woman asthma.
3) A 50 year old postmenopausal woman.
4) A 28 year old woman with angina.

RATIONALE: 3) Women are more prone to UTI's after menopause. Urinary stasis may develop due to a loss of pelvic muscle tone and prolapse of the bladder or uterus. Reduced estrogen levels lead to reduced levels of vaginal Lactobacilli bacteria, which protect against infection.
While chronic diseases, including diabetes mellitus and impaired immunity, increase the risk of UTI, angina, asthma, and fractures don't increase the risk of UTI.

A client is hospitalized and diagnosed with acute hydronephrosis. Which complaint does the nurse expect from this client?
1) Sudden onset of acute, colicky pain
2) Sharp left flank pain
3) Sharp, throbbing pain
4) Felling of pressure and distention

RATIONALE: 1) Sudden, acute colicky pain is a clinical sign of acute hydronephrosis. Hydronephrosis occurs when urine collects in the renal pelvis and calyces due to obstruction or atrophy of the urinary tract.
Flank pain most commonly indicates a kidney infection, although it may occur hydronephrosis.
Distention and pressure are commonly felt in the pelvis and bladder with lower urinary tract obstructions.

A nurse is instructing a client with renal calculi about recommended daily fluid consumption. The nurse would be most helpful by telling the client to drink approximately:
1) 4 cups per day
2) 8 cups per day
3) 12 cups per day
4) 16 cups per day

RATIONALE: 3) A client with renal calculi should drink 3L (12 cups) of fluid per day.

A nurse is caring for a client after a renal biopsy. The nurse observes the client for:
1) Increased activity
2) Bleeding
3) Changes in mental status
4) Increased blood pressure

RATIONALE: 2) A renal biopsy is obtained through needle insertion into the lower lobe of the kidney, which can need to hemorrhage, so the nurse needs to watch for signs and symptoms of bleeding.
After the procedure, the client should remain still for 4 to 12 hours.
Changes in mental status (unless the client is bleeding heavily) or blood pressure aren't related to renal biopsy.

A nurse is writing the teaching plan for a client with cystitis who's receiving phenazopyridine (Pyridium). What instruction should the nurse include?

1) Call the physician if urine turns orange-red
2) Take phenazopyridine just before urination to relieve pain
3) Discontinue prescribed antibiotics after painful urination is relieved
4) Stop taking phenazopyridine after painful urination is relieved.

RATIONALE: 4) Phenazopyridine is taken to relieve dysuria because it provides an analgesic and anesthetic effect on the urinary tract mucosa. The client can stop taking it after the dysuria is relieved.
Warn the client that the dye in the drug (azo dye) may temporarily turn the urine red or orange but that isn't cause for calling the physician.
Phenazopyridine is usually taken three times per day for 2 days. It isn't taken just before voiding.
Antibiotics must be taken for the full course of therapy, even if the burning on urination is relieved.

A nurse is teaching a female client how to prevent the recurrence of urinary tract infection. The nurse should teach her to do which action?

1) Wipe from back to front after urination or a bowel movement.
2) Urinate every 2 to 3 hours.
3) Drink at least 8 oz (236.6ml) of fluid each day.
4) Take daily bubble baths.

RATIONALE: 2) The nurse should instruct the client to void every 2 to 3 hours to flush bacteria from the urethra and prevent urinary stasis in the bladder.
Wiping from front to back (Not back to front) after a bowel movement or urination moves bacteria away from the urethral meatus.
Drink 2 to 3 quarts (2 to 3L) of fluid per day helps flush bacteria out of the urinary tract.
The nurse should tell the client to avoid bubble baths because they can irritate the urethra, increasing the risk of inflammation and infection.

A nurse is caring for a client with chronic renal failure. The laboratory results indicate hypocalcemia and hyperphosphatemia. When assessing the client, the nurse should be alert for which of the following? SELECT ALL THAT APPLY.

1) Trousseau's sign
2) Cardiac arrhythmia
3) Constipation
4) Decreased clotting time
5) Drowsiness and lethargy
6) Fractures

RATIONALE: 1, 2, 6.
Hypocalcemia is a calcium deficit that causes irritability and repetitive muscle spasms.
S/S of hypocalcemia include Trousseau's sign, cardiac arrhythmias, diarrhea, increased clotting times, anxiety, and irritability.
The calcium-phosphorus imbalance leads to brittle bones and pathologic fractures.

