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Questions and Answers
Which of the following statements by the client indicates an understanding of the preoperative teaching for right knee arthroplasty? (Select all that apply)
Which of the following statements by the client indicates an understanding of the preoperative teaching for right knee arthroplasty? (Select all that apply)
- I will probably be going home with a walker (correct)
- My physical therapy will start after I leave the hospital
- I will be sure to ask for pain medication before my knee starts to hurt too bad (correct)
- I will need to do the breathing exercises every 1 to 2 hours after the surgery (correct)
A client can refuse surgery at any time regardless of previous consent.
A client can refuse surgery at any time regardless of previous consent.
True (A)
Which instructions should the nurse include for a client who is 2 weeks postoperative following a gastrectomy? (Select all that apply)
Which instructions should the nurse include for a client who is 2 weeks postoperative following a gastrectomy? (Select all that apply)
- Consume high-protein snacks (correct)
- Eat several small meals (correct)
- Maintain a high carbohydrate intake
- Avoid drinking fluids with meals (correct)
- Avoid highly seasoned foods (correct)
Dumping syndrome requires a high carbohydrate diet.
Dumping syndrome requires a high carbohydrate diet.
What should a client do regarding physical therapy after knee arthroplasty?
What should a client do regarding physical therapy after knee arthroplasty?
What does an elevated WBC count indicate?
What does an elevated WBC count indicate?
The client's heart rate is within the expected reference range.
The client's heart rate is within the expected reference range.
An elevated potassium level places a client at risk for cardiac dysrhythmias.
An elevated potassium level places a client at risk for cardiac dysrhythmias.
What heart rate indicates improvement in a client's condition?
What heart rate indicates improvement in a client's condition?
What is a respiratory rate indicating improvement?
What is a respiratory rate indicating improvement?
What is the blood pressure reading indicating improvement?
What is the blood pressure reading indicating improvement?
What oxygen saturation level indicates improvement?
What oxygen saturation level indicates improvement?
What should the nurse do as a priority after a parathyroidectomy?
What should the nurse do as a priority after a parathyroidectomy?
Which food has the greatest amount of calcium to recommend after thyroidectomy?
Which food has the greatest amount of calcium to recommend after thyroidectomy?
What statement indicates a client's understanding of telemetry monitoring?
What statement indicates a client's understanding of telemetry monitoring?
Which INR value is desired for a client taking warfarin?
Which INR value is desired for a client taking warfarin?
What should the nurse do after noting a pacemaker artifact followed by a QRS complex?
What should the nurse do after noting a pacemaker artifact followed by a QRS complex?
What should the nurse instruct a client with mechanical ventilation who appears anxious?
What should the nurse instruct a client with mechanical ventilation who appears anxious?
Stress ulcers are associated with long-term mechanical ventilation.
Stress ulcers are associated with long-term mechanical ventilation.
What is the first action for a client unable to void post hip arthroplasty?
What is the first action for a client unable to void post hip arthroplasty?
What statement shows a client's understanding of preventing complications from Lyme disease?
What statement shows a client's understanding of preventing complications from Lyme disease?
What indicates a client is coping successfully with a diagnosis of type 1 diabetes?
What indicates a client is coping successfully with a diagnosis of type 1 diabetes?
What should be included in teaching clients with a history of UTIs?
What should be included in teaching clients with a history of UTIs?
What urine output can contribute to delayed wound healing?
What urine output can contribute to delayed wound healing?
What clinical deficits should a nurse expect after a right-hemispheric stroke?
What clinical deficits should a nurse expect after a right-hemispheric stroke?
Who should a nurse refer to physical therapy preoperatively?
Who should a nurse refer to physical therapy preoperatively?
What should the nurse do for a client with bacterial meningitis?
What should the nurse do for a client with bacterial meningitis?
What oxygen delivery system provides the highest concentration?
What oxygen delivery system provides the highest concentration?
What should the nurse do for a client with MRSA?
