Med Surg II Hesi (2) Flashcards
stroke and dysphagia
Put pt in the upright position to prevent aspiration
A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding?
Persistent coughing while drinking
A client with Addison’s disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client’s laboratory values include; sodium 129 mEq/l (129mmol/l SI), glucose 54 mg/dl (2.97mmol/l SI) and potassium 5.3 mmol/l SI). When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medications?
hydrocortisone
The nurse is preparing a client for discharge who was recently diagnosed with Addison’s disease. Which instruction is most important for the nurse to include in the client’s discharge teaching plan?
Take prescribed cortisone accurately
A client admitted to the telemetry unit is having unrelieved chest pain after receiving 3 sublingual nitroglycerin tablets and morphine 8 mg IV. The electrocardiogram reveals sinus bradycardia with ST elevation. In what order should the nurse implement the nursing actions? (Arrange first to last)
- Call the rapid response team to assist
- Move the crash cart to the client room
- Notify the client’s healthcare provider
- Inform the family of the critical situation
The nurse is obtaining a health hx from a new pt with a hx of kidney stones. What statement by the pt indicates an incr risk of renal calculi?
Answer: eats a vegetarian diet with cheese 2-3x daily
In teaching a client newly diagnosed with multiple sclerosis (MS), which approach should the nurse emphasize as most likely to prevent an exacerbation of symptoms?
develop pre planned mechanisms to avoid or minimize the effects of triggers
ABG’s PE
a. Hypoxemia and hypocapnia, and respiratory alkalosis (this makes sense bc you are hyperventilating)
b. Arterial blood gas (ABG) results reflect respiratory alkalosis.
c. pH - 7.5 PaCO2 - 32
d. HCO3 - 24 PaO2 - 60
ARDS - COPD
Compensation occurs over time in clients with COPD and ABGs are altered. As COPD worsens, the amount of O2 decrease in the blood (hypoxemia) and the amount of CO2 increases (hypercapnia) causing chronic respiratory acidosis
How are the pathophysiological mechanisms responsible for ascites related to liver failure? (Select all that apply)
a. Fluid shifts from intravascular to interstitial area due to decreased serum protein
b. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen
c. Increased circulating aldosterone levels that increase sodium and water retention
A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.)
-Monitor abdominal girth
-Report serum albumin and globulin levels.
-Note signs of swelling and edema
A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first?
evaluate swallow
The nurse is caring for a postoperative pneumonectomy client. Which finding on assessment of the client is an adverse sign or symptom indicating pulmonary edema?
Lung crackles in the remaining lung
The nurse is caring for a client with heart failure who develops respiratory distress and coughs up pink frothy sputum. Which action should the nurse take first?
Position in a high Fowler’s position with the legs down.
Atrial Flutter
Atrial flutter is a common abnormal heart rhythm similar to atrial fibrillation, the most common abnormal heart rhythm, both conditions are a type of supraventricular tachycardia. In AFL the upper chambers of the heart beat too fast, which results in atrial muscle contractions that are faster than and out of sync with the lower chambers
A-flutter
a. Description is a saw-toothed waveform, fluttering in the chest, and ventricular rhythm stays regular.
b. Treatment is cardioversion to treat atrial dysrhythmias, antidysrhythmic drugs, radiofrequency catheter ablation.
A client with ARF has been treated with sodium polystyrene sulfonate (Kayexalate) by mouth. The nurse would evaluate this therapy as effective if which of the following lab values was noted on a follow-up lab testing?
Potassium: 2.9 mEq/L
A client with acute renal injury (AKI) who weighs 50 kg had a potassium level of 6.7 mEq/L Is admitted to the hospital. Which prescribed medication should the nurse administer 1st?
Sodium polystyrene sulfonate 15 grams PO
Client has not been taking cortisone for either 2 weeks or 2 months and husband brings her into the ED. Husband states that she has not been feeling well and that she needed help getting ready today. (Patient has SIADH). What should you do?
Initiate fall precautions
Guillain Barre- swallow
a. Paresthesia (tingling and numbness)
b. Muscle weakness of legs progressing to the upper extremities, trunk, and face
c. Paralysis of the ocular, facial, and oropharyngeal muscles, causing marked difficulty in talking, chewing, and swallowing.
What is the first few s/sx of ARDS
confusion, restlessness, agitation
Chest pain ACS algorithm
Beta-Blocker: this will lower the workload of the heart. ↓HR↓BP↓Contractility.
A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client’s EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, “I feel like an elephant just stepped on my chest” The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform?
Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula.
The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain. Which assessment data is most important for the nurse to obtain?
Eating patterns and dietary intake
Which symptom of chronic pancreatitis also occurs with acute pancreatitis?
Abdominal pain
Nursing assessment: Chronic pancreatitis
a. Continuous burning or gnawing abdominal pain
b. Recurring attacks of severe upper abdominal and back pain
Renal diet CKD
a. Avoid salt substitutes.
b. A client with CKD should restrict sodium and potassium dietary intake, and salt substitutes usually contain potassium
After teaching a male client with chronic kidney disease (CKD) about therapeutic diet…which menu of foods indicates that the teaching was effective? Select all that apply
a. A slice of whole grain toast
b. A bowl of cream of wheat
Postop circulation after hip replacement
a. Post hip replacement complication → swelling/inflammation
b. check for the distal circulation: neurovascular circulation
c. color, sensation, warmth
A pt arrives at the ED with pain. Which description should prompt the nurse to suspect an MI?
Produces chest heaviness with left arm pain
An elderly female is admitted because of a change in her level of sensorium. During the evening shift, the client attempts to get out of bed and falls, breaking her left hip. Buck’s skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client’s plan care?
Ensure proper alignment of the leg in traction.
Stroke/TIA
-tinnitus
-diplopia
-dysarthia