A nurse is teaching a male client how to collect a clean-catch midstream urine specimen. What cleaning technique should the nurse include in her teaching?

1) Clean in a circular motion, starting at the urethral meatus and moving several inches down the shaft of the penis.
2) Clean in circular patterns, starting several inches down the penis and moving up toward the tip of the penis.
3) Scrub back and forth across the urethral meatus and down the shaft of the penis.
4) Wipe in rows starting at the urethral meatus and moving down the shaft of the penis.

RATIONALE: 1) before collecting a clean-catch urine specimen, a male client should clean around the urethral meatus in a circular motion and move several inches down the shaft of the penis.
When the penis is cleaned from down the shaft to up toward the urethral meatus, organisms from the skin of the penis are dragged toward the meatus.
Scrubbing back and forth repeatedly moves organisms across the urethral meatus, not away from it.
Some areas of the skin around the tip of the penis may be missed when cleaning is done in rows.

A client is receiving peritoneal dialysis. What should the nurse do when the return fluid is slow to drain?

1) Check for kinks in the outflow tubing
2) Raise the drainage bag above the level of the abdomen
3) Place the client in a reverse Trendelenburg position
4) Ask the client to cough

RATIONALE: 1) Tubing problems are common cause of outflow difficulties. When the return fluid is slow to drain, check the tubing for kinks and ensure all clamps are open.
Other measures that may improve drainage include having the client change positions (moving side to side or sitting up in bed), applying gentle pressure over the abdomen, or having a bowel movement.
Placing the drainage bag lower (not higher) than the abdomen may also improve drainage.
Placing the client in reverse Trendelenburg position wouldn't help drainage and could impair respirations.
Coughing doesn't affect drainage time.

After a retropubic prostatectomy, a client needs continuous bladder irrigation. The client has an I.V. of D5W infusing at 40ml/hr and a triple lumen urinary catheter with normal saline solution infusing at 200,l/hr. A nurse empties the urinary catheter drainage bag 3 times during an 8 hr period, for a total of 2780ml. How many milliliters does the nurse calculate as urine? Round to the nearest whole number. ________ ml

RATIONALE: During 8 hrs, 1600ml of bladder irrigation has been infused (200ml x 8hrs = 1600ml/8hrs).
The nurse then subtracts this amount of infused bladder irrigation from the total volume in the drainage bag (2780ml - 1600ml = 1180ml) to determine urine output.

A nurse is caring for a client in the immediate postoperative period after a prostatectomy.
What complication requires priority assessment?

1) Pneumonia
2) Hemorrhage
3) Urine retention
4) Deep vein thrombosis

RATIONALE: 2) Immediately after a prostatectomy, , hemorrhage is a potential complication.
Pneumonia may occur if the client doesn't turn, cough, and breathe deeply after surgery.
Urine retention isn't a problem immediately after surgery because a catheter is in place.
Thrombosis may occur later if the client doesn't ambulate.

A client is scheduled to undergo a transurethral prostatectomy (TURP) under spinal anesthesia. During the preoperative teaching, the nurse explains to the client that as a result of spinal anesthesia he'll:

1) Be unable to move his arms immediately after surgery
2) Require analgesics to relieve pain in his back
3) Be unable to move his legs immediately after surgery
4) Require a special machine to help him breathe after surgery

RATIONALE: 3) a client who had anesthesia can't move extremities below the level of the anesthesia. This client wouldn't be able to move his legs but could move his arms.
Back pain isn't necessarily caused by spinal anesthesia.
He wouldn't have difficulty breathing.

While undergoing hemodialysis, a client becomes restless and tells a nurse that he has a headache and feels nauseous. Which complication does the nurse suspect?