What should the nurse do for a client with MRSA?
What finding indicates possible compartment syndrome?
What finding indicates possible compartment syndrome?
What finding indicates lung re-expansion in a client with pneumothorax?
What finding indicates lung re-expansion in a client with pneumothorax?
What medication should the nurse notify the provider about before cataract surgery?
What medication should the nurse notify the provider about before cataract surgery?
When will the nurse remove the drain post-mastectomy?
When will the nurse remove the drain post-mastectomy?
What finding is a priority for a client receiving chemotherapy?
What finding is a priority for a client receiving chemotherapy?
Which conditions does the nurse assess for a client presenting with respiratory symptoms?
Which conditions does the nurse assess for a client presenting with respiratory symptoms?
What actions should the nurse take for a client likely experiencing cholecystitis?
What actions should the nurse take for a client likely experiencing cholecystitis?
What condition is the client likely experiencing with increased respiratory rate?
What condition is the client likely experiencing with increased respiratory rate?
Match the following prescriptions with their classification for the client:
Match the following prescriptions with their classification for the client:
Which of the following actions should the nurse take after reviewing the client's EMR? (Select 3 actions)
Which of the following actions should the nurse take after reviewing the client's EMR? (Select 3 actions)
Which of the following statements made by the client indicates an understanding of discharge teaching? (Select all that apply)
Which of the following statements made by the client indicates an understanding of discharge teaching? (Select all that apply)
How often should a client with AIDS take their temperature?
How often should a client with AIDS take their temperature?
What prescription should the nurse expect for a client who sustained a rattlesnake bite?
What prescription should the nurse expect for a client who sustained a rattlesnake bite?
What is an important exercise recommendation for a client with heart failure?
What is an important exercise recommendation for a client with heart failure?
What is the purpose of erythropoietin therapy in clients with chronic kidney disease?
What is the purpose of erythropoietin therapy in clients with chronic kidney disease?
What finding is expected in a client with peripheral arterial disease?
What finding is expected in a client with peripheral arterial disease?
What dietary recommendation should a client taking an oral iron supplement follow?
What dietary recommendation should a client taking an oral iron supplement follow?
What should the nurse do for a client expressing concern about morphine addiction?
What should the nurse do for a client expressing concern about morphine addiction?
The nurse should administer __ mL of phenytoin 600 mg PO daily to a client based on the available concentration.
The nurse should administer __ mL of phenytoin 600 mg PO daily to a client based on the available concentration.
What laboratory finding indicates a myocardial infarction?
What laboratory finding indicates a myocardial infarction?
Which medication is known to interact with feverfew?
Which medication is known to interact with feverfew?
What action should the nurse take when administering packed RBCs?
What action should the nurse take when administering packed RBCs?
What should a nurse instruct a client taking psyllium?
What should a nurse instruct a client taking psyllium?
Which findings in a client with a gastric hemorrhage require follow-up?
Which findings in a client with a gastric hemorrhage require follow-up?
Which findings should the nurse highlight to indicate a potential problem?
Which findings should the nurse highlight to indicate a potential problem?
What should the nurse first address when prioritizing client care?
What should the nurse first address when prioritizing client care?
What are the anticipated actions for a client? (Select all that apply)
What are the anticipated actions for a client? (Select all that apply)
Which findings in the client’s medical record require nursing intervention? (Select 3)
Which findings in the client’s medical record require nursing intervention? (Select 3)
Based on the client's heart rate, which finding should the nurse report to the provider?
Based on the client's heart rate, which finding should the nurse report to the provider?
What sensation does a TENS unit produce when applied to the painful area?
What sensation does a TENS unit produce when applied to the painful area?
Which findings should be identified as a component of Cushing's triad in a client with a traumatic brain injury?
Which findings should be identified as a component of Cushing's triad in a client with a traumatic brain injury?
What should a family do to help a client with Alzheimer's disease select outfits?
