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102 exam 4

Terms in this set (50)

You are caring for a patient admitted with a diagnosis of renal failure. When you review your patient's laboratory reports, you note that the patient's magnesium levels are high. What signs of potential complications demands immediate action?
Diminished deep tendon reflexes
You are working on a burn unit. One of your patients is exhibiting signs and symptoms of third spacing, which occurs when fluid moves out of the intravascular space but not into the intracellular space. Based upon this fluid shift, what would you expect the patient to demonstrate?
Hypovolemia
A nurse is caring for a client who is dehydrated. Which of the following clinical manifestations should the nurse assess for that is indicative of fluid volume deficit
Tachycardia
A nurse is caring for a client who has a laboratory finding of serum potassium of 5.9 mEq/L (Hyperkalemia). The nurse should assess for which of the following clinical manifestations?
ECG changes
You are the nurse caring for a 65-year-old female patient who is in renal failure. During your shift assessment, the patient complains of tingling in her lips and fingers. She also complains that whenever anyone takes her blood pressure her hand and fingers become spastic and go into palmer flexion. What would you suspect?
Hypocalcemia
The nurse identifies the priority problem of potential for injury for a patient with hyponatremia. What is the etiology of this priority patient problem?
Altered mental capabilities
The nurse is caring for a client who has GERD. What symptom, if present, would be characteristic of [condition]?
Loss of tooth enamel
A nurse is doing preoperative teaching with a patient who will undergo a laparoscopic cholecystectomy. Which of the following should be included in the teaching?
You may have shoulder pain after surgery
You are caring for a patient on the oncology floor with a diagnosis of hyperparathyroidism. This patient also has lost some bone density due to immobility and is on a thiazide diuretic for her edema. What other condition is this patient most likely to be experiencing?
Hypercalcemia
The nursing instructor is reviewing IV fluids with the class. The class would demonstrate adequate knowledge and indicate understanding of this topic by stating: ___________ solutions have a greater osmolarity than blood plasma.
Hypertonic
You are caring for a patient with a diagnosis of hypermagnesemia. In caring for the patient, the nurse should be alert for what complications of hypermagnesemia?
Shallow respirations
The nurse is assessing the patient for the presence of a Chvostek's sign. What electrolyte imbalance does a positive Chvostek's sign indicate?
Hypocalcemia
The nurse is caring for a patient with hypovolemia secondary to severe diarrhea and vomiting. In evaluating the respiratory system for this patient, what does the nurse expect to find on assessement?
Increased respiratory rate, because the body perceives hypovolemia as hypoxia
An adult patient is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the patient has completed the test?
Fluids must be increased to facilitate the evacuation of the stool.
A patient has come in to the radiology department to undergo testing for possible polyps. Which diagnostic test may be done to identify and diagnose this type of lesion?
Barium enema
You are explaining a flexible scope procedure to a patient. For a flexible scope procedure, in which position should the nurse place the patient?
Lying on the left side with legs drawn toward the chest
A patient is scheduled to have a fecal occult blood test. Before the test, the nurse should instruct the patient to avoid:
Nonsteroidal anti-inflammatory drugs
The nursing instructor is teaching new nursing students how to perform an abdominal assessment. When performing an abdominal assessment, what examination sequence should the nurse follow?
Inspection, auscultation, percussion, and palpation
A student nurse is doing clinical hours on your unit. The student asks you to auscultate the patient's abdomen to verify what he has heard. The student tells you he has heard one or two bowel sounds in a 2-minute period of time. How would you tell the student to document the patient's bowel sounds?
Hypoactive
Which finding does the nurse not document after inspecting a patient's abdomen?
Presence of borborygmus
The nursing instructor is discussing the gastrointestinal system. Why would the instructor discuss assessment of the oral cavity with her students?
Disorders such as cancer can be manifested by changes in the oral cavity.
A client who underwent a gastric resection 3 weeks ago is having her diet progressed on a daily basis. Following her latest meal, the client reports dizziness and palpitations. Inspection reveals that the client is diaphoretic. What is the nurse's best action?
Monitor the client closely for further signs of dumping syndrome.
A nurse is reviewing discharge teaching to a patient who has Crohn's disease. Which of the following should be included in the teaching?
Drink canned protein supplements
After surgery for esophageal cancer, the patient is instructed to remain upright for at least 2 hours to allow the food to move through the gastrointestinal tract. What drug is used to promote gastric motility in these patients?
Reglan
The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. The nurse should monitor for what major complication of TPN?
Hyperglycemia
The nurse is caring for a patient who has been diagnosed with a peptic ulcer. The patient ask the nurse what a peptic ulcer is. Which of the following best describes a peptic ulcer?
Erosion of the lining of the stomach or intestine
A patient comes to the clinic complaining of pain in the epigastric region. The nurse suspects that the patient's pain is related to a peptic ulcer in the duodenum when the patient states the pain occurs when?
2-3 hours after eating
You are doing patient teaching with a patient has just been prescribed Prevacid. What statement would indicate that the patient correctly understands the action of this medication?
"The medication inhibits acid secretions."
A patient presents to the walk-in clinic complaining of vomiting and burning in their mid-epigastria. The nurse knows that to confirm peptic ulcer disease, the physician is likely to order a diagnostic test to detect the presence of what?
Infection with Helicobacter pylori
A patient with a peptic ulcer has asked the nurse for help in selecting their dinner menu. Which beverage would be most appropriate for this patient?
Room-temperature grape juice
Which of the following describes the current approved therapy used for the treatment of peptic ulcers?
Antibiotics, proton pump inhibitors, and bismuth ( Pepto Bismol)
A patient admitted with acute diverticulitis is being cared for by a staff nurse and a student nurse. The student asks the staff nurse what the signs of bowel perforation are. What should the staff nurse answer the student?
An elevated white cell count
A nurse is presenting to a group of nursing students on Peritonitis. The students know that one of the main symptoms of this condition is what?
Boardlike abdomen
The nursing instructor is discussing hemorrhoids with the nursing class. Which of the following patients is most likely to develop hemorrhoids?
A pregnant woman at 38 weeks' gestation
A 16-year-old female presents at the emergency department complaining of right lower quadrant pain. She is diagnosed with appendicitis. When assessing this patient, which of the following signs or symptoms should the nurse expect to find?
Rebound tenderness, McBurney's sign, fever
The nurse caring for a patient with a newly created ileostomy assesses the patient and notes symptoms that may be indicative of an intestinal obstruction. What evaluation data should be reported to the primary health care provider immediately?
Nausea and abdominal distention
A nurse is caring for a patient who has acute diverticulitis. The nurse notes that the nasogastric (NG) tube is draining green liquid bile. What intervention is needed when the patient is having the tube drain this green bile?
Know this is normal and document the findings
A 5 year-old boy with muscular dystrophy has a bowel obstruction. What kind of bowel obstruction would this boy most likely have?
A functional obstruction
You are caring for a patient with advanced cirrhosis. You know that the most significant source of bleeding in a patient with cirrhosis is what?
Esophageal varices
A client has a nasogastric tube for continuous tube feeding. The nurse does all the following every shift to verify placement (select all options that apply):
A) Confirms the tip of the tube with radiology
B) Inserts 90 mL of tap water through the nasogastric tube
C) Checks the pH of the gastric contents
D) Visually assesses the color of the aspirate
E) Compares exposed tube length with original measurement
cde
A client seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education?
"Instead of eating three meals a day, try eating smaller amounts more often."
The nurse is caring for a patient admitted with a suspected malabsorption disorder. The nurse knows that one of the accessory organs of the digestive system is the pancreas. What digestive enzymes does the pancreas secrete? (SELECT ALL THAT APPLY)
a)
Pepsintoninosis
b)
Lipase
c)
Amylase
d)
Trypsin
e)
Ptyalin
bcd
The physiology instructor asks the pre-nursing students what the accessory digestive organs are. What should the students answer? (SELECT ALL THAT APPLY)