1) Infection
2) Disequilibrium syndrome
3) Air embolus
4) Acute hemolysis

RATIONALE: 2) Disequilibrium syndrome is caused by a rapid reduction in urea, sodium, and other solutes from the blood. This may lead to cerebral edema and increased intracranial pressure (IICP).
S/S of ICCP include HA, nausea, and restlessness as well as vomiting, confusion, twitching, and seizures.
Fever and elevated WBC may indicate infection.
Popping or ringing in the ears, chest pain, dizziness, or coughing suggests an air embolus.
Chest pain, dyspnea, burning at the access site and cramping suggests acute hemolysis.

A nurse is caring for a client with end stage renal disease. Which nursing diagnosis has priority?

1) Activity intolerance
2) Excess fluid volume
3) Deficient knowledge
4) Chronic pain

RATIONALE: 2) Excess Fluid Volume is a top priority nursing diagnosis for a client with end stage renal disease because the kidney can no longer remove fluid and wastes. The other diagnoses may also apply, but they don't take priority.

A nurse is caring for a client with renal calculi. Which drug does the nurse expect the physician to order?

1) Opioids analgesics
2) Nonsteroidal anti-inflammatory drugs
3) Muscle relaxants
4) Salicylates

RATIONALE: 1) Opioid analgesics are usually needed to relieve the severe pain of renal calculi.
NSAIDs and Salicylates are used for their anti-inflammatory and antipyretic properties and to treat less severe pain.
Muscle relaxants are typically used to treat skeletal muscle spasms.

A client admitted with renal failure is in the oliguric phase. A nurse expects the client's 24-hr urine output to be less than what amount?

1) 200ml
2) 400ml
3) 800ml
4) 1,000ml

RATIONALE: Oliguria is defined as a diminished urine output of less than 400ml/24hrs

A client in acute renal failure becomes severely anemic and the physician prescribes 2 units of packed red blood cells. A nurse should plan to administer each unit:

1) As quickly as the client can tolerate the infusion
2) Over 30minutes to an hour
3) Between 1 and 3 hours
4) Up to 6 hours, but no longer

RATIONALE: Infusing a unit of RBCs over 1 to 3 hours is standard practice.

A nurse is teaching a client how to collect a clean catch midstream urine specimen for culture and sensitivity testing. What instructions should a nurse include?

1) Collect the first 30ml of urine voided on rising in the morning
2) Discard the first void urine; collect for the next 24hrs
3) Collect a specimen after discarding the first 30ml of urine
4) Collect all urine voided until the bladder is empty

RATIONALE: 3) To collect a clean catch midstream urine specimen; tell the client to void 30ml, stop, and then begin collecting the urine in a sterile urine container. After the sterile container is removed, the client should then finish voiding rest of the urine in the bladder.
Discarding the first 30ml of urine flushes away microorganisms that may be around the urinary meatus and distal portions of the urethra.
Collecting the first 30ml of urine voided on rising in the morning results in a contaminated specimen.
Urine isn't collected for 24hrs for a clean-catch specimen.
The first and last voided urine are discarded in a clean catch specimen.

A client with chronic renal failure is undergoing peritoneal dialysis. A nurse knows that the proper infusion time for the dialysate is:

1) 15 min
2) 30min
3) 1hr
4) 2hrs

RATIONALE: 1) Dialysate should be infused quickly. When performing dialysis, the dialysate should be infused over 15 minutes or less. The fluid then dwells in the peritoneum, whre the exchange of fluid and waste products takes place over a period ranging from 30min to several hours.

A client with hiatal hernia reports to the nurse that he has trouble sleeping because of abdominal pain. The nurse should instruct the client to sleep:

1) With his upper body elevated
2) In a prone position
3) Flat or in a side lying position
4) With his lower body slightly elevated

RATIONALE: 1) Upper body elevation can reduce the gastric reflux associated with hiatal hernia.
Sleeping in a prone or side lying position, or with his lower body slightly elevated, won't help the client.

A nurse is caring for a client with hepatic encephalopathy. The nurse expects which of the following lab values to be abnormal?

