PN Adult Medical Surgical Practice 2023
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Questions and Answers

Which of the following interventions should the nurse include in the plan of care?

  • Administer an antiemetic to the client. (correct)
  • Encourage ambulation.
  • Perform deep breathing exercises.
  • Increase fluid intake.
  • What statement indicates a client understands teaching about chronic kidney disease management?

    I will limit my daily intake of protein.

    What instruction should the nurse include in the discharge plan for a client following total hip arthroplasty?

    Obtain a raised toilet seat.

    What action should the nurse take to prepare a client suspected of having a myocardial infarction for an ECG?

    <p>Cleanse the client's skin prior to electrode placement.</p> Signup and view all the answers

    Which prescription should the nurse verify with the provider before administering medications?

    <p>Ceftriaxone.</p> Signup and view all the answers

    What finding should the nurse anticipate in a client with acute pancreatitis?

    <p>Elevated serum amylase level.</p> Signup and view all the answers

    Select the findings that require follow-up by the nurse.

    <p>Visual disturbances</p> Signup and view all the answers

    Match the following findings with their potential conditions.

    <p>Nausea = Migraine, Meningitis Visual changes = Migraine, Stroke, Meningitis Pain = Migraine, Stroke, Meningitis Family history = Migraine, Stroke</p> Signup and view all the answers

    The nurse should identify that the client is most likely experiencing a ______ and should address the client's ______.

    Signup and view all the answers

    What finding should the nurse report before administering furosemide?

    <p>Decreased potassium</p> Signup and view all the answers

    Withdrawal from which medication precipitated the adrenal crisis?

    <p>Prednisone</p> Signup and view all the answers

    What should the nurse do if the client's apical pulse is 58/min while taking digoxin?

    <p>Withhold the dose.</p> Signup and view all the answers

    How often should a client with diabetes mellitus have their HbA1c checked?

    <p>Twice per year.</p> Signup and view all the answers

    Which instructions should the nurse include about transmission-based precautions for Clostridium difficile? (Select all that apply)

    <p>Provide the client with disposable utensils and dishes for meals.</p> Signup and view all the answers

    What should be added to the diet of a client with coronary artery disease?

    <p>Oily fish twice weekly.</p> Signup and view all the answers

    What is Mohs surgery?

    <p>Mohs surgery is a horizontal shaving of thin layers of the tumor.</p> Signup and view all the answers

    What change associated with aging should a nurse expect regarding taste?

    <p>Food tastes bland even after seasoning.</p> Signup and view all the answers

    What food choice should increase vitamin C intake for better absorption of iron supplements?

    <p>1 cup of boiled broccoli.</p> Signup and view all the answers

    What should the nurse check first in a client who is postoperative after a foot amputation?

    <p>Check the incisional dressing.</p> Signup and view all the answers

    For the postoperative client, which actions should the nurse take? (Select all that apply)

    <p>Report the client's urinary output to the charge nurse.</p> Signup and view all the answers

    Which nursing interventions should be indicated for a client receiving dialysis? (Select all that apply)

    <p>Place the client in reverse Trendelenburg position.</p> Signup and view all the answers

    What is an important reminder for a client using nystatin suspension for oral candidiasis?

    <p>Swish the medication in their mouth.</p> Signup and view all the answers

    What precaution should be included for a caregiver of a client with a halo vest?

    <p>Change the sheepskin liner weekly.</p> Signup and view all the answers

    How many calories will a client receive in 12 hours with a continuous tube feeding of 60 mL/hr at 1.2 cal/mL?

    <p>864 cal.</p> Signup and view all the answers

    Which insulin should be withdrawn first when preparing regular and NPH insulin?

    <p>Regular insulin.</p> Signup and view all the answers

    What should the nurse do first when assisting a client out of bed 4 hours after laparoscopic cholecystectomy?

    <p>Obtain the client's blood pressure.</p> Signup and view all the answers

    What finding should a nurse expect in a client with age-related macular degeneration?

    <p>Distorted central vision of the eyes.</p> Signup and view all the answers

    What food could improve the taste of bland food on a low-sodium diet?

    <p>Lemon juice.</p> Signup and view all the answers

    What tube should the nurse select for a client with peptic ulcer disease needing a gastric sump tube?

    <p>Clear with blue tube.</p> Signup and view all the answers

    What intervention should a nurse include in the care plan for a client with tuberculosis (TB)?

    <p>Place the client in a negative-pressure airflow room.</p> Signup and view all the answers

    Which interprofessional team member should the nurse recommend a referral to for a stroke patient before oral intake?