a) The liver

b)
The Pancreas

c)
The spleen

d)
The gallbladder

e)
The stomach
abd
Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply.
A) Distended neck veins
B) Crackles in the lung fields
C) Shortness of breath
D) Decreased blood pressure
E) Bradycardia
abc
You are teaching a cardiac rehab class about potassium-rich foods to monitor in their diet. Your teaching should include careful monitoring of which high potassium foods? (SELECT ALL THAT APPLY)
a) Bananas
b) Sweet potatoes
c) Yogurt
d) Mackerel fish
e) Milk
abc
or dinner your client drank a two 4 oz containers of apple juice, 1 cup (8 oz) of coffee, and an 8 ounce can of Sustacal. The client drank his entire 900 mL pitcher of water during the shift. The client voided 2 times on your shift (500 mL, 950 mL).
Intake 1620 mL Output 1450 mL
The physician orders 1000 mg of ceftazidime IV. The label on the 2 g vial of ceftazidime reads to reconstitute with 10 mL of sterile water. How many mL should the nurse give?
5 mL
Lasix is available in a vial labeled 10 mg in 1 mL. Prepare a 15 mg dose.
1.5 mL
Solu-Medrol 80 mg IVP is ordered for your postpartum client. The vial sent from the pharmacy is 125 mg/mL. How many mL of the medication would you administer?
0.6 mL
Order: Decadron 0.5 mg, PO.
Drug available:
Decadron 100 tablets 0.25mg

How many tabs would you administer to obtain the proper dose?
2 tabs
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