FINAL Qs Flashcards
A pt who had gastric bypass surgery 5 weeks ago calls the office to report feelings of nausea, sweating, and diarrhea shortly after eating meals. What response by the nurse is most appropriate? SATA
Avoid large meals & limit sweets.
Lie down for about 30 min after eating.
At his first postoperative check up appt after a gastrojejunostomy (Billroth II), a pt reports that dizziness, weakness, and palpitations occur about 20 min after each meal. What should the nurse teach the pt to do?
Lie down for about 30 min after eating
The nurse will be teaching self management to pts after gastric bypass surgery. Which information will the nurse plan to include? SATA
Drink fluids between meals but NOT WITH meals
A pt admitted with a peptic ulcer disease has a NG tube in place. When the pt develops sudden severe upper abdominal pain, diaphoresis, and a firm abdomen which actions should the nurse take first?
Check the vital signs
Which information about peptic ulcer disease should the nurse include when teaching a nursing student? SATA
A gastric ulcer pain usually starts 1-2 hrs after a meal.
Gastric ulcers are more likely to result in hemorrhage and hematemesis.
Duodenal ulcer pain can be relieved by eating food.
The nurse is discussing the impact of cirrhosis on the liver function with the family of a dying pt. The nurse explains that when the damage caused by cirrhosis blocks the blood flow thru the liver, it can lead to which complications? SATA
Portal hypertension.
Decrease in clotting factors.
Increase in ascites.
Which of the following will the nurse include in the teaching plan for risk factors of colorectal cancer? SATA
Personal hx of colorectal polyps.
Family hx of colon cancer.
Ulcerative colitis
A 19 yr old pt has a familial adenomatous polyposis (FAP). Which action will the nurse in the gastrointestinal clinic include in the plan of care?
Schedule the pt for yearly colonoscopy.
The nurse is caring for a pt 1 day postoperative after a transverse colostomy. When assessing the stoma, which finding requires the nurses immediate action?
A purplish red stoma
The nurse is providing discharge teaching for a pt who has undergone colon resection surgery with a colostomy. Which statements by the client indicate that the instruction was understood? SATA
I will use warm water & a soft washcloth to clean around the stoma.
I will start bicycling and swimming again once my incision has healed.
I will cut the flange so it fits snugly around the stoma to avoid skin breakdown.
**one answer was changed
The nurse is caring for a pt who has been diagnosed with Crohn’s disease. When providing education concerning dietary recommendations, which statement indicates that the nurse’s teaching has been successful? SATA
I should not have milk products.
Reducing dietary fat and fiber will be helpful in managing my condition.
I should try to eat foods like white rice and lean poultry.
The nurse is planning care for a pt with an acute exacerbation of IBD. Which actions are most important for the nurse to include in the care plan? SATA
Assess for internal bleeding.
Encouraging periods of rest.
Auscultate bowel sounds.
Assess number and characteristics of stools.
The nurse explains that the most beneficial diet for a person with IBD is a _____ diet.
Low fat, low fiber.
Which nursing action will be included in the plan of care for a 25 yr old female pt with a new diagnosis of IBS?
Encourage the pt to express concerns & ask questions about IBS.
–also look at the notes in the study guide for this one
A pt with advanced cirrhosis develops esophageal varices. The nurse anticipates that what complication will be addressed by which type of medications? SATA
Vasodilators.
IV vasopressin.
Beta blockers.
The nurse is caring for a pt with esophageal varices with a new order for vasopressin (Pitressin). The nurse reviews the pt hx and notes that the pts comorbidities including CAD, DM2, GERD, and fibromyalgia. The nurse should immediately notify the HCP about which component of the pt’s hx?
CAD
The nurse caring for a pt recently admitted with acute pancreatitis. Which actions should the nurse include in the daily assessments? SATA
Monitor for effectiveness of pain control.
Auscultate bowel sounds.
Monitor urine output.
Monitor respiratory function.
The nurse is planning care for a pt with acute severe pancreatitis. What is the highest priority patient outcome?
Maintaining normal respiratory function.
Which action should the nurse take after a pt treated with intramuscular glucagon for hypoglycemia regains consciousness?
Give the pt a snack of peanut butter & crackers.
Which lab values are consistent with a pt in DKA? SATA
Potassium 5.6
BUN 35 mg/dL
A pt with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage?
Lispro
A pt with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage? SATA
Lispro (Humalog)
&
Regular
The nurse watches a pt perform an insulin injection. Which observations indicates the pt needs additional instructions? SATA
The pt shakes the insulin bottle vigorously before administration.
The pt rubs the injection site after admin of the insulin injection.
The pt draws up the cloudy insulin and then the clear insulin.
When discussing exercise programs with the Type 1 diabetic pt, which instructions are important for the nurse to include? SATA
Delay exercise until glucose is controlled.
Use the abdominal injection site for insulin.
Keep a quick source of glucose readily available while exercising.
Begin slowly and build up to 30-45 minutes.
Which pt action indicates accurate understanding of the nurse’s teaching about administration of aspart (Novolog) insulin?
test my have different answers refer to study guide
The pt cleans the skin with soap and water before insulin administration.
After teaching a client with Type 2 diabetes, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching?
Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick.
A 26 yr old female who has Type 2 diabetes develops a sore throat and runny nose after caring for her sick toddler. The pt calls the clinic for advice about her symptoms and reports a blood glucose level of 220 mg/dL despite taking her usual glargine (Lantus) and lispro (Humalog) insulin. What should the nurse advise the pt to do?
Monitor blood glucose every 4 hours and contact the clinic if it rises.
To monitor for long term complications in a pt with Type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually? SATA
Monifilament testing of the foot.
Urine for microalbuminuria.
Retinal exam.