1) Ammonia
2) Amylase
3) Calcium
4) Potassium

RATIONALE: 1) Hepatic encephalopathy is a degenerative disease of the brain caused by advanced liver disease. It develops because of increasing blood ammonia levels. Ammonia levels increase because of proper shunting of blood, causing ammonia to enter the systemic circulation, with carries it to the brain. Excess protein intake, sepsis, excessive accumulation of nitrogenous body wastes (from constipation or GI hemorrhage), and bacterial action on protein and urea also lead to increases in ammonia levels.
Amylase levels increase with panceatitis, and inflammation of the pancreas.
Hepatic encephalopathy doesn't result from increasing levels of potassium or calcium.

A client is admitted to the med-surg. Floor with a diagnosis of acute pancreatitis. His BP 136/76, P 96 bpm, R 22 breaths/min, and T 101F/38.3C. His PMHx reveals hyperlipidemia and alcohol abuse. The physician prescribes an NG tube for the client. The nurse knows the NG tube will:

1) Empty the stomach of fluids and gas
2) Prevent spasms at the spincter of Oddi
3) Prevent air from forming in the small and large intestines
4) Remove bile from the gallbladder

RATIONALE: 1) an NG tube is inserted into the client's stomach to drain fluids and gas.
An NG tube doesn't prevent spasms at the sphincter of Oddi or prevent air from forming in the small and large intestine.
A T tube collects bile drainage from the common bile duct.

While preparing a client for an upper GI endoscopy, which interventions should the nurse implement?
SELECT ALL THAT APPLY!

1) Administer a preparation, such as polyethylene glycol (GoLYTELY), to clean the GI tract
2) Tell the client not to eat or drink 6-12 hrs prior to procedure
3) Tell the client to consume only clear liquids for 24 hrs prior to procedure
4) Inform the client that he'll receive a sedative before the procedure
5) Inform the client that he may eat and drink immediately after the procedure.

RATIONALE: 2) and 4) The client shouldn't eat or drink for 6-12 hrs before the procedure to ensure that his upper GI tract is clear for viewing.
The client will receive a sedative before the endoscope is inserted that will help him relax while allowing him to remain conscious.
GI tract cleansing and liquid diet are interventions before a lower GI tract procedure such as colonoscopy. Food and fluids must be withheld until the gag reflex returns.

A client returns from the operating room after extensive abdominal surgery. He has 1,000ml of lactated Ringer's solution infusing via central line. The physician orders the I.V. fluid to be infused at 125ml/hr plus the total output of the previous hour. The drip factor of the tubing is 15gtt/min. The client's output for the previous hour was 75m. via Foley catheter, 50ml via NG tube, and 10ml via Jackson-Pratt tube. How many drops per minute should the nurse set the I.V. flow rate at to deliver the correct amount of fluid? Record as a whole number. ______ ggt/minute.

RATIONALE: 65ggt/min. First calculate the volume to be infused in milliliters: 75ml + 50ml + 10ml = 135ml total output for the previous hour; 135ml + 125ml ordered as a constant flow = 260ml to be infused over the next hour.
Next, used the formula: Volume to be infused/ Total minutes to be infused x Drip Factor = Drops per min.
In this case, 260ml divided by 60min x 15 ggt/min = 65 ggt/min

A nurse is teaching the family of a client with liver failure. The nurse instructs them to limit which foods in the client diet?

1) Meats and beans
2) Butter and gravies
3) Potatoes and pasta
4) Cakes and pastries

RATIONALE: 1) Meats and beans are high in protein foods. In liver failure, the liver can't metabolize protein adequately, causing protein by-products to build up in the body rather than be excreted. This causes such problems as hepatic encephalophathy (a neurologic syndrome that develops as a result of rising blood ammonia levels).
One intervention in liver failure is to limit the client's intake of protein. Although other nutrients, such as fat and carbohydrates, may be regulated, it's mostly important to limit protein.

A nurse is conducting discharge teaching for a client with Hepatitis B. Which statement by the client indicates that he understands the teaching?

1) Now I can never get Hepatitis again
2) I can safely give blood after 3 months
3) I'll never have a problem with my liver again, even if I drink alcohol
4) My family knows that if I get tired and start vomiting, I may be getting sick again.

RATIONALE: 4) Hep.B is characterized by reappearing S/S, including fatigue, nausea, vomiting, bleeding and bruising.
Hep.B can recur.
Clients who have had Hepatitis are permanently barred from donating blood. Alcohol is metabolized by the liver and should be avoided by the client with Hep.B

A client is experiencing an acute episode of ulcerative colitis. What should be the nurse's highest priority?