    <p>Speech-language pathologist.</p> Signup and view all the answers

    What white blood cell count should a nurse identify as a complication of surgery?

    <p>WBC count of 15,000/mm3.</p> Signup and view all the answers

    What indicates understanding of pursed-lip breathing for a client with COPD?

    <p>Pursed-lip breathing works best for activities like walking up stairs.</p> Signup and view all the answers

    What information about joint protection should be included for a client with rheumatoid arthritis?

    <p>Apply cold packs to the inflamed joints.</p> Signup and view all the answers

    What indicates a client understands the process of dealing with mitral valve disease?

    <p>I should call my doctor if my ankles swell.</p> Signup and view all the answers

    What adverse effect should be mentioned for corticosteroid use in a client with asthma?

    <p>Orthostatic hypotension.</p> Signup and view all the answers

    What contraindication should be recognized for hormone replacement therapy in a client with a history of blood clots?

    <p>History of treatment for blood clots.</p> Signup and view all the answers

    What intervention should be included in the care plan for a COPD client who is dyspneic?

    <p>Encourage abdominal breathing.</p> Signup and view all the answers

    What birth control method is contraindicated for a client with a history of breast cancer?

    <p>Combination oral contraceptives.</p> Signup and view all the answers

    What statement indicates a client understands about preventing complications of peripheral vascular disease?

    <p>I don't cross my legs anymore.</p> Signup and view all the answers

    What outcome should a nurse expect from digoxin in a client with heart failure?

    <p>Decreased shortness of breath.</p> Signup and view all the answers

    What suggestion should be made to a client on chemotherapy who reports loss of appetite and taste?

    <p>Eat several small-portioned meals daily.</p> Signup and view all the answers

    Which findings in a newly admitted client require follow-up? (Select the 3 that apply)

    <p>Wound dressing.</p> Signup and view all the answers

    What condition is the client most likely experiencing based on respiratory findings?

    <p>Hemothorax.</p> Signup and view all the answers

    What should the nurse attend to first in a client regarding oxygenation?

    <p>Oxygenation.</p> Signup and view all the answers

    For each provider prescription, specify if it is anticipated or contraindicated. Which of the following prescriptions are anticipated or contraindicated?

    <p>Prepare the client for chest tube insertion.</p> Signup and view all the answers

    What actions should the nurse take following chest tube placement? (Select all that apply)

    <p>Place the client in high-Fowler's position.</p> Signup and view all the answers

    What findings indicate that the client's condition is improving after chest tube insertion? (Select all that apply)

    <p>Client reports shortness of breath has decreased.</p> Signup and view all the answers

    What should the nurse do first when preparing to suction a client with a tracheostomy?

    <p>Ventilate the client with 100% oxygen.</p> Signup and view all the answers

    What statement indicates an understanding of tuberculosis (TB) transmission risk?

    <p>I can develop TB by breathing in the infection.</p> Signup and view all the answers

    Which steps should a nurse follow if a client begins to have a seizure? (Place these in the correct order)

    <p>Time the length of the client's seizure.</p> Signup and view all the answers

    What complication of IV therapy is indicated by a hardened vein and pain at the site?

    <p>Thrombophlebitis.</p> Signup and view all the answers

    Which client should the nurse prioritize seeing first after the change of shift?

    <p>A client who is dehydrated, has mental confusion, and has tried to get out of bed several times.</p> Signup and view all the answers

    What information should be included in teaching about a continuous passive motion (CPM) machine? (Select all that apply)

    <p>The machine will help in your rehabilitation process.</p> Signup and view all the answers

    What action should be implemented to prevent aspiration in a client with difficulty swallowing?

    <p>Give the client liquids with increased viscosity.</p> Signup and view all the answers

    What should the nurse do for a client with Ménière's disease?

    <p>Implement a plan of care addressing symptoms and treatment.</p> Signup and view all the answers

    Which of the following interventions should the nurse include in the plan of care?

    <p>Administer an antiemetic to the client</p> Signup and view all the answers

    What statement indicates the client's understanding of teaching about chronic kidney disease management?

    <p>I will limit my daily intake of protein.</p> Signup and view all the answers

    What should the nurse include in the discharge plan for a postoperative client following a total hip arthroplasty?

    <p>Obtain a raised toilet seat.</p> Signup and view all the answers

    What action should the nurse take to prepare a client suspected of having a myocardial infarction for an ECG?

    <p>Cleanse the client's skin prior to electrode placement.</p> Signup and view all the answers

    Which prescription should the nurse verify with the provider?

    <p>Ceftriaxone.</p> Signup and view all the answers

    What finding should the nurse anticipate in a client with acute pancreatitis?

