Adult Medical Surgical Practice 2019 -2023 with NGN Flashcards
A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse’s priority?
Anorexia
Abdominal pain radiating to the right shoulder
Tachycardia
Rebound abdominal tenderness
Tachycardia
-Tachycardia is a manifestation of biliary colic, which can lead to shock. The nurse should position the head of the client’s bed flat and report this finding immediately
A nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and tingling sensation in their hands. Which of the following medications should the nurse plan to administer?
Epoetin alfa
Furosemide
Captopril
Calcium carbonate
Calcium carbonate
A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To help reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client avoid?
Shellfish
Aged cheese
Peppermint candy
Enriched pasta
Aged cheese
A nurse is caring for a client who has hepatic encephalopathy that is being treated withy lactulose. The client is experiencing excessive stools. Which of the following findings is an adverse effect of this medication?
Hypokalemia
Hypercalcemia
Gastrointestinal bleeding
Confusion
Hypokalemia
A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?
Heart rate 110/min
Blood pressure 138/90 mm Hg
Urine specific gravity 1.020
BUN 15 mg/dL
Heart rate 110/min
-A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and an elevated heart rate.
A nurse is caring for a client who was just admitted from the emergency department (ED).
0945:
Client is experiencing a sickle cell crisis.
1200:
Client is sitting up in high-Fowler’s position and appears anxious. Client reports shortness of breath and severe chest pain as 9 on a scale of 0 to 10. Client states that they have started coughing and are expectorating pink-tinged mucus.
Lung sounds with increased wheezing in left lung and clear on the right side. Equal chest expansion noted. Neck veins flat. No peripheral edema observed.
The client is most likely experiencing _____ and _____.
Fluid volume overload
Right-sided heart failure.
Acute chest syndrome
Pneumonia
Pneumothorax
The client is most likely experiencing Acute chest syndrome and pneumonia.
rationale
Acute chest syndrome is correct. which can be caused by respiratory infections and debris from sickled cells. The client is displaying manifestations of acute chest syndrome, which include cough, shortness of breath, wheezing, tachypnea, fever, and chest pain.
Pneumonia is correct. as evidenced by the manifestations of cough, shortness of breath, fever, tachypnea, blood-tinged sputum, and chest pain.
A nurse is assessing a male client for an inguinal hernia. Which of the following areas should the nurse palpate to verify that the client has an inguinal hernia?
Belly button
Upper groin
Lower groin
Upper groin
A nurse in a provider’s office is caring for a client who requests sildenafil to treat erectile dysfunction. Which of the following statements should the nurse make?
“You might need to take a stool softener while taking this medication.”
“You will not be abled to use sildenafil if you have diabetes.”
“You will need to limit your caffeine intake if you start taking sildenafil.”
“You will not be able to use sildenafil if you are taking nitroglycerin.”
“You will not be able to use sildenafil if you are taking nitroglycerin.”
A nurse is caring for a client has who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis?
Metabolic alkalosis
Hyperkalemia
Increased hemoglobin
Hypophosphatemia
Hyperkalemia
-chronic glomerulonephritis can experience hyperkalemia as a result of kidney failure. Kidney failure results in decreased excretion of potassium.
Rationale
-hyperphosphatemia as a result of decreased excretion of phosphorus through the kidneys
-can experience anemia as a result of decreased RBC production..
A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take?
Teach the importance of a clear liquid diet after discharge
Tell the client to remove the incisional adhesive strips 3 days after discharge.
Demonstrate ways to deep breathe and cough
Instruct the client to maintain bed rest for 48 hr
Demonstrate ways to deep breathe and cough
-demonstrate deep breathing and coughing exercises and explain the importance of splinting the incision to reduce the risk for respiratory complications.
Rationale
-instruct the client to ambulate as soon as possible to prevent postoperative complications, such as deep-vein thrombosis or pneumonia.
-incisional adhesive strips will begin to fall off 7 to 10 days after application and that the provider might remove the adhesive strips during that timeframe.
A nurse in the ICU is assessing a client who has traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing’s triad?
Hypotension
Tachypnea
Nuchal rigidity
Bradycardia
Bradycardia
-increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing’s triad. The other components of Cushing’s triad are severe hypertension and a widened pulse pressure.
Rationale
-Nuchal rigidity, or neck stiffness, is an indication of meningitis.
-traumatic brain injury can develop decreased cerebral blood flow, which results in increased arterial pressure/hypertension. The changes to arterial pressure cause changes in blood pressure.
A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect?
Negative urine ketones
BUN 32 mg/dL
pH 7.43
HCO3 23 mEq/L
BUN 32 mg/dL
A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements should the nurse include in the teaching?
“You will still have the urge to void.”
“You can apply an aspirin tablet to the pouch to reduce odor.”
“You should cut the opening of the skin barrier one-eight inch wider than the stoma.”
“You should use a moisturizing soap when washing the skin around the stoma.”
“You should cut the opening of the skin barrier one-eight inch wider than the stoma.”
-cut the opening of the skin barrier 0.3 cm (1/8-in) wider than the stoma to minimize irritation of the skin from exposure to urine.
A nurse is teaching a young adult client how to perform testicular self-examination. Which of the following instructions should the nurse include?
Compare both testicles by examining them simultaneously.
Roll each testicle between the thumb and fingers.
Perform testicular self-examination before a warm bath or shower.
Perform self-examination of the testicles every 2 weeks.
Roll each testicle between the thumb and fingers.
A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide?
Increase fluid intake.
Take an over-the-counter antidiarrheal medication.
Expect black ,tarry stools.
Follow a low-fiber diet.
Increase fluid intake.
-Increasing fluid intake will help to prevent constipation. increase fluid intake to facilitate the elimination of the barium used during the test.
Rationale
-expect stools to appear chalky white until the barium is completely eliminated, takes between 24 and 72 hr.