1) Replace loss of fluid and sodium
2) Monitor for increased serum glucose level from steroid therapy
3) Restrict the dietary intake of foods high in potassium
4) Note any change in color and consistency of stool

RATIONALE: 1) Diarrhea caused by an acute episode of ulcerative colitis leads to fluid and electrolyte losses; therefore; fluid and sodium replacement is necessary.
There is no need to restrict foods high in potassium; potassium may need to be replaced.
If the client is taking steroid medications, the nurse should monitor his glucose levels, but this isn't the highest priority.
Noting changes in stool consistency is important, but fluid replacement takes priority.

A client is receiving pancrelipase (Viokase) for the treatment of chronic pancreatitis. Which observation by the nurse best indicates the treatment is effective?

1) Aspirate for gastric secretions with a syringe
2) Begin feeding slowly to prevent cramping
3) Get an X-ray of the tip of the tube within 24 hrs.
4) Clamp off the tube until the feedings begin.

RATIONALE: 1) before starting a feeding, it's essential to ensure that the tube is in the proper location. Aspiration for stomach contents confirms correct placement.
Giving the feeding without confirming proper placement puts the client at risk for aspiration.
If an x-ray is ordered, it should be done immediately, not in 24 hrs.
Clamping the tube provides no information about tube placement.

A client, with cirrhosis of the liver, develops asciteis. The nurse should expect the physician to write which of the following orders.

1) Restrict fluid to 1,000ml per day
2) Ambulate 100ft, TID
3) High Sodium diet
4) Maalox 30 mg PO BID

RATIONALE: Restrict fluids decreases in the amount fluid present in the body, thus decreasing the amount of fluid, accumulation in the peritoneal space.
Other temp. treatments include a restriction of physical activity, a low-sodium diet. And the use of diuretics.

A client is receiving pancrelipase (Viokase) for the treatment of chronic pancreatitis. Which observation by the nurse best indicates the treatment.

1) The client has no skin breakdown.
2) The client's appetite improves
3) The client loses more than 10lbs/4.5kg
4) The client's stool have increased in frequent by and are less fatty in appearance.

RATIONALE: 4) Pancrelipase provides a exocrine and pancreatic enzyme necessary for proper protein, fat and carbohydrate digestion.
With increased fat digestion and absorption, stools become less frequent and are normal in appearance.
Lack of skin breakdown, an improved appetite, and weight loss aren't effects of pancrelipase.

A nurse is caring for a client diagnosed with diverticulous. Which should be the nurse expect to institute?

1) Low Fiber diet and fluid restriction
2) Total parenteral nutrition and bed rest.
3) High fiber diet and administration of psyllium
4) Administer of analgesics and antacids

RATIONALE: 3) Diverticulosis is characterized by an out-pouching of the colon. The client needs a high fiber diet and psyllim (bulk laxative) administration to promote normal soft stools.
A low fiber diet, decreased fluid intake, bed rest, analgesics, and some antacids can lead to constipation.

A nurse is caring for a client who requires a NG tube for feeding. What should the nurse do immediately after inserting an NG tube for enteral feedings.

1) Aspirate for gastric secretions with a syringe
2) Begin feeding slowly to prevent cramping
3) Get an xray of the tip of the tube within 24 hrs
4) Clamp off tube until feedings begin.

RATIONALE: 1) Before starting a feeding, it's essential to ensure that the tube is in the proper location. Aspirating for stomach contents confirms correct placement.
Giving the feeding without proper placement puts the client at risk for aspiration.
If an X-ray is ordered, it should be done immediately, not in the next 24 hrs. Clamp tube provided no informal about the tube placement.

A client with a history of long term anti inflammatory use has dark, tarry stools. The nurse knows that this indicates bleeding in the:

1) Upper colon
2) Lower colon
3) Upper GI tract
4) Small intestine

RATIONALE:
3) Melena is the passage of dark, tarry stools that contain a large amount of digested blood. It occurs with bleeding from the upper GI tract.
Passage of red blood from the rectum indicates lower GI (colon, small intestine, and rectum) bleeding.
Bleeding in the lower colon would cause bright red blood in the stool.