What should a family do to help a client with Alzheimer's disease select outfits?
What precaution should be included in the plan of care for a client with burn injuries?
What precaution should be included in the plan of care for a client with burn injuries?
What is the recommended daily fiber intake for a client with irritable bowel syndrome?
What is the recommended daily fiber intake for a client with irritable bowel syndrome?
What urine specific gravity finding is expected in a client with diabetes insipidus?
What urine specific gravity finding is expected in a client with diabetes insipidus?
The IV pump for TPN should be set at _____ mL/hr to provide 2,000 kcal per day.
The IV pump for TPN should be set at _____ mL/hr to provide 2,000 kcal per day.
What finding should a nurse report for a client who is 4 hours postoperative following a vaginal hysterectomy?
What finding should a nurse report for a client who is 4 hours postoperative following a vaginal hysterectomy?
What should a nurse ensure is available at the bedside for a client with dysphagia?
What should a nurse ensure is available at the bedside for a client with dysphagia?
Changing a pet's litter box is safe for a client receiving chemotherapy.
Changing a pet's litter box is safe for a client receiving chemotherapy.
What should a nurse check to ensure a newly applied plaster cast is not too tight?
What should a nurse check to ensure a newly applied plaster cast is not too tight?
An allergy to which food can indicate a latex allergy?
An allergy to which food can indicate a latex allergy?
What should be administered for a client with diabetic ketoacidosis?
What should be administered for a client with diabetic ketoacidosis?
What should a client with esophageal cancer use to clean the radiation area?
What should a client with esophageal cancer use to clean the radiation area?
What should the nurse do for a client experiencing supraventricular tachycardia?
What should the nurse do for a client experiencing supraventricular tachycardia?
What heart rate change should alert the nurse to possible hemorrhage in a postoperative client?
What heart rate change should alert the nurse to possible hemorrhage in a postoperative client?
What is necessary for a client with active tuberculosis until there are three negative cultures?
What is necessary for a client with active tuberculosis until there are three negative cultures?
What blood pressure finding indicates a risk for thyroid storm in a client with hyperthyroidism?
What blood pressure finding indicates a risk for thyroid storm in a client with hyperthyroidism?
How much wider should the skin barrier opening be cut in relation to the stoma?
How much wider should the skin barrier opening be cut in relation to the stoma?
What item should be kept in the room of a client with a sealed radiation implant?
What item should be kept in the room of a client with a sealed radiation implant?
Which supplement can interfere with levothyroxine effectiveness?
Which supplement can interfere with levothyroxine effectiveness?
What should the nurse instruct for a client with a partial-thickness burn on the hand?
What should the nurse instruct for a client with a partial-thickness burn on the hand?
What history finding requires further assessment before a CT scan with IV contrast?
What history finding requires further assessment before a CT scan with IV contrast?
What urine specific gravity finding is indicative of hypertonic dehydration?
What urine specific gravity finding is indicative of hypertonic dehydration?
After administering magnesium sulfate, what adverse effect should the nurse monitor for?
After administering magnesium sulfate, what adverse effect should the nurse monitor for?
What should the nurse do for a client postoperative TURP with clots in the catheter?
What should the nurse do for a client postoperative TURP with clots in the catheter?
What indication shows a client understands self-care for venous insufficiency?
What indication shows a client understands self-care for venous insufficiency?
Where should enoxaparin be injected for better absorption?
Where should enoxaparin be injected for better absorption?
What action can a nurse take to avoid restraining a client with dementia who is agitated?
What action can a nurse take to avoid restraining a client with dementia who is agitated?
What laboratory value indicates an adverse effect of amphotericin B in a client with AIDS?
What laboratory value indicates an adverse effect of amphotericin B in a client with AIDS?
What is the priority assessment finding in a client with acute cholecystitis?
What is the priority assessment finding in a client with acute cholecystitis?
What findings should require follow-up for a nurse in an assessment?
What findings should require follow-up for a nurse in an assessment?