A tumor of the pituitary gland has caused the syndrome of SIADH. Which intervention should the nurse plan? SATA
Record accurate urine.
Weigh the pt daily.
Implement seizure precautions.
Assess for changes in level of consciousness.
Which pt statement indicates to the nurse that additional instructions is needed for a pt with chronic syndrome of inappropriate antidiuretic hormone (SIADH)?
I need to shop for foods low in sodium and avoid adding salt to food.
Which finding indicates to the nurse that demeclocycline is effective for a pt with SIADH?
Urinary output is decreased.
An 82 yr old pt in a long term care facility is newly diagnosed with hypothyroidism. The nurse will need to consult with the HCP before administering the prescribed?
Diazepam (Valium)
The nurse is evaluating the lab results of a pt suspected of having hyperparathyroidism. Which findings would be consistent with this condition? SATA
Renal calculi.
Decreased serum phosphate levels.
Increased serum calcium levels.
Which information will the nurse teach a pt who has been newly diagnosed with Graves’ disease?
Antithyroid medications may take several months for full effect.
The nurse is educating a pt who has a new prescription for methimazole. Which instruction is most important for the nurse to include? SATA
Take the medication on a strict schedule.
Report any fever or sore throat.
The pt with hyperthyroidism is undergoing ablation therapy with radioactive iodine. Which precaution is most important for that nurse to employ? SATA
Enforce avoiding contact with children for 2 days.
Take radioactive precautions with utensils & bedpans.
Increase fluid intake after the therapy.
Which information obtained by the nurse in the endocrine clinic about a pt who has been taking prednisone 40 mg daily for 3 wks is most important to report to the HCP?
Pt stopped taking the medication 2 days ago.
A nurse assesses a pt with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? SATA
Administer oxygen to keep saturations greater than 94%.
Administer prescribed albuterol (Proventil) inhaler.
The nurse teaches a pt who has asthma about peak flow meter use. Which action by the pt indicates that teaching was successful?
The pt uses albuterol (Ventolin HFA) for peak flows in the yellow zone.
The nurse is assessing a pt with COPD. Which assessment finding indicates a potential complication and requires the nurse’s immediate attention?
Distended neck veins.
A nurse is caring for a pt with COPD. The pts medication regimen has been recently changed and the nurse is assessing for therapeutic effect of a new bronchodilator. What assessment parameters suggest a consequent improvement in respiratory status? SATA
Increased expiratory flow rate.
Relief of dyspnea.
A nurse teaches a pt who has COPD. Which statements related to nutrition should the nurse including in this pts teaching? SATA
Avoid drinking fluids just before & during meals.
Rest before meals if you have dyspnea.
Have about 6 small meals a day.
Some answers may have changed for exam
The nurse is caring for a pt with a closed chest drainage system with chest tubes. Which observation confirms that the system is intact and working?
The water level in the water seal chamber fluctuates.
The nurse is caring for a pt with ARDS who is receiving mechanical ventilation and PEEP (positive end expiratory pressure). The alarm sounds, indicating high pressure alarm in the system. What is the nurses best action?
Assess lung sounds.
(Always assess the pt first, the ventilator second)
When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible PE (pulmonary embolism)? SATA
Exercise on a regular basis.
Maintain a healthy weight.
Stop smoking cigarettes.
A pt is admitted with PE. The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate?
Teach the client about factor V Leiden testing.
The nurse is caring for a pt with heart failure. Which interventions should the nurse include in the plan of care? SATA
Discourage intake of canned soups.
Alternate rest with activity.
The home health nurse is caring for a pt with heart failure. Which assessment finding should the nurse report immediately to the physician?
A 6 lb weight gain over the course of a week.
The nurse is performing an initial assessment on a new pt with suspected rightsided heart failure. Which findings are consistent with the pts potential diagnosis? SATA
Splenomegaly.
Abdominal distention.
Weight gain.
Two days after an acute MI, a pt reports stabbing chest pain that increases with a deep breath. Which action will the nurse take first?
Auscultate the heart sounds.
After receiving change of shift report on four pts admitted to a heart failure unit, which pt should the nurse assess first?
A pt who has new onset confusion and restlessness and cool, clammy skin.
Which action by a nurse caring for a pt after an implantable cardioverter-defibrillator (ICD) insertion indicates a need for more teaching about the care of pts with ICDs? SATA
The nurse encourages the pt to do active ROM exercises for all extremities.
The nurse assesses a friction rub in a pt who is 2 days post MI. The nurse recognizes this finding indicates which problem?
Pericarditis
The nurse will plan discharge teaching about the need for prophylactic antibiotics when having dental procedures for which patient? SATA
Pt being treated for infective endocarditis after having prolonged IV therapy.
Pt who has a mitral valve replacement with a mechanical valve.
The nurse obtains a health history from an older adult with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse helps identify a risk factor for IE?
Have you had dental work done recently?
Which pt will need the nurse to plan discharge teaching about prophylactic antibiotics before dental procedures?
*Turned into a SATA for exam.
Pt who had a mitral valve replacement with a mechanical valve.
Maybe: infective endocarditis & mitral valve replavement
After receiving a report on the following pts, which pt should the nurse assess first?
Pt with acute aortic regurgitation whose blood pressire is 86/54 mm Hg
The nurse is caring for a pt with aortic stenosis. Which assessment data would be most important to report to the HCP?
The pt reports chest pressure when ambulating
A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below. What should the nurse do?
Assess airway, breathing, and LOC
Which factors are potential causative agents for arrhythmias? SATA
Infarct damage.
Hyperkalemia.
Excess fluid.
Valvular disease.
A pt develops the following dysrhythmia and complains of dizziness. Which action should the nurse take first?
Either: apply the transcutaneous pacemaker pads
OR check oxygen saturation
