medsurg practice test – Flashcards
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A Korean-American client, who speaks very little English, is being discharged following surgery. Which nurse should the nurse manager assign to provide the discharge instructions for the client? A) A graduate registered nurse (RN) with three weeks of experience. B) The registered nurse (RN) case manager for the unit with 1 year's experience. C) A floating registered nurse (RN) with five years of nursing experience. D) A Korean-American practical nurse (PN) with six years of nursing experience.
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The RN case manager (B) is the best qualified nurse to assess and provide discharge educational needs, obtain resources for the client, enhance coordination of care, and prevent fragmentation of care. The RN graduate (A) lacks the experience to provide individualized and complete discharge instructions. The float nurse (C) lacks case management expertise to advocate adequately for the client, coordinate care, and provide community resources. It is not in the scope of practice for the PN (D) to give discharge instructions.
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A client who returns to the unit after having a percutaneous transluminal coronary angioplasty (PTCA) complains of acute chest pain. What action should the nurse implement next? A) Inform the healthcare provider. B) Obtain a 12-lead electrocardiogram. C) Give a sublingual nitroglycerin tablet. D) Administer prescribed analgesic.
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After a percutaneous transluminal coronary angioplasty (PTCA), a client who experiences acute chest pain may be experiencing cardiac ischemia related to restenosis, stent thrombosis, or acute coronary syndrome involving any coronary artery. The first action is to administer nitroglycerin (C) to dilate the coronary arteries and increase myocardial oxygenation. Then, (A, B, and D) are implemented.
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Several hours after surgical repair of an abdominal aortic aneurysm (AAA), the client develops left flank pain. The nurse determines the client's urinary output is 20 ml/hr for the past 2 hours. The nurse should conclude that these findings support which complication? A) Infection. B) Hypovolemia. C) Intestinal ischemia. D) Renal artery embolization.
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Postoperative complications of surgical repair of AAA are related to the location of resection, graft, or stent placement along the abdominal aorta. Embolization of a fragment of thrombus or plaque from the aorta into a renal artery (D) can compromise blood flow in one of the renal arteries, resulting in renal ischemia that precipitates unilateral flank pain. Intraoperative blood loss or rupture of the aorta anastomosis can cause acute renal failure related to hypovolemia (B), which involves both kidneys and causing bilateral flank pain. (A and C) are not associated with these symptoms.
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The nurse is caring for a client with human immunodeficiency virus (HIV) infection who develops Mycobacterium avium complex (MAC). What is the most significant desired outcome for this client? A) Free from injury of drug side effects. B) Return to pre-illness weight. C) Adequate oxygenation. D) Maintenance of intact perineal skin.
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MAC is an opportunistic infection that presents as a tuberculosis-like pulmonary process. MAC is a major contributing factor to the development of wasting syndrome, so the most significant desired outcome is the client's return to a pre-illness weight (B) using oral, enteral, or parenteral supplementation as needed. Drug schedules and side effects (A) remain a life long management problem. Client outcomes for adequate oxygenation (C) are often dependent on management of anemia, maintenance of activities without fatigue, and supplemental oxygen to prevent hypoxia. Skin integrity (D) is dependant upon diarrhea, which is not as significant as optimal nutrition.
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A client with a fractured right radius reports severe, diffuse pain that has not responded to the prescribed analgesics. The pain is greater with passive movement of the limb than with active movement by the client. The nurse recognizes that the client is most likely exhibiting symptoms of which condition? A) Acute compartment syndrome. B) Fat embolism syndrome. C) Venous thromboembolism. D) Aseptic ischemic necrosis.
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A These signs are specific indications of Acute Compartment Syndrome (A), and should be treated as an emergency situation. The signs do not indicate (B, C, or D).
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The nurse is caring for a client who had an excision of a malignant pituitary tumor. Which findings should the nurse document that indicate the client is developing syndrome of inappropriate antidiuretic hormone (SIADH)? A) Hypernatremia and periorbial edema. B) Muscle spasticity and hypertension. C) Weight gain with low serum sodium. D) Increased urinary output and thirst.