After an abdominal resection for colon cancer, the client returns to his room with a Jackson-Pratt drain in place. The client's spouse asks the nurse about the purpose of the drain. The best response would be for the nurse to say:

1) It irrigates the incision with a saline solution
2) It helps prevent bacterial infection of the incision
3) It measures the amount of fluid lost after surgery
4) It helps prevent the accumulation of drainage in the wound.

RATIONALE:
4) The accumulation of fluid in a surgical wound interferes with the healing process. A Jackson-Pratt drain promotes wound healing by allowing fluid to escape from the wound. The drain may be placed in the client's incision, or it may be placed in the wound and brought out to the skin surface through a stab wound near the incision.
The incision doesn't need to be irrigated.
Fluid from the drain is absorbed into the dressings and can't be measured accurately.
A Jackson-Pratt drain doesn't prevent infection.

A nurse is doing preoperative teaching with a client expected to undergo a herniorrhaphy (surgical repair of a hernia). The nurse should instruct the client to:

1) Avoid the use of pain medication
2) Cough and deep breathe every 2 hrs
3) Splint the incision if he can't avoid sneezing or coughing
4) Apply heat to scrotal swelling.

RATIONALE:
3) After herniorrhaphy, teach the client to avoid activities that increase intra-abdominal pressure, such as coughing, sneezing, or straining with bowel movement. If the client must cough or sneeze, splinting the incision with a pillow is helpful. Encourage the use of analgesics for pain or discomfort. The client should be instructed not to cough, but deep-breathing exercises should be still be preformed q2hrs. Ice may be used to reduce scrotal edema and pain after herniorrhaphy.

Daily abdominal girth measurements are prescribed for a client with liver dysfunction and ascites. To increase accuracy, the nurse should use which landmark?

1) Xiphoid process
2) Umbilicus
3) Illiac crest
4) Symphysis pubis

RATIONALE:
2) The proper technique for measuring abdominal girth involves using the umbilicus as a landmark while encircling the abdomen with a tape measure.
Using the xiphoid process, the iliac crest, or the symphysis pubis as a landmark would yield inaccurate measurements.

Following abdominal surgery, a client has developed a gaping incision due to delayed wound healing. The nurse is preparing to irrigate the incision using a piston syringe and sterile normal saline solution. Which method should the nurse use as a part of the irrigation process.

1) Rapidly instill a stream of irrigating solution into the wound
2) Apply a wet-to-dry dressing to the wound after the irrigation
3) Moisten the area around the wound with normal saline solution after the irrigation
4) Irrigate continuously until the solution becomes clear or until all of the solution is used.

RATIONALE:
4) To wash away tissue debris and drainage effectively, irrigate the wound until the solution becomes clear or until all of the solution is used.
After the irrigation, dry the area around the wound; moistening it promotes microorganism growth and skin irritation.
When the area is dry, apply sterile dressing rather than a wet-to-dry dressing.
Always instill the irrigating solution gently; rapid or forceful instillation can damage tissues.

A nurse is caring for a client who requires total parenteral nutrition (TPN). The client asks the nurse why he's getting TPN. The nurse best response is:

1) It adds necessary fluids and electrolytes to the body
2) It gives you complete nutrition by the I.V. route until you can eat again.
3) These tube feedings provide nutritional supplementation.
4) It contains liquid protein to supplement your diet between meals.

RATIONALE:
2) TPN is given I.V. to provide all the nutrients the client needs; it provides more than just fluids and electrolytes.
TPN solutions typically provide glucose, amino acids, trace elements and vitamins, and fats.
TPN is neither a tube feeding nor a liquid dietary supplement.

The nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following should the nurse include?

1) Administering a lactulose enema as ordered.
2) Encouraging a protein rich diet
3) Adminis.tering sedatives as needed.
4) Encouraging ambulation at least 4 times a day.

