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Med Surg 1 Exam 3
Questions and Answers
1. The nurse instructs a client about how to increase folic acid in the diet. The nurse determines teaching is effective if the client makes which statement? a) "I like oatmeal for breakfast." b) "My favorite lunch is a spinach salad." c) "I will eat more grapes, apples, and bananas each day." d) "I will eat more chicken.": b) "My favorite lunch is a spinach salad." spinach contains 108 mg of folic acid per half-cup serving; other folate-rich sources include organ meats, broccoli, asparagus, milk, orange juice, wheat germ and Grape- Nuts 2. The nurse cares for a client with a nasogastric tube in place. The client reports discomfort in the back of the throat. Which action by the nurse isBEST? a) Move the tube out 2 inches b) Change feedings to full liquids c) Reinsert tube into other nostril
d) Spray with viscous lidocaine solution: d) Spray with viscous lidocaine solution viscous lidocaine is a local anesthetic; spraying it on the irritated surface may relieve the discomfort in the back of the client's throat; tube only repositioned if the tube isn't draining after irrigation
3. The nurse gives discharge instructions to the family of a patient diagnosed with hepatic encephalopathy. The nurse determines further teaching is neces-sary if the family makes which of the following statements? a) We should contact the physician if Dad is restless at night." b) "Cephulac will cause Dad to have 2 - 3 stools per day." c) "Dad should eat meat at every meal." d) "Cephulac may cause bloating and cramps.": c) "Dad should eat meat at everymeal." low-protein, high-calorie diet for clients with hepatic encephalopathy; instruct familyto observe for and report any mental status changes; hepatic encephalopathy occurswith profound liver disease and results from the accumulation of ammonia in the blood; earliest s/s are mental changes, such as exhibiting periods of lethargy and euphoria and progressing to coma
6. The nurse performs a home care visit on a client with a diagnosis of right-sided cerebrovascular accident. The client's spouse complains about having frequent loose stools, and the physician diagnosed viral gastroenteri-tis. The nurse is MOST concerned if which of the following is observed? a) The spouse washes hands frequently b) The spouse drinks Gatorade c) The spouse uses a separate tube of toothpaste d) The spouse prepares lunch for the client: d) The spouse prepares lunch for theclient due to diarrhea, should not prepare foods that will be eaten by others; gastroenteritis is inflammation of the mucous membranes of the small bowel - s/s include N/V, and diarrhea
7. he nurse understands the MOST common reason for insertion of a nasogas-tric tube in a postop client diagnosed with a duodenal ulcer includes which reason? a) Take samples of gastric acid b) Assess the stomach for bleeding c) Decompress the stomach d) Permit saline irrigations: c) Decompress the stomach the stomach is decompressed postoperatively to prevent distention and pressure on the suture lines 8. The nurse preforms preoperative teaching for a patient scheduled for a colostomy. The nurse explains to the patient that 24 hours after the surgerythe colostomy drainage will be which of the following? a) A large amount of bloody output b) A large amount of liquid stool c) Formed stool with water d) A scant amount of bright bloody drainage: d) A scant amount of bright bloody drainage small amount of bleeding at stoma expected; report excessive amounts of bleeding; initial stool will be liquid after colostomy begins functioning and if colostomy is placed in the ascending colon, the stool will always be liquid
a) Auscultate breath sounds b) Cut the balloon port on the Sengstaken-Blakemore tube c) Obtain and record blood pressure and pulse d) Contact the health care provider: b) Cut the balloon port on the Sengstak-en- Blakemore tube keep a pair of scissors at bedside; cutting the port will deflate the balloon and allowthe nurse to remove the tube
11. The nurse cares for a patient 18 hours after a gastrectomy. The nurse isMOST concerned if which of the following is observed? a) The Levinn's tube is attached to low continuous suctioning b) The patient's output during the previous 6 hours was 500 cc c) The patient asks for pain medication d) The patient performs deep breathing every two hours: a) The Levin's tube isattached to low continuous suctioning Levin's tube is a single lumen tube with no air vent, suction should be intermittent; continuous suction appropriate for a Salem tube 12. The nurse cares for a client with a diagnosis of ulcerative colitis. Whenreviewing the client's record, the nurse expects to find which lab value? 1. Red blood cell count (RBC) 4 million/mm3.