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SIADH most frequently occurs when cancer cells manufacture and release ADH, which is manifested by water retention causing weight gain and hyponatremia (C). Other manifestations include oliguria, weakness, not (A, B, and D), anorexia, nausea, vomiting, personality changes, seizures, decrease in reflexes, and coma.
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A client with type II diabetes arrives at the clinic with a blood glucose of 50 mg/dL. The nurse provides the client with 6 ounces of orange juice. In 15 minutes the client's capillary glucose is 74 mg/dL. What action should the nurse take? A) Obtain a specimen for serum glucose level. B) Administer insulin per sliding scale. C) Provide cheese and bread to eat. D) Collect a glycosylated hemoglobin specimen.
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Once blood glucose is greater than 70 mg/dl, the client should eat a regularly scheduled meal or a snack to prevent hypoglycemia from recurring (C). Blood glucose has just been checked and a serum level is not indicated at this time (A). The blood glucose does not indicate a need for insulin (B) which may further exacerbate a hypoglycemic response. A glycosylated hemoglobin (hemoglobin A1C) level is not indicated at this time (D).
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A client with Ménière's disease is incapacitated by vertigo and is lying in bed grasping the side rails and staring at the television. Which nursing intervention should the nurse implement? A) Encourage fluids to 3000 ml per day. B) Change the client's position every two hours. C) Keep the head of the bed elevated 30 degrees. D) Turn off the television and darken the room.
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To decrease the client's vertigo during an acute attack of Ménière's disease, any visual stimuli or rotational movement, such as sudden head movements or position changes, should be minimized. Turning off the television and darkening the room (D) minimize fluorescent lights, flickering television lights, and distracting sound. (A, B, and C) are ineffective in managing the client's symptoms.
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A client who has a chronic cough with blood-tinged sputum returns to the unit after a bronchoscopy. What nursing interventions should be implemented in the immediate post- procedural period? A) Keep the client on bed rest for eight hours. B) Check vital signs every 15 minutes for two hours. C) Allow the client nothing by mouth until the gag reflex returns. D) Encourage fluid intake to promote elimination of the contrast media.
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The nasal pharynx and oral pharynx are anesthetized with local anesthetic spray prior to bronchoscopy, and the bronchoscope is coated with lidocaine (Xylocaine) gel to inhibit the gag reflex and prevent laryngeal spasm during insertion. The client should be NPO until the client's gag reflex returns (C) to prevent aspiration from any oral intake or secretions. (A, B, and D) are not indicated after bronchoscopy.
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The nurse working in the oncology clinic at a cancer center is involved in supporting clients and families who must cope with the diagnosis of cancer. Which client is likely to cope best with the diagnosis of cancer? A) An older man who is always happy and chooses to view only the good in every situation. B) A single mother who seeks the support of her two teenage daughters during difficult times. C) A successful businessman who is accustomed to handling highly-stressful situations. D) A teacher who seeks information about her disease and wants to continue teaching.
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Those who seek information about their disease while attempting to carry on with their lives as best they can (D) are likely to handle the diagnosis of cancer best. Those who use repression (A) to deal with traumatic events often have difficulty expressing their feelings. Depending on children for support (B), especially when the children are teenagers, may be disappointing. Someone who is used to handling high-stress situations (C) is used to being in control, and control over a life-threatening diagnosis is not always possible.
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A male client with a prostatic stent is preparing for discharge. What should the nurse ensure the client understands? A) Ongoing antibiotic therapy is needed for one year. B) The client should not undergo magnetic resonance imaging. C) Increased frequency of assessment for prostatic cancer is needed. D) The client should not be catheterized through the stent for at least three months.