RATIONALE:
1) Hepatic encephalopathy is a degenerative disease of the brain that is a complication of cirrhosis. For the client with hepatic encephalopathy, the nurse may administer the laxative lactulose to reduce ammonia levels in the colon.
Protein intake is usually restricted to reduce serum ammonia levels until the client's mental status begins to improve.
Sedatives are avoided because they can cause respiratory or circulatory failure.
Bed rest is encouraged because physical activity increases metabolism, leading to an increased production of ammonia.

A client is admitted with inflammatory bowel syndrome (Crohn's disease). Which treatment measures should the nurse expect to be part of the care plan?
SELECT ALL THAT APPLY!

1) Laculose therapy
2) High fiber diet
3) High protein milkshakes
4) Corticosteroid therapy
5) Antidiarrheal medications

RATIONALE:
4) and 5) Corticosteroids, such as prednisone, reduce the S/S of diarrhea, pain, and bleeding by decreasing inflammation. Antidiarrheals, such as diphenoxylate (Lomotil), combat diarrhea by decreasing peristalsis.
Lactulose is used to treat chronic constipation and would aggravate the symptoms.
A high fiber diet, milk, and milk products are contraindicated in clients with Crohn's disease because they may promote diarrhea.

A client who recently had abdominal surgery tells the nurse he felt a popping sensation in his incision during a coughing spell, following by severe pain. The nurse anticipates an evisceration.
Which supplies should she bring to the client's room?

1) A suture kit
2) Sterile water and a suture kit
3) Sterile water and sterile dressings
4) Sterile saline solution and sterile dressings

RATIONALE:
4) Saline solution is isotonic, or close to body fluids in content, and is used along with sterile dressings to cover an eviscerated wound (a wound that opened, allowing the intestines to protrude outside the body) and keep it moist.
Sterile water and a suture kit aren't used. The physician will contacted, and the client will most likely return to the operating room for closure.

A client is admitted with upper GI bleeding. The nurse promotes hemodynamic stability by:

1) Encouraging oral fluid intake
2) Monitoring central venous pressure (CVP)
3) Monitoring laboratory test results and vital signs
4) Giving blood, electrolyte, and fluid replacement.

RATIONALE:
4) to stabilize a client with acute bleeding, normal saline solution or lactated Ringer's solution is given until blood pressure rises and urine output returns to 30ml/hr.
A CVP line is inserted to monitor circulatory volume.
When shock is severe, plasma expanders are given until typed and crossmatched blood is available. Oral fluid intake is contraindicated with upper GI bleeding.
Monitoring vital signs and laboratory values enables the nurse to evaluate the results of treatment, but these measures don't facilitate hemodynamic stabilization.

A client has undergone a colostomy for a ruptured diverticulum. The nurse is assessing the client's colostomy stoma 2 days after surgery. Which assessment finding should the nurse report to the physician?

1) Blanched stoma
2) Edematous stoma
3) Reddish pink stoma
4) Brownish black stoma

RATIONALE:
4) A brownish black stoma color indicates a lack of blood flow to the stoma, and necrosis is likely.
A blanched or pale stoma indicates possible decreased blood flow and should be assessed regularly.
2 days postoperatively, the stoma should be edematous and reddish pink.

A nurse is caring for a client with liver cirrhosis who has developed ascites and requires paracentesis. Relief of which symptom indicates that the paracentesis was effective?

1) Pruritus
2) Dyspnea
3) Jaundice
4) Peripheral neuropathy

RATIONALE:
2) Ascites (fluid buildup in the abdomen) puts pressure on the diaphragm. Paracentesis (surgical puncture of the abdominal cavity to aspirate fluid) is done to remove fluid from the abdominal cavity and thus reduce pressure on the diaphragm.
The goal is to improve the client's breathing.
Pruritus, jaundice, and peripheral neuropathy are signs of cirrhosis that aren't relieved or treated by paracentesis.

A client admitted with peritonitis is under a NPO order. The client is complaining of thrist. Which action is the most appropriate for the nurse to take?

1) Increase the I.V. infusion rate
2) Use diversion activities
3) Provide frequent mouth care
4) Give ice chips every 15 minutes

RATIONALE:
3) frequent mouth care helps relieve dry mouth. Increasing the I.V. infusion rate does not alleviate the feeling of thirst. Diversion activities aren't specific. Ice chips are a form of liquid and shouldn't be given as long as the client is under an NPO order.