2. Platelet count 75,000/mm3. 3. Hemoglobin (Hgb) 18.2 g/dL (182 g/L). 4. White blood cell count (WBC) 15,000/mm3.: White blood cell count (WBC) 15,000/mm ||Due to inflammation, WBC and erythrocyte sedimentation rate will be elevated; SODIUM, POTASSIUM, and CHLORIDE may be DECREASED due to frequent diarrhea.||
- The nurse on the surgical unit cares for a patient after an ileostomy. Whichof the following actions should the nurse take FIRST? 1. Empty the ileostomy bag from the bottom. 2. Apply lotion to the skin around the stoma. 3. Cover the ileostomy with three layers of gauze. 4. Measure the output and record it in the chart.: Measure the output and record
- The nurse assesses the elderly client at the long-term care facility. Theclient tells the nurse, "I have recently developed constipation." It is most important for the nurse to take which action? 1. Encourage the client to eat more grains and fruits. 2. Determine the frequency and characteristics of the bowel movements. 3. Instruct the client to increase fluid intake. 4. Teach the client about the importance of exercise.: Determine the frequencyand characteristics of the bowel movement. || ^ the answer is an assessment. The # of bowel movements varies from 1-3 a day
to 3 a week; Nurse should FIRST determine the frequency and the characteristicsof the bowel movement before determining the proper interventions ||
- The nurse cares for a patient after an appendectomy. The day after surgery,the patient has severe abdominal pain, a temperature of 101° F, and a rigid abdomen. The nurse suspects that the patient is experiencing which of the following? 1. Anesthesia intolerance. 2. Abnormal pain tolerance. 3. Infection of the peritoneal sac. 4. Bladder distention.: Infection of the peritoneal sac. || Peritonitis can be caused by ruptured appendix. Signs and symptoms of peritonitis include 1.severe abdominal pain 2.abdomen rigidity 3.decreased bowel sounds 4.nausea and vomiting 5.increased temperature 6. shock 7. paralytic ileus ; monitorVS, administer antibiotics and IVS, NG tube to suction, surgery to correct cause ||
- The home care nurse makes a visit to a client receiving enteral feeding through a gastrostomy tube. The client's daughter reports the client has fre- quent loose stools. Which of the following statements, if made by the daughterto the nurse, warrants further investigation? 1. "My dad gets 300 cc of formula in one hour." 2. "I warm the formula in a basin of hot water." 3. "I hang a new bag and tubing every 24 hours." 4. "It's so easy to give liquid medicine through the tube.": "It's so easy to giveliquid medicine through the tube"
|| Procedure involves removal of fluid from the client's abdomen through a trocar; the client may have bladder injured if it is not emptied and small. ||
- The nurse in the same day surgery prepares a client for discharge after conventional herniorrhaphy. The nurse should intervene if the client makes which statement? 1. "I should not strain when having a bowel movement." 2. "I should cough and deep breathe every two hours." 3. "I can walk up and down the stairs as soon as I get home." 4. "I should call the health care provider if I have an elevated temperature.": "Ishould cough and deep breathe every two hours" || Due to hernia repair, they should AVOID coughing. Deep breathing does not present a problem ||
- The nurse assesses a client in the outpatient clinic with a diagnosis of R/O ulcerative colitis. During the history, the nurse expects the client to makewhich statement? 1. "I feel an intermittent sharp pain in my lower abdomen." 2. "I feel an intermittent gnawing pain in my lower abdomen." 3. "I feel an intermittent cramping pain in my lower abdomen." 4. "I feel a constant crushing pain in my lower abdomen.": " I feel an intermittent cramping pain in my lower abdomen." || Pain is USUALLY described as cramping and intermittent; IMPORTANT that thenurse assess the character and intensity of the pain; pain due to ulcerative colitis usually
occurs prior to defacation; obtain diet history and assess for bowel soundsand for areas of tenderness ||
- The nurse understands that the primary reason for maintaining a constantrate of infusion with parenteral nutrition (PN) is to prevent which complica- tion? 1. The risk of fluid overload. 2. An unstable blood glucose level. 3. Potential clotting of the catheter. 4. Electrolyte imbalance.: An unstable blood glucose level. || The potential problem of administration of PN is the high glucose concentration.