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To prevent complications, the client should be cautioned against catheterization through the stent for three months after stent placement (D). Long term antibiotic use for one year (A) is not a part of illness management. There is no contraindication for magnetic resonance imaging (B). Frequent assessment of prostate health is part of client teaching for health promotion (C), but is not increased because of the stent placement.
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A client is receiving a continuous bladder irrigation at 1000 ml/hour after a prostatectomy. The nurse determines the client's urine output for the past hour is 200 ml. What action should the nurse implement first? A) Notify the healthcare provider. B) Stop the irrigation flow. C) Document the finding and continue to observe. D) Irrigate the catheter with a large piston syringe.
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The urinary output should be at least the volume of irrigation input plus the client's actual urine. A significant decrease in output indicates obstruction in the drainage system, and the irrigation flow should be stopped (B) to prevent severe bladder distention. The next action is to check the external system for kinks or obstruction. If no output occurs, the catheter is irrigated with 30 to 50 ml of normal saline using a large iston syringe (D). If the obstruction is not resolved, then the healthcare provider (A) should be implemented.
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What is the primary nursing diagnosis for a client with asymptomatic primary syphilis? A) Acute pain. B) Risk for injury. C) Sexual dysfunction. D) Deficient knowledge.
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An asymptomatic client with primary syphilis is most likely unaware of this disease, so to prevent transmission to others and recurrence in the client, the priority nursing diagnosis is deficient knowledge (D). Asymptomatic primary syphilis is not painful, so (A) is not applicable at this time. Although the client is at risk for injury (B) and sexual dysfunction (C) related to complications, teaching the client about transmission and treatment is instrumental in preventing the progression to systemic secondary or tertiary syphilis.
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What assessment findings should the nurse identify before referring a client for furtherevaluation to rule out skin cancer? (Select all that apply.) A) White patches. B) Cherry angiomas. C) Border irregularity. D) Lesion with asymmetry. E) Lesion with color variations. F) Lesion of 3 to 5 mm diameter.
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Correct selections are (C, D, and E). ABCDE is the acronym used by the American Cancer Society (ACS) to monitor lesions needing further evaluation to rule out skin cancer: A for asymmetry of the lesion (D); B for irregular border (C); C for color, usually dark (E); D for diameter equal to or greater than 6 mm; and E for elevation. A lesion with any of the characteristics of ABCDE should be evaluated by a healthcare provider. (A) lack the color variable. (B) are raised, dome-shaped, benign clusters of blood vessels that do not require treatment. Lesions of 3 to 5 mm diameter are small and may be monitored instead of treated (F).
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While assessing the hair and scalp of an adult client, the nurse notes that the client has dry, brittle hair. Which information should the nurse obtain first? A) Unexplained weight gain. B) Current hair care practices. C) Family history of alopecia. D) Absence of axillary hair.
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Dry and brittle hair may be a result of hair treatments such as hair dyes, rinses, permanents, straighteners, or frequent blow-drying (B). Although an unexplained weight gain (A) could be related to hypothyroidism, which causes hair to become dry and brittle, assessing current hair care practices should be determined first because of the prevalent use of cosmetic products. Next, a family history of alopecia (C) and absence of axillary hair (D) should be assessed to identify other problems contributing to hair abnormalities, such as nutritional deficiencies, endocrine dysfunction, or genetic predisposition.
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Which intervention should the nurse implement that best confirms placement of an endotracheal tube (ET) tube? A) Use an end-tital CO2 detector. B) Ascultate for bilateral breath sounds. C) Obtain pulse oximeter reading. D) Check symmetrical chest movement.
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The end-tital carbon dioxide detector indicates the presence of CO2 by a color change or a number (A), which is evidence that the ET is in the trachea, not the esophagus. Other assessments, such breath sounds (B), pulse oximetry (C) and chest movement (D), are methods to evaluate the effectiveness of ventilation and oxygenation, but do not measure CO2 in expired air from the ET.
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A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further? A) A scalp laceration oozing blood. B) Serosanguineous nasal drainage. C) Headache rated 10 on a 0-10 scale. D) Dizziness, nausea and transient confusion.