Study Notes
Heart Failure and Digoxin Toxicity
- Heart rate of 55/min indicates potential digoxin toxicity; report to provider.
- Baseline heart rate was 74/min, showing a significant decrease.
TENS Unit for Pain Management
- TENS unit application leads to a tingling sensation that may alleviate pain.
- Small electric currents allow the client to adjust until pain is overridden.
Cushing's Triad and Brain Injury
- Bradycardia is a sign of increased intracranial pressure, part of Cushing's triad.
- Other components include severe hypertension and widened pulse pressure.
Alzheimer's Disease Care
- Encourage family to create and present complete outfits for daily selection by the client.
Infection Precautions for Burn Victims
- Avoid live plants or flowers in the room to prevent Pseudomonas aeruginosa infections.
Irritable Bowel Syndrome (IBS) Management
- Increase dietary fiber intake to at least 30 g daily to promote regular bowel patterns.
Diabetes Insipidus Assessment
- Expect low urine specific gravity (1.001 - 1.005) due to decreased water reabsorption.
Total Parenteral Nutrition (TPN) Calculation
- IV pump setting: Approximately 167 mL/hr for 2000 kcal with a solution of 500 kcal/L.
Postoperative Care Following Hysterectomy
- Report saturated perineal pad and large clots; indicate possible hemorrhage.
Dysphagia Precautions
- Keep a suction machine at bedside for clients with dysphagia to ensure airway clearance.
Chemotherapy Infection Prevention
- Client should avoid changing pet litter boxes to prevent exposure to toxoplasmosis.
Cast Care Protocol
- Ensure one finger fits beneath the cast to prevent complications from tightness.
Allergies and Latex Sensitivity
- Allergies to avocados may suggest a latex allergy; monitor for reactions.
Management of Diabetic Ketoacidosis (DKA)
- Administer regular insulin IV bolus (20 units) for managing DKA complications.
Radiation Therapy for Esophageal Cancer
- Clean the radiation area with hands rather than using a washcloth for skin protection.
Supraventricular Tachycardia Intervention
- Synchronized cardioversion is indicated for heart rates >200/min with low blood pressure.
Postoperative Hemorrhage Indicators
- Increased heart rate to 110/min may signify hemorrhaging after nephrectomy.
Tuberculosis Management
- Obtain sputum specimens every 2-4 weeks until three negative cultures confirm no infectious status.
Hyperthyroidism Priority Assessment
- Blood pressure of 170/80 mm Hg is critical; indicates a risk for thyroid storm.
Ureterostomy Teaching
- Skin barrier opening should be cut 1/8 inch wider than the stoma to minimize irritation.
Radiation Implant Safety
- Keep a lead-lined container in the room for potential dislodgement of a sealed radiation implant.
Levothyroxine Administration Guidance
- Advise clients to avoid calcium supplements within 4 hours of taking levothyroxine to prevent interference.
Burn Care Instructions
- Wrap fingers with individual dressings to promote healing and functional mobility.
CT Scan Precautions
- History of asthma requires further assessment due to potential contrast dye reactions.
Hypertonic Dehydration Indicator
- Urine specific gravity of 1.045 suggests hypertonic dehydration.
Magnesium Sulfate Adverse Effects
- Monitor for respiratory paralysis, a life-threatening effect of magnesium sulfate administration.
Indwelling Catheter Management Post TURP
- Irrigate the urinary catheter to remove clots and restore urine flow.
Venous Insufficiency Self-Care
- Daily usage of clean graduated compression stockings is vital for management.
Enoxaparin Administration
- Inject medication into the anterolateral abdominal wall to enhance absorption and reduce hematoma risk.
Dementia Care Strategies
- Engage clients with manual activities to prevent agitation and distraction from IV catheters.
Amphotericin B Monitoring
- Elevated BUN indicates possible nephrotoxicity associated with amphotericin B treatment.