    <p>Elevated serum amylase level.</p> Signup and view all the answers

    Select the 3 findings that require follow-up by the nurse.

    <p>Headache</p> Signup and view all the answers

    Match the following findings with their disease processes:

    <p>Nausea = Migraine, Meningitis Visual changes = Migraine, Stroke, Meningitis Pain = Migraine, Stroke, Meningitis Family history = Migraine, Stroke</p> Signup and view all the answers

    Following the administration of sumatriptan, the nurse should monitor for ______ due to the risk for ______.

    <p>chest pain, myocardial ischemia</p> Signup and view all the answers

    Which of the following statements by the client indicates understanding of discharge teaching for migraines?

    <p>Foods that contain tyramine might trigger my headaches.</p> Signup and view all the answers

    What action should the nurse take for a postoperative client with a portable wound bulb suction device?

    <p>Compress the bulb reservoir and then close the drainage valve.</p> Signup and view all the answers

    What statement should the nurse include in teaching for a client with Crohn's disease?

    <p>Maintain a low-residue diet.</p> Signup and view all the answers

    What action should the nurse take to reduce confusion in a client with dementia due to Alzheimer's disease?

    <p>Encourage reminiscence of past experiences.</p> Signup and view all the answers

    Which finding should the nurse recognize as priority for a postoperative client with an epidural infusion?

    <p>Dyspnea.</p> Signup and view all the answers

    What instruction should the nurse include in teaching post-surgery regarding wound care?

    <p>Report purulent drainage to the provider.</p> Signup and view all the answers

    What finding should the nurse expect when caring for a client undergoing testing for multiple sclerosis?

    <p>Muscle spasticity.</p> Signup and view all the answers

    What statement by the client indicates understanding of the teaching regarding leg cast removal?

    <p>I will feel vibrations on my leg from the cast cutter.</p> Signup and view all the answers

    What statement indicates understanding of osteoporosis prevention?

    <p>I will limit my coffee intake.</p> Signup and view all the answers

    What medication should the nurse expect for a client experiencing heroin withdrawal?

    <p>Methadone.</p> Signup and view all the answers

    What manifestation should the nurse anticipate in a client with hypothyroidism?

    <p>Bradycardia.</p> Signup and view all the answers

    What intervention should the nurse include in the plan for a client post-total knee arthroplasty?

    <p>Assist the client to change positions at least every 2 hr.</p> Signup and view all the answers

    What finding should the nurse report as possible melanoma?

    <p>Irregular borders.</p> Signup and view all the answers

    What statement by the client indicates understanding of GERD teaching?

    <p>I should wait at least 2 hours after eating before going to bed.</p> Signup and view all the answers

    What finding indicates therapeutic effectiveness in a client receiving treatment for AIDS-related pneumonia?

    <p>Decrease in exertional dyspnea.</p> Signup and view all the answers

    Which of the following client statements indicates understanding of using budesonide and albuterol inhalers? (Select all that apply)

    <p>I never forget to rinse my mouth after using my budesonide inhaler.</p> Signup and view all the answers

    What information should the nurse include about genital herpes?

    <p>The virus can be transmitted without lesions being present.</p> Signup and view all the answers

    What nursing intervention should be implemented for a client with neutropenia?

    <p>Limit visitors to healthy adults.</p> Signup and view all the answers

    What action should the nurse take to decrease episodes of dumping syndrome post-gastrectomy?

    <p>Place the client in the supine position after meals.</p> Signup and view all the answers

    What should the nurse recommend to promote comfort for a client with osteoarthritis?

    <p>Sleep on a firm mattress.</p> Signup and view all the answers

    What intervention should be included in the plan of care for a client with pertussis?

    <p>Apply a mask to the client if transport is needed.</p> Signup and view all the answers

    What information should be included in teaching about HbA1c testing for a client with diabetes?

    <p>HbA1c results measure glucose control for the prior 3 months.</p> Signup and view all the answers

    What action should be included in the plan for a client at risk for increased intracranial pressure due to a head injury?

    <p>Use a turn sheet to reposition the client.</p> Signup and view all the answers

    What instruction should be included for a client with cirrhosis regarding diet?

    <p>Consume foods that are low in sodium.</p> Signup and view all the answers

    What information should the nurse include regarding tuberculosis (TB) for a client on isoniazid and rifampin?

    <p>Household family members should be tested for TB.</p> Signup and view all the answers

    What intervention should the nurse take when preparing to remove a client's NG tube to reduce aspiration risk?

    <p>Pinch the NG tube.</p> Signup and view all the answers

    What laboratory result indicates the client is experiencing a myocardial infarction?