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Any nasal discharge should be evaluated (B) to determine the presence of cerebral spinal fluid which indicates a tear in the dura making the client susceptible to meningitis. The scalp is highly vascular and results in blood oozing from wounds (A). Pain is expected and can be treated after further assessment of the presence of nasal discharge (C). Dizziness, nausea, and transient confusion (D) are expected manifestations following a traumatic brain injury and need ongoing monitoring, but (B) is most important.
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The nurse is caring for a client who is two days postoperative. Which observation should alert the nurse to call the Rapid Response Team (RRT)? A) Fresh bleeding noted on abdominal surgical wound dressing. B) Pulse change from 85 to160 beats/minute lasting more than 10 minutes. C) Temperature of 103.1° F and white blood cell (WBC) count of 16,000 mm3. D) Weakness, diaphoresis, complaints of feeling faint. BP 100/56 mm Hg.
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The RRT should be called to intervene for a client with an acute life-threatening change, such as (B). (A) indicates possible hemorrhage and needs further investigation and monitoring. (B) indicates an infection and (D) may indicate post operative diuresis with corresponding hypotension. Although these symptoms needs prompt collaborative attention, they can be dealt with through normal channels such providing supportive care and calling the healthcare provider.
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The nurse completes visual inspection of a client's abdomen. What technique should the nurse perform next in the abdominal examination? A) Percussion. B) Auscultation. C) Deep palpation. D) Light palpation.
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Auscultation (B) of the client's abdomen is performed next because manual manipulation (A, C, and D) can stimulate the bowel and create false sounds heard during auscultation.
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A client's susceptibility to ulcerative colitis is most likely due to which aspect in the client's history? A) Jewish European ancestry. B) H. pylori bowel infection. C) Family history of irritable bowel syndrome. D) Age between 25 and 55 years.
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Ulcerative colitis is 4 to 5 times more common among individuals of Jewish European or Ashkenazi ancestry (A). H. pylori is associated with stomach inflammation and ulcer development (B). Irritable bowel syndrome (C) does not progress to inflammatory bowel disease. UC has a peak between the ages of 15 and 25 years, then a second peak between 55 and 65 years, not (D).
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A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a cottage-cheese appearance. Which prescription should the nurse implement first? A) Cleanse perineum with warm soapy water 3 times per day. B) Instill the first dose of nystatin (Mycostatin) vaginally per applicator. C) Perform glucose measurement using a capillary blood sample. D) Obtain a blood specimen for sexually transmitted diseases (STDs).
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Candidiasis, also known as a yeast infection, is characterized by a white, vaginal discharge with a cottage-cheese appearance and vaginal nystatin (Mycostatin) should be implemented first (B) to initiate treatment to provide relief of symptoms. (A, C, and D) may implemented after (B).
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While auscultating the lungs of a client who is being mechanically ventilated, the nurse hears coarse, snoring sounds over the upper anterior chest with clear sounds over the other lung fields. Based on these assessment findings, which action should the nurse take? A) Notify respiratory therapy immediately for a PRN bronchodilator treatment. B) Obtain a prescription to increase the tidal volume setting on the ventilator. C) Stop mechanical ventilation and re-assess the client's lung sounds bilaterally. D) Suction the client's endotracheal tube and auscultate following suctioning.
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Coarse, snoring sounds (rhonchi) heard over large upper airways are frequently produced by secretions partially blocking air passages and usually disappear after suctioning (D). (A) is indicated for a bronchospasm, which typically produces wheezing or musical adventitious lung sounds. Increasing the tidal volume (B) does not help resolve the problem. Mechanical ventilators produce noise that makes lung auscultation difficult, but removal of the ventilator to listen to breath sounds (C) is contraindicated, as this may reduce oxygenation.
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The nurse is assessing a client who is bedfast and refuses to turn or move from a supine position. How should the nurse assess the client for possible dependent edema? A) Compress the flank and upper buttocks. B) Measure the client's abdominal girth. C) Gently palpate the lower abdomen. D) Apply light pressure over the shins.