Acute Cholecystitis Priority Findings
- Tachycardia is a priority assessment finding; may indicate impending shock.
Assessment Follow-Up Findings
- Significant findings include weight loss, abdominal pain, guarding, and elevated temperature, necessitating further evaluation.
Diagnosing Appendicitis vs. Crohn's Disease
- Pain location, temperature, and GI concerns support both appendicitis and Crohn's Disease.
Care Prioritization Framework
- Address abdominal findings first, focusing on inflammatory markers to prevent complications.
Anticipated vs. Contraindicated Actions
- Anticipate obtaining blood cultures and vital signs; contraindications include bolus IV fluids when stable.
Postoperative Preparations
- Ensure informed consent, administer gentamicin, and prepare for an exploratory laparotomy if necessary.### Patient Care Guidelines
- Schedule multiple rest periods daily for recovery post-exploratory laparotomy.
- Monitor and report temperature exceeding 101°F as a potential infection indicator post-surgery.
HIV Client Education
- Daily temperature checks are essential for clients with AIDS, with a fever threshold of 37.8°C (100°F) indicating possible infection.
Emergency Management
- For rattlesnake bites, expect prescriptions for opioid analgesics to alleviate pain.
Heart Failure Management
- Encourage clients with heart failure to maintain a regular walking routine, ideally at least three times weekly.
Chronic Kidney Disease Treatment
- Erythropoietin is administered to enhance energy levels and increase hematocrit in patients with anemia.
Peripheral Arterial Disease Signs
- Expect hair loss on lower legs as a characteristic finding due to inadequate arterial circulation.
Iron Supplement Teaching
- Advise an increase in high-fiber foods to mitigate constipation, a common side effect of oral iron supplements.
Pain Management Alternatives
- For clients hesitant about morphine due to addiction fears, suggest nonpharmacologic therapies like relaxation and distraction techniques.
Medication Dosage Calculation
- Administer 24 mL of phenytoin oral solution for a daily dose of 600 mg, based on available strength.
Myocardial Infarction Indicators
- An elevated troponin level (18 ng/mL) is a significant marker of myocardial infarction.
Drug Interactions
- Beware of potential bleeding risks when using feverfew alongside naproxen due to both impairing platelet aggregation.
Blood Transfusion Safety
- Remain with the client for the first 15-30 minutes of packed RBC transfusion to monitor for hemolytic reactions.
Psyllium Administration
- Recommend drinking 240 mL (8 oz) of water after taking psyllium to enhance effectiveness.
Emergency Response Sequence
- Prioritize oxygen administration via nonrebreather mask, followed by IV therapy, NG tube insertion, and famotidine administration for shock management in gastric hemorrhage.
Allergy Testing Considerations
- Postpone allergy skin testing if the client is on specific medications (e.g., ACE inhibitors or glucocorticoids) that can affect test results.
Fall Prevention Strategies
- Educate families of hemianopsia clients to encourage visual scanning during ambulation to reduce fall risk.
External Fixation Device Safety
- Instruct clients with external fixation devices to use crutches equipped with rubber tips to prevent falls.
HIV Treatment Monitoring
- A decreased viral load indicates effective response to HIV treatment.
Symptoms of Pernicious Anemia
- Glossitis (smooth red tongue) can signal pernicious anemia, often resulting from vitamin deficiencies.
Follow-Up Diagnostic Findings
- Elevated BUN, WBC count, PCO2, and decreased oxygen saturation levels necessitate nursing follow-up for intervention.
Identifying Client Improvement
- Monitor heart rate (72 bpm), respiratory rate (20/min), blood pressure (128/56 mm Hg), and oxygen saturation (95%) to assess client health status improvement.
Postoperative Priority Actions
- After parathyroidectomy, ensure a tracheostomy tray is readily available to address potential airway obstructions.
Dietary Recommendations Post-Thyroidectomy
- Advise inclusion of foods high in calcium, such as 12 almonds, to prevent hypocalcemia following removal of parathyroid glands.
