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Med Surg Practice A
Terms in this set (90)
A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client is experiencing excessive stools. Which of the following findings is an adverse effect of this medication?
Hypokalemia: Lactulose works by stimulating the production of excess stools to rid the body of excess ammonia. These excessive stools can result in hypokalemia and dehydration (hyponatremia).
A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first.
Administer propofol to the client.
Instruct the client to allow the machine to breathe for them.
Disconnect the machine and manually ventilate the client.
Instruct the client to allow the machine to breathe for them.
(When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness when trying to "fight the ventilator.")
A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate the risk, which of the following dietary alterations should the nurse recommend.
Add full-fat yogurt to the diet.
Add cabbage to the diet.
Replace butter with coconut oil.
Replace shellfish with red meat.
Add cabbage to the diet. (To help reduce the risk for colorectal cancer, the client should consume a diet that is high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber.)
A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric stroke. Which of the following neurologic deficits should the nurse expect to find when assessing the client? (select all that apply)
Visual spatial deficits
Visual spatial deficits
Left sided stroke:
expressive aphasia, right hemiplegia
A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen?
Simple face mask
Partial rebreather mask
Nonrebreather mask (80-95%)**
Partial rebreather mask (60-75%)
Simple face mask (40-60%)
A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client has dyspnea with a productive cough and is using accessory muscles to breathe. Which of the following actions should the nurse take first?
Obtain a prescription for ABGs.
Administer IV antibiotics to the client.
Instruct the client to use the incentive spirometer.
Place the client in high-Fowler's position.
Place the client in high-Fowler's position.**
(The greatest risk to this client is injury from airway obstruction. Therefore, the priority intervention the nurse should take is to move the client into high-Fowler's position. High-Fowler's position facilitates lung expansion and improves ventilation and gas exchange.)
A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent a Pseudomonas aeruginosa infection?
Encourage the client to eat raw fruits and vegetables.
Avoid placing plants or flowers in the client's room.****
Limit visitors to members of the client's immediate family.
Wear a N95 respirator mask when providing care to the client.
(Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds and cause life-threatening complications. The nurse should ensure no one brings live plants or flowers into the client's room. P. aeruginosa spreads by contact and is not airborne)
An older adults client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration?
Serum sodium level 145 mEq/L
Forearm skin tents when pinched
Respiratory rate decreased
Urine specific gravity 1.045****
(A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration.)
Hypertonic dehydration: over 145 Na, skin tents for older adults on sternum, respiratory rate increases
A nurse in an emergency department is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse expect?
Apply ice to the client's puncture wounds.
Initiate corticosteroid therapy for the client.
Keep the client's leg above heart level.
Administer opioid analgesic to the client. ****
bees and wasps: antihistamines and corticosteroids
spiders: apply ice
keep extremity AT heart level.
A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings?
(Dysphagia indicates that this client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity. Therefore, the nurse should place priority on this finding.)
aphasia: risk for communication impairment
ataxia: risk for injury from falling
hemianopsia: risk for injury when ambulating
A nurse is teaching a young adult client how to perform testicular self-examination. Which of the following instructions should the nurse include?
Compare both testicles by examining them simultaneously.
Roll each testicle between the thumb and fingers.****
Perform testicular self-examination before a war bath or shower.
Perform self-examination of the testicles every 2 weeks.
Instruct to use both hands to examine the testicles separately, roll each horizontally between thumbs and fingers to feel for any lumps deep in the center, during of after warm bath/shower, every 1 month.
A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching?
"I will monitor my blood sugar carefully because the medication increases the secretion of insulin."
"I should take this medication with a meal."****
"I can expect to gain weight while taking this medication."
"While taking this medication, I will experience flushing of my skin."
Metformin: decreases the amount of glucose produced in the liver, increases tissue sensitivity to insulin, take with or immediately after meals to improve absorption and minimize GI distress, weight loss due to N/V, flushing of skin is NOT and adverse effect.
A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
"I should avoid walking as much as possible"
"I should sit down and read for several hours a day."
"I will wear clean graduated compression stockings every day."**
"I will keep my legs level with my body when I sleep at night."
Venous insufficiency: exercise regimen, avoid sitting/standing for long periods, clean compression stockings, elevate legs above heart to facilitate venous return and avoid venous stasis.
A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority?
Abdominal pain radiating to the right shoulder.
Rebound abdominal tenderness
Acute cholecystitis: abdominal pain radiating to right shoulder and rebound abdominal tenderness is an expected finding. Tachycardia is a manifestation of biliary colic, which can lead to shock. Position head of bed flat and report to provider.
A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings?
Ibuprofen PRN for headaches
Olmesartan 20mg PO daily
Prednisone 5mg PO daily
Hx and Physical:
Gouty arthritis 3 years, HTN dx 5 years ago, 1 pack/day smoker for 15 years, Fam hx: prostate cancer
Blood glucose (fasting) 102 mg/dL
Creatinine 1 mg/dL
Prostate Specific Antigen (PSA) 1.5
The nurse should review the meds and identify: ACE inhibitors, theophylline, nifedipine, glucocoriticosteroids. They can all alter the allergy skin test results and diminish the run to the allergens. Nurse should notify provider and instruct client to discontinue prednisone for 2 weeks before the skin testing.
Allergy testing: identify hx of diseases that alter the immune response.
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