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Dependent edema collects in dependent areas, such as the flank and upper buttocks (A) of the client who is persistently flat in bed. (B) provides data about ascites (fluid collection in the abdomen), rather than dependent edema, and (C) provides data about abdominal distention. (D) provides data about the collection of dependent edema for a client whose lower extremities are often in a dependent position, such as when sitting in a chair.
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In planning care for a client with an acute stroke resulting in right-sided hemiplegia, which positioning should the nurse should use to maintain optimal functioning? A) Mid-Fowler's with knees supported. B) Supine with trochanter rolls to the hips. C) Sim's position alternated with right lateral position q2 hours. D) Left lateral, supine, brief periods on the right side, and prone.
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After an acute stroke, a positioning and turning schedule that minimizes lying on the affected side, which can impair circulation and cause pain, and includes the prone position (D) to help prevent flexion contractures of the hips, prepares the client for optimal functioning and ambulating. (A, B, and C) do not maintain the client for optimal functioning.
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The nurse is assessing a postmenopausal woman who is complaining of urinary urgency and frequency and stress incontinence. She also reports difficulty in emptying her bladder. These complaints are most likely due to which condition? A) Cystocele. B) Bladder infection. C) Pyelonephritis. D) Irritable bladder.
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This constellation of signs in a postmenopausal woman are characteristic of a cystocele (A). These symptoms are not characteristic of (B, C, or D).
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The nurse is assessing a client with a chest tube that is attached to suction and a closed drainage system. Which finding is most important for the nurse to further assess? A) Upper chest subcutaneous emphysema. B) Tidaling (fluctuation) of fluid in the water-seal chamber. C) Constant air bubbling in the suction-control chamber. D) Pain rated 8 (0-10) at the insertion site.
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Subcutaneous emphysema (A) is a complication and indicates air is leaking beneath the skin. Tidaling in the water-seal chamber and constant bubbling with suction in the suction-control chamber (B and C) are expected findings that indicate the closed drainage system is working. Pain at the insertion site is an expected finding (D) and the prescribed analgesia should be given to assist the client to breathe deeply and facilitate lung expansion.
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Which sexually transmitted infection (STI) should the nurse include in a client's teaching plan about the risk for cervical cancer? A) Neisseria gonorrhoea. B) Chlamydia trachomatis. C) Herpes simplex virus. D) Human papillomavirus.
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Human papillomavirus (D) is known to alter cervical epithelium cytology, which is consistent with early changes of cervical cancer. Although STIs (A, B, and C) place the client at risk for exposure to HPV, these are likely to place the client at risk for pelvic inflammatory disease, infertility sequela, and painful reoccurrence.
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A client's family asks why their mother with heart failure needs a pulmonary artery (PA) catheter now that she is in the intensive care unit (ICU). What information should the nurse include in the explanation to the family? A) A central monitoring system reduces the risk of complications undetected by observation. B) A pulmonary artery catheter measures central pressures for monitoring fluid replacement. C) Pulmonary artery catheters allow for early detection of lung problems. D) The healthcare provider should explain the many reasons for its use.
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Pulmonary artery catheters are used to measure central pressures and fluid balance (B). Even though all clients in the ICU require close monitoring, they do not all need a PA catheter (A). PA lines do not detect pulmonary problems (C). (D) avoids the family's question.
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A young adult female reports that she is experiencing a lack of appetite, hypersomnia, stress incontinence, and heart palpitations. Which symptom is characteristic of premenstrual syndrome? A) Heart palpitations. B) Anorexia. C) Hypersomnia. D) Stress incontinence.
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Characteristic features of premenstrual syndrome include heart palpitations (A), sleeplessness, increased appetite and food cravings, and oliguria or enuresis. (B, C, and D) are not consistent with symptoms of premenstrual syndrome.