A nurse is preparing to teach a client who has been newly diagnosed with stomach cancer.
Which statement should the nurse include in her teaching?

1) Stomach pain is typically a late symptom of stomach cancer.
2) Surgery is commonly a successful treatment for stomach cancer.
3) Chemotherapy and radiation are usually successful treatments for stomach cancer.
4) You may be on TPN for an extended time.

RATIONALE:
1) Stomach pain is typically a late sign of stomach cancer; outcomes are particularly poor when the cancer reaches that point.
Surgery, chemotherapy, and radiation have minimal positive effects on stomach cancer.
TPN may increase the growth of cancer cells.

A client is admitted with acute pancreatitis. Which laboratory result should the nurse expect?

1) Creatinine of 4.3 mg/dl
2) ALT of 124 international units/L
3) Amylase of 306 units/L
4) Troponin level of 3.5 mcg/L

RATIONALE:
3)Pancreatitis involves activation of pancreatic enzymes, such as amylase and lipase. Therefore, serum amylase and lipase levels are elevated in a client with acute pancreatitis.
Serum creatinine levels are elevated with kidney disfunction.
Injury or disease of the liver elevated ALT levels.
Troponin levels are elevated with heart damage such as myocardial infarction.

A client is admitted with possible bowel obstruction. Which intervention is most important for the nurse to perform?

1) Obtain daily weights.
2) Measure abdominal girth.
3) Keep strict intake and output.
4) Encourage the client to increase fluids.

RATIONALE:
2) With a bowel obstruction, abdominal distention occurs. Measuring abdominal girth provides quantitative information about increases or decreases in the amount of distention.
Monitoring daily weights provides information about fluid status. An increase In daily weight usually indicates fluid retention.
Measuring intake and output provides no information about abdominal distention or obstruction. A client with an obstruction would receive a NPO order.

A nurse is advising a client with a colostomy who reports problems with flatus. Which food should the nurse recommend?

1) Peas
2) Cabbage
3) Broccoli
4) Yogurt

RATIONALE:
4)High fiber food stimulate peristalsis and thus, flatulence.
Tell the client to include yogurt in his diet to reduce gas formation. Other helpful foods include crackers and toast.
Peas, cabbage, and broccoli are all gas forming foods.

speed shock

caused by rush of IV fluid administered; med races to blood-rich heart and brain and floods them w/toxic levels of med

s/s of speed shock

dizziness, facial flushing, HA, chest tightness, hypotension, irregular pulse, progression of shock

What does RN do if hematoma develops

- elevate
- cool compress if blood is new
- warm compress if blood is old

how often should IV site be checked by RN

q 1-2 hrs

What is empiric treatment?

treatment that is started before C & S comes back with definitive cause of infection.

3 types of phlebitis:

1) mechanical (cannula causes issue)
2) chemical (solution is irritating)
3) bacterial (microorganism introduced to vein)

s/s of phlebitis:

palpable cord, pain, redness

s/s of infection:

redness, fever, pain, increased WBC

s/s fluid overload:

rapid/bounding pulse, distended neck veins, HTN, cough, SOB, crackles, HA, restlessness

s/s of IV infection:

local- redness, pain, drainage @ site
systemic - fever, chills, elevated WBC, shock

antacid:

medication that neutralizes acid that's already been made

What classification of meds decreases bowel motility?

anti-diarrheals

True or False an anti-diarrheal is contraindicated w/a bowel obstruction:

True - colitis, N/V, and diarrhea should not be suppressed if underlying cause is not known

What is acid reflux?

when stomach acid splashes up into esophagus

Maalox & Mylanta commonly interfere w/absorption of other meds. T or F

true - especially when kidneys have failed

What classification is Pepcid and what does it treat?

H2 antagonist (blocks histamine receptor)
Treats dyspepsia, GERD, PUD, esohagitits

When teaching a patient about taking Pepcid what should you include:

Take 1 hr before meals (causes acid-producing parietal cells of stomach to be less responsive to stimulation-blocks 90% of acid secretion)

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