    <p>Elevated troponin.</p> Signup and view all the answers

    The client is experiencing manifestations of ______ due to the client's ______.

    <p>peritonitis, abdominal x-ray results</p> Signup and view all the answers

    What should the nurse do if a client reports pain and swelling at the IV site during sodium chloride infusion?

    <p>Check IV site, stop infusion, withdraw the IV catheter, elevate the affected arm, notify the charge nurse.</p> Signup and view all the answers

    Study Notes

    Medication Administration and Monitoring

    • Furosemide should not be administered if potassium levels are decreased due to risk of hypokalemia.
    • In adrenal crisis, withdrawal from prednisone can precipitate symptoms.
    • Digoxin must be withheld if the apical pulse is below 60 beats per minute.
    • HbA1c should be checked twice a year for diabetes management.
    • Regular and NPH insulin should be prepared by drawing the regular insulin first.

    Patient Care and Dietary Considerations

    • Clients with Clostridium difficile should use disposable utensils and clean surfaces with bleach; blood pressure cuffs should remain in the client's room.
    • Oily fish should be included in the diet for those with coronary artery disease to improve health.
    • Vitamin C-rich foods, like boiled broccoli, enhance absorption of oral iron supplements.
    • For clients on a low-sodium diet, introduce lemon juice to improve food flavor.

    Surgical and Postoperative Care

    • Monitor incisional dressings and report any unusual findings postoperatively.
    • In the case of a hemothorax, follow-up necessary findings include oxygen saturation levels and pain intensity.
    • Chest tubes require secure connections and proper position of the client for optimal drainage.

    Respiratory and Cardiac Considerations

    • Pursed-lip breathing is beneficial in COPD management, especially during physical activities.
    • Orthostatic hypotension can occur as an adverse effect of corticosteroids in asthma patients.
    • Chest x-rays are not indicated when the patient has hypotension and is stable on other management strategies.

    Nursing Interventions and Education

    • Proper protocols should be followed for clients experiencing seizure activity, including protecting the patient's head and timing the seizure.
    • Use of a continuous passive motion (CPM) machine includes ensuring the knee is moved as prescribed.
    • Instruct clients with difficulty swallowing to consume thicker liquids to prevent choking.

    Health Promotion and Safety Measures

    • Clients with rheumatoid arthritis should apply cold packs to inflamed joints for pain relief.
    • Regular monitoring is essential for clients with heart failure and those receiving anticoagulants following surgical procedures.
    • Families of clients with halo vests need to be educated on hygiene practices like changing liners.

    Recognizing Complications and Disease Management

    • High white blood cell counts post-surgery could indicate infection.
    • Understanding and managing chronic kidney disease includes dietary protein restrictions.
    • Birth control methods that contain estrogen, like combination oral contraceptives, are contraindicated in clients with a history of breast cancer.

    Home Health and Discharge Planning

    • Clients should be advised against crossing their legs to prevent complications from peripheral vascular disease.
    • Safe discharge post-hip arthroplasty involves ensuring mobility aids like raised toilet seats are available for client use.

    Clinical Scenario Management

    • When caring for a client after a penetrating chest wound, monitor vital signs carefully for changes indicating complications like hemothorax.
    • Always prioritize oxygenation followed by blood pressure stabilization in emergency situations.
    • Ensure that hand hygiene and infection control practices are enforced when managing clients with tuberculosis.### Elevated Serum Amylase Level
    • Elevated amylase levels may indicate conditions such as pancreatitis, pancreatic duct obstruction, or perforated peptic ulcer.

    Client Assessment Findings

    • Visual disturbances, particularly flashing lights, may suggest migraines or neurologic issues.
    • Throbbing pain behind the left eye, rated a 7/10, may relate to migraines; photophobia and nausea are common migraine symptoms.
    • Vital signs reflect mild tachycardia (112 bpm) and elevated respiratory rates (22/min), alongside normal blood pressure (138/80 mm Hg) and stable oxygen saturation (98% on room air).

    Neurological Condition Follow-up

    • Follow-up required for visual disturbances, headache, and nausea as potential indicators of migraine, stroke, or meningitis.

    Diagnosis Consistency

    • Nausea can indicate a migraine or meningitis.
    • Visual changes are associated with migraine, stroke, or meningitis.
    • Headache is common in all three conditions: migraine, stroke, and meningitis.

    Migraine Management

    • The likely diagnosis for the client experiencing headache and symptoms is migraine.
    • Pain management is essential in addressing a client's migraine.

    Nursing Interventions for Migraine

    • Anticipated interventions include administering sumatriptan and dimming lights in the client's room for comfort.