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The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH). This condition is most often related to which predisposing condition? A) Small cell lung cancer. B) Active tuberculosis infection. C) Hodgkin's lymphoma. D) Tricyclic antidepressant therapy.
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Cancer is the most common cause of the syndrome of inappropriate antidiuretic hormone (SIADH), with small cell lung cancer (A) being the most common cancer that increases ADH, which causes dilutional hyponatremia and fluid retention. (B, C, and D) are also possible causes, but secondary to CNS trauma or disease.
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The unlicensed assistive personnel (UAP) reports that an 87-year-old female client who is sitting in a chair at the bedside has an oral temperature of 97.2° F. Which intervention should the nurse implement? A) Document the temperature reading on the vital sign graphic sheet. B) Report the temperature to the healthcare provider immediately. C) Instruct the UAP to take the client's temperature again in 30 minutes. D) Advise the UAP to assist the client in returning to her bed.
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A subnormal temperature of 97.2° F (orally) is a common finding in elderly clients, so the nurse should document the findings (A) and continue with the plan of care. (B, C, and D) are not indicated unless the temperature falls below 97° F or if other symptoms occur.
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Which client should the nurse report to the healthcare provider as needing a prescription for Rh Immune Globulin (RhoGAM)? A) Woman whose blood group is AB Rh-positive. B) Newborn with rising serum bilirubin level. C) Newborn whose Coombs test is negative. D) Primigravida mother who is Rh-negative.
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RhoGAM is indicated during pregnancy for a woman who is Rh-negative or within 72 of birth of a Rh-positive infant (D). RhoGAM is not indicated for (A, B, and C).
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A 24-year-old female client diagnosed with a human papillomavirus infection (HPV) is angry at her ex-boyfriend and says she is not going to tell him that he is infected. What response is best for the nurse to provide? A) You do not have to tell him because this is not a reportable disease. B) Because there is no cure for this disease, telling him is of no benefit to him or to you. C) Even though you are angry, he should be told, so he can take precautions to prevent the spread of infection. D) You should tell him, so he can feel as guilty and miserable as you do now, knowing that you have this disease.
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Anger is a common emotional reaction when confronted with the diagnosis of a STI, and often lay blame and project this anger at the sexual partner. Although HPV is not a reportable disease in many states, all contacts should be informed of the infection, treatment, transmission, and precautions to minimize infecting others (C). (A and B) provide false information and increase the risk of complications and transmission. (D) is not therapeutic.
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A client with osteoarthritis requests information from the nurse about what type of exercise regimen would be most beneficial for him. The nurse should communicate which information? A) Low impact exercise, walking, swimming and water aerobics. B) Repetitive strength-building exercises with weights or resistance bands. C) Circuit training alternating with frequent rest periods. D) High-impact aerobic exercise.
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Low impact exercises such as walking or swimming (A), that do not cause further harm to damaged joints, are most beneficial to clients with osteoarthritis. Strength-building exercises, circuit training, and high-impact aerobics (B, C and D) may cause too much stress on the joint areas and subsequently increase inflammation and damage.
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A client is admitted to the emergency department after being lost for four days while hiking in a national forest. Upon review of the laboratory results, the nurse determines the client's serum level for thyroid-stimulating hormone (TSH) is elevated. Which additional assessment should the nurse make? A) Body mass index. B) Skin elasticity and turgor. C) Thought processes and speech. D) Exposure to cold environmental temperatures.
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TSH influences the amount of thyroxine secretion which increases the rate of metabolism to maintain body temperature near normal. Prolonged exposure to cold environmental temperatures (D) stimulates the hypothalamus to secrete thyrotropin-releasing hormone, which increases anterior pituitary serum release of TSH. (A) may reflect weight loss from lack of food. Tenting of the skin (B) is indicative of dehydration. Slow or confused thought processes (C) or speech patterns may be related to sleep deprivation.