1. Grandpa can have his daily glass of prune juice." 2. "My husband really likes apple juice." 3. "My dad drinks cranberry juice in the evening." 4. "Grandpa can eat a cherry popsicle with me.": "Grandpa can have his dailyglass of prune juice." || clear liquid diet: allows clear liquids (liquids that the nurse can see through or foods that are fluid at room temperature) ; orune juice allowed on a FULL liquid diet; diverticulitis is infection and inflammation of the diverticulum; signs include irregular bowel function with episodes of diarrhea, crampy pain in left lower quadrant, and low- grade fever ||
- A client is being taught how to care for an ileostomy appliance. Which should the nurse emphasize as most important when applying a new bag?
1. The bag should fit snugly. 2. The bag should be long enough. 3. Drying powder should be used in the bag. 4. The bag should have an air vent.: The bag should fit snugly. ||Drainage from an ileostomy is constant and liquid, and it contains enzymes; bag must fit snugly to prevent extrusion of this fluid into the abdomen and excoriation oractual digestion of the skin ||
- The nurse cares for a client admitted with a diagnosis of acute pancreatitis. An IV is begun and the nurse inserts a nasogastric tube and attaches it to in- termittent low suction. The nurse gives frequent oral hygiene and administers morphine for reports of pain. Which client behavior indicates to the nurse themedication is effective? 1. The client sleeps for one hour. 2. The client frequently changes position in bed. 3. The client states there is less nausea. 4. The client does not report thirst.: The client sleeps for one hour. || Acute pancreatitis causes severe abdominal pain; pain increases body metabo- lism, which increases secretion of pancreatic and gastric enzymes; client sleeping indicates morphine is effective; important to evaluate the effectiveness of the med-ication ||
- A client has a gastroscopy performed and a gastric aspirate taken for analysis. The nurse understands the purpose of a gastric aspirate includeswhich reason? 1. Assess acid secretion and bacterial activity in the stomach.
2. as much fruit as desired. 3. cooked cereal. 4. yogurt and bananas: Cooked cereal. || Full liquid diet includes milk and milk products (pudding, custards), all vegetable juices, all fruit juices, refined or strained cereals, eggs in custard, butter, margarine,and cream ||
- The health care provider orders a clear liquid diet for a client after an appendectomy. The nurse explains to the client a clear liquid diet was orderedfor which reason? 1. Provide adequate calories. 2. Relieve thirst and maintain fluid balance. 3. Stimulate the gastrointestinal (GI) tract so the client will have bowel move-ments 4. Provide complete nutrition.: Relieve thirst and maintain fluid balance. || Offer clear fluids or foods that are fluid at body temperature; requires minimal digestion and leaves minimal residue; clear liquids are the initial feeding after surgeryor parenteral nutrition. ||
- The nurse instructs the client about the bowel preparation required priorto a sigmoidoscopy. The nurse identifies teaching is successful if the client makes which statement? 1. "I can not eat eight hours prior to the test." 2. "I will be asleep when this test is performed." 3. "I will have an enema the morning of the test."
4. "I will have nasogastric suction decompression.": "I will have an enema themorning of the test." ||sigmoidoscopy is direct visualization of sigmoid colon, rectum, and anal canal; tap water enema or fleet's given until returns are clear the morning of the procedure ||
- The nurse cares for clients in the outpatient clinic. The nurse obtains a history on a client reporting diarrhea. It is most important for the nurse to follow up on which client statement? 1. "I eat a lot of processed foods." 2. "I've been taking cephalexin for the last week." 3. "I eat small meals four to six times per day." 4. "I prefer to eat my food cold.": "I've been taking cephalexin for the last week."