    Monitoring Post-Sumatriptan

    • Chest pain should be monitored after sumatriptan administration due to the risk of myocardial ischemia.

    Discharge Instructions Post-Migraine

    • Clients should be educated on dietary triggers, tracking food and headache occurrences, and using cool compresses during migraine attacks to manage symptoms effectively.

    Postoperative Care with Wound Suction

    • To care for a client with a portable wound bulb suction device, compress the bulb reservoir and close the drainage valve effectively.

    Dietary Teaching for Crohn's Disease

    • A low-residue diet is recommended for managing Crohn's disease and minimizing gastrointestinal irritations.

    Dementia Care Strategies

    • Encouraging reminiscence of past experiences can help reduce confusion in clients with dementia due to Alzheimer's disease.

    Postoperative Priority Findings

    • Dyspnea is a priority finding in clients with an epidural infusion due to the risk for respiratory complications.

    Wound Care Education

    • Report any purulent drainage from surgical sites to healthcare providers during discharge education.

    Multiple Sclerosis Anticipations

    • Muscle spasticity is commonly expected in clients testing for multiple sclerosis.

    Cast Removal Understanding

    • Clients should be aware they may feel vibrations from the cast cutter during removal.

    Osteoporosis Prevention Teaching

    • Limiting coffee intake is advised to aid in osteoporosis prevention understanding.

    Substance Withdrawal Management

    • Methadone is typically prescribed for clients undergoing withdrawal from heroin.

    Hypothyroidism Manifestations

    • Bradycardia is a common symptom to anticipate in clients with hypothyroidism.

    Postoperative Mobility Interventions

    • Encourage clients to change positions at least every 2 hours post knee arthroplasty surgery to prevent complications.

    Skin Lesions Evaluation

    • Irregular borders of skin lesions should be reported as potential melanoma indicators.

    GERD Education

    • Waiting at least 2 hours after eating before lying down is a recommended practice for GERD management.

    Effectiveness of Pneumonia Therapy

    • A decrease in exertional dyspnea indicates the effectiveness of intervention for clients with AIDS-related pneumonia.

    Asthma Inhaler Education

    • Clients should rinse their mouths post-budesonide inhaler use, keep records on albuterol inhaler usage, utilize albuterol before swimming, and understand inhalation order.

    Genital Herpes Awareness

    • The herpes virus can be transmitted even when lesions are not present, highlighting the importance of safe practices.

    Neutropenia Care Protocols

    • To protect a neutropenic client, limit visitors to healthy adults.

    Post-Gastrectomy Measures

    • Keeping clients in a supine position after meals can help minimize episodes of dumping syndrome.

    Osteoarthritis Comfort Strategies

    • Sleeping on a firm mattress can enhance comfort for clients with osteoarthritis.

    Droplet Precautions for Pertussis

    • Apply a mask to clients suspected of having pertussis during transport to prevent transmission.

    HbA1c Testing for Diabetes Management

    • HbA1c results reflect glucose control over the previous three months, essential for managing diabetes.

    Managing Increased Intracranial Pressure

    • Using a turn sheet is advised to reposition clients at risk for increased ICP post head injury.

    Cirrhosis Dietary Guidelines

    • Low-sodium food consumption is critical for clients with cirrhosis to manage fluid retention and complications.

    Tuberculosis Education

    • Household members of clients with tuberculosis should undergo testing to prevent further spread.

    NG Tube Removal Protocol

    • Pinching the NG tube is essential to minimize aspiration risks prior to removal.

    Myocardial Infarction Indicators

    • Elevated troponin levels are a key indicator of myocardial infarction.

    Peritonitis Signs and Symptoms

    • Cloudy dialysate, abdominal pain, fever, and red/warm dialysis access site indicate peritonitis in clients undergoing peritoneal dialysis.

    Burn Injury Risks

    • Clients with burn injuries face risks of hypovolemia and respiratory failure during the emergent phase of care.

    Prostate Cancer Symptoms

    • Tumor obstruction of the urethra is a common cause of urinary difficulties in clients with prostate cancer.

    Cholecystitis Management

    • Actions for cholecystitis include administering morphine IV, ensuring the client remains NPO, while monitoring for jaundice and increasing temperature.

    IV Site Complications Management

    • Steps for managing pain and swelling at the IV site: check the IV site, stop the infusion, withdraw the catheter, elevate the arm, and notify the charge nurse.

    Respiratory Disease Findings

    • Symptoms like elevated temperature, specific breath sounds, respiratory rate of 26/min, and cough may indicate pneumonia, asthma, or emphysema.

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