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The nurse assesses a long-term resident of a nursing home and finds the client has a fungal infection (candidiasis) beneath both breasts. To prevent nosocomial infection, which protocol should the nurse review with the rest of the staff? A) Follow contact isolation procedures. B) Wash hands after caring for the client. C) Wear gloves when providing personal care. D) Restrict pregnant staff or visitors into the room.
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The organism Candida albicans, that causes this infection, is part of the normal flora on the skin of most adults. Good handwashing (B) is all that is needed to prevent nosocomial spread. (A) is not necessary. Standard precautions (C) should be used during moisture management and when applying a prescription for the active infection, but the client is not considered a risk to others (D).
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A client with acute pancreatitis is admitted to the medical unit. During the nurse's admission interview, which assessment has the highest priority? A) History of alcohol intake. B) Time of last meal. C) Frequency of vomiting. D) Intensity of pain.
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The hallmark sign of pancreatitis is severe abdominal pain (D), due to autodigestion of the pancreas by the enzymes amylase and lipase. (A, B, and C) are also important but are of less priority then (D).
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The home health nurse is assessing a client with terminal lung cancer who is receiving hospice care. Which activity should be assigned to the hospice practical nurse (PN)? A) Administer medications for pain relief, shortness of breath, and nausea. B) Clarify family members' feelings about the meaning of client behaviors and symptoms. C) Develop a plan of care after assessing the needs of the client and family. D) Teach the family to recognize restlessness and grimacing as signs of client discomfort.
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Hospice care provides symptom management and pain control during the dying process and enhances the quality of life for a client who is terminally ill. Administering medication and monitoring for therapeutic and adverse effects (A) is within the scope of practice for the PN. Nursing actions that require the skills of the RN include assessing and clarifying the feelings of family members (B), planning care (C), and teaching symptom recognition (D).
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What is the priority nursing action while caring for a client on a ventilator when an electrical fire occurs in the intensive care unit? A) Tell another staff member to bring extinguishing equipment to the bedside. B) Close the doors to the client's area when attempting to extinguish the fire. C) Use a bag-valve-mask resuscitator while removing the client from the area. D) Implement an emergency protocol to remove the client from the ventilator.
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A client on a ventilator should have respirations maintained with a manual bag-valve-mask resuscitator while being moved away from the oxygen wall outlet and fire source (C). (A, B, and D) are not the priority in maintaining client safety during a fire in the client care area.
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The PET (positron emission tomography) scan is commonly used with oncology clients to provide for which diagnostic information? A) A description of inflammation, infection, and tumors. B) Continuous visualization of intracranial neoplasms. C) Imaging of tumors without exposure to radiation. D) An image that describes metastatic sites of cancer.
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PET scans provide information regarding certain diseases of the heart (determination of tissue viability), brain (dementia, Parkinson's disease), and early detection of tumors and their aggressiveness. This diagnostic test scans the body to detect the spread of cancer (metastasis) (D). (A, B, and C) are not the purpose of PET.
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A client with acute appendicitis is experiencing anxiety and loss of sleep about missing final examination week at college. Which outcome is most important for the nurse to include in the plan of care? A) Sleeping six to eight hours. B) Achieve a sense of control. C) Utilize problem solving skills. D) Increased focus of attention.
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The experience of psychological discomfort may be as real as physical pain for the client and should be seen as a priority in care. Because the client is experiencing anxiety, achieving a sense of control is a key need (B) before (A, C and D) are addressed.
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Duplex scanning confirms the presence of a deep venous thrombosis for a client with swelling and pain of the lower leg. While the client is receiving continuous heparin infusion, what actions should the nurse implement? A) Avoid any intramuscular medications to prevent localized bleeding. B) Have vitamin K available in the event the client begins to bleed. C) Notify the healthcare provider if the partial thromboplastin time is greater than 50 seconds. D) Start instruction for self-administered SC heparin injections for long-term home therapy.