Continuous Telemetry Monitoring
- Educate clients with cardiac dysrhythmias on the importance of continuous telemetry monitoring for real-time heart rhythm assessment.### Pacemaker Management
- Telemetry assesses the functionality of heart pacemaker cells by detecting cardiac impulses.
Warfarin Therapy
- Desired INR for clients on warfarin for chronic atrial fibrillation is 2.5, within a therapeutic range of 2 to 3.
- Warfarin reduces risks of stroke, MI, and PE by preventing blood clot formation.
Pacemaker Artifact
- A pacemaker artifact appears as a spike on an ECG, followed by a QRS complex indicating successful depolarization.
Mechanical Ventilation
- Clients on mechanical ventilation may exhibit anxiety; instructing them to relax and let the machine breathe for them is essential.
- High-pressure alarms indicate resistance that may be alleviated through calming interventions.
Complications of Mechanical Ventilation
- Long-term mechanical ventilation can lead to stress ulcers due to increased hydrochloric acid secretion.
Postoperative Urinary Retention
- If a postoperative client cannot void, the first action is to assess bladder volume using a portable ultrasound.
Lyme Disease
- Joint pain in Lyme disease indicates progression from stage I to II if untreated, leading to chronic issues in later stages.
Diabetes Management
- Regular foot inspections reflect adaptive coping strategies in newly diagnosed type 1 diabetes clients.
Preventing Urinary Tract Infections
- Daily cranberry supplements or low-fructose cranberry juice can help reduce UTI risk by preventing bacterial adherence.
Pressure Injury Wound Healing
- Low urine output (25 mL/hr) can signal dehydration, hindering wound healing in pressure injuries.
Stroke Recovery Expectations
- Clients post right-hemispheric stroke may show visual-spatial deficits, left hemianopsia, and one-sided neglect.
Physical Therapy Referrals
- Clients undergoing preoperative teaching for knee arthroplasty should be referred to physical therapy for education on postoperative care.
Dementia Care
- Personal items like photographs at the bedside can provide cognitive support for clients with dementia.
Infection Control
- For clients with bacterial meningitis, droplet precautions require masks for nursing staff.
Oxygen Delivery for Pneumonia
- A nonrebreather mask is recommended for clients with fluctuating low oxygen levels to provide high-concentration oxygen.
MRSA Infection Control
- Bathing with chlorhexidine solution decreases the risk of MRSA transmission during care.
Compartment Syndrome Symptoms
- Pain increasing with passive movement indicates potential compartment syndrome, requiring immediate attention.
Closed-Chest Drainage Monitoring
- The absence of bubbling in the water seal chamber signifies lung re-expansion after pneumothorax treatment.
Preoperative Medication Review
- Warfarin is contraindicated for clients scheduled for cataract surgery due to increased bleeding risk.
Post-Surgery Drain Management
- A drainage system post-mastectomy will be removed when output is 25 mL or less over 24 hours.
Monitoring for Chemotherapy Complications
- A sore throat in chemotherapy patients may indicate infection risk and requires prompt assessment.
Assessment of Respiratory Conditions
- Key manifestations of emphysema, asthma, and pneumonia are similar, including respiratory rates, cough, and corresponding vital signs.
Cholecystitis Management in the ED
- Administer opioid analgesics like morphine for pain in clients suspected of cholecystitis; maintain them NPO.
Postoperative Norms for Knee Arthroplasty
- Clients should practice breathing exercises and request pain medication proactively after knee surgery.
Post-Gastrectomy Dietary Teaching
- Post-gastrectomy clients should avoid drinking fluids with meals, consume small meals, choose high-protein snacks, and limit seasoned foods.
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Description
Test your knowledge on adult medical-surgical nursing practices with these flashcards. Covering essential topics related to heart failure and patient follow-up care, this quiz helps reinforce critical concepts. Perfect for nurses preparing for exams or enhancing their clinical skills.