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A
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The healthcare provider prescribes high-protein, high-fat, low-carbohydrate diet with limited fluids during meals for a client recovering from gastric surgery. The client asks the nurse what the purpose is for this type of diet. Which rationale should be included in the nurse's explanation to this client? A) It is quickly digested. B) It does not cause diarrhea. C) It does not dilate the stomach. D) It is slow to leave the stomach.
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This type of diet is slowly digested and is slow to leave the stomach (D). Because of its density from proteins and fats, and the reduction of fluids with the meal, the possibility of dumping syndrome is reduced. (A, B, and C) are incorrect rationales.
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A client with a markedly distended bladder is diagnosed with hydronephrosis and left hydroureter after an IV pyelogram. The nurse catheterizes the client and obtains a residual urine volume of 1650 ml. This finding supports which pathophysiological cause of the client's urinary tract obstruction? A) Obstruction at the urinary bladder neck. B) Ureteral calculi obstruction. C) Ureteropelvic junction stricture. D) Partial post-renal obstruction due to ureteral stricture.
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Hydroureter (dilation of the renal pelvis), vesicoureteral reflux (backward movement of urine from the lower to upper urinary tracts), and hydronephrosis (dilation or enlargement of the renal pelvis and calyces) result from post-renal obstruction which can consequently result in chronic pyelonephritis and renal atrophy. Ascending urinary reflux occurs when normal ureteral peristaltic pressure is met with an increase in urinary pressure occurring during bladder filling if the urinary bladder neck is obstructed (A). A large residual urine does not occur with (B, C, and D) because the urine can not get to the bladder.
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The nurse is providing discharge instructions to a client who has undergone a left orchiectomy for testicular cancer. Which statement indicates that the client understands his post-operative care and prognosis? A) I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle. B) I should wear an athletic supporter and cup to prevent testicular cancer in my remaining testicle. C) I should always use a condom because I am at increased risk for acquiring a sexually transmitted disease. D) I should make sure my sons know how to perform TSE because they are at increased risk for this type of cancer.
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Although testicular cancer protocols, such as surgery, radiation, or chemotherapy, focus on the primary site of testicular cancer, these treatments do not reduce the risk of testicular cancer in the remaining testicle, so early recognition is the best prevention. The client's understanding is reflected in the statement to perform monthly TSE for changes in size, shape, or consistency of the testis that may indicate early cancer (A). Although an athletic support (B) protects the testicle from trauma, it does not address the client's understanding of self-care. The client's risk of STD is not related to a history of testicular cancer, but to direct exposure (C). Although continue TSE himself.
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Which finding should the nurse report to the healthcare provider for a client with a circumferential extremity burn? A) Full thickness burns rather than partial thickness. B) Supinates extremity but unable to fully pronate the extremity. C) Slow capillary refill in the digits with absent distal pulse points. D) Inability to distinguish sharp versus dull sensations in the extremity.
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A circumferential burn can form an eschar that results from burn exudate fluid that dries and acts as a tourniquet as fluid shifts occur in the interstitial tissue. As edema increases tissue pressure, blood flow to the distal extremity is compromised, which is manifested by slow capillary refill and absent distal pulses (C), so the healthcare provider should be notified about any compromised circulation that requires escharotomy. Although eschar formation occurs more readily over full thickness burns (A), the circumferential location of the burn is most likely to constrict underlying structures. to pain. (D) may be related to the depth of the burn.
question
The nurse is preparing discharge instructions for a client who is going home with a surgical wound on the coccyx that is healing by second intention. What is the priority nursing diagnosis that should guide the discharge instruction plan? A) Acute pain. B) Risk for infection. C) Disturbed body image. D) Risk for deficient fluid volume.
answer
A wound healing by second intention is an open wound that is at risk for infection (B). Discomfort should be minimal 2 days after surgery, and acute pain (A) is not the priority. Risk for deficient fluid volume (D) requires a significant amount of wound draining, which is not evident. Although a wound may contribute to a disturbed body image (C), the client's distress may be minimal because the wound is not visible to others.
