Terms in this set (52)
Check for correct placement of the NG tube.
With a nasogastric (NG) tube for decompression in place, nausea may
indicate tube displacement or obstruction. Checking its placement can
determine whether it is in the stomach; once placement is verified, fluid
then can be instilled to ensure patency. The antiemetic may relieve the
After abdominal surgery, a client's discomfort, but it will not determine the cause. Auscultation of the client's
postoperative prescriptions include a abdomen should occur with the nurse's other assessments, but it will not
nasogastric (NG) tube to lower help determine the cause of the nausea. The nurse should assess the
intermittent wall suction and an situation before notifying the health care provider.
antiemetic every 6 hours as needed
for nausea. When the client reports
feeling nauseated, which action would
the nurse take first?
Check for correct placement of the
NG tube.
Administer the prescribed antiemetic.
Assess the client's bowel sounds.
Notify the primary health care
provider.
, Identifying the concerns and helping the client explore feelings
After a myocardial infarction, a client
asks the nurse, "What's the chance of
me having another heart attack if I
watch my diet and stress levels
carefully?" What is the most
appropriate initial response by the
nurse?
Identifying the concerns and helping
the client explore feelings
Telling the client that it is important
to be especially careful with diet and
stress
Suggesting that the client discuss the
feelings of vulnerability with the
primary health care provider
Understanding that the client is
frightened and suggesting a talk with
the psychiatric nurse
, fever, tachypnea, abdominal rigidity
The metabolic rate will be increased, and the temperature-regulating center
in the hypothalamus resets to a higher-than-usual body temperature because
A client develops peritonitis and of the influence of pyrogenic substances related to the peritonitis.
sepsis after the surgical repair of a Tachypnea results as the metabolic rate increases and the body attempts to
ruptured diverticulum. Which signs meet cellular oxygen needs. With increased intra-abdominal pressure, the
would the nurse expect when abdominal wall will become rigid and tender. Hypovolemia and
assessing the client? Select all that hypotension, not hypertension, results because of a loss of fluid,
apply. One, some, or all responses electrolytes, and protein into the peritoneal cavity. Peristalsis and associated
may be correct. bowel sounds will decrease or be absent in the presence of increased intra-
abdominal pressure.
Fever
Tachypnea
Hypertension
Abdominal rigidity
Increased bowel sounds
, Palpating the neck or face
Subcutaneous emphysema refers to the presence of air in the tissue that
surrounds an opening in the normally closed respiratory tract; the tissue
A client develops subcutaneous appears puffy, and a crackling sensation is detected when trapped air is
emphysema after the surgical creation compressed between the nurse's palpating fingertips and the client's tissue.
of a tracheostomy. Which assessment Gas exchange and thus blood gases are not affected. The lungs are not
by the nurse most readily detects this affected.
complication?
Palpating the neck or face
Evaluating the blood gases
Auscultating the lung fields
Reviewing the chest x-ray film
Check for correct placement of the NG tube.
With a nasogastric (NG) tube for decompression in place, nausea may
indicate tube displacement or obstruction. Checking its placement can
determine whether it is in the stomach; once placement is verified, fluid
then can be instilled to ensure patency. The antiemetic may relieve the
After abdominal surgery, a client's discomfort, but it will not determine the cause. Auscultation of the client's
postoperative prescriptions include a abdomen should occur with the nurse's other assessments, but it will not
nasogastric (NG) tube to lower help determine the cause of the nausea. The nurse should assess the
intermittent wall suction and an situation before notifying the health care provider.
antiemetic every 6 hours as needed
for nausea. When the client reports
feeling nauseated, which action would
the nurse take first?
Check for correct placement of the
NG tube.
Administer the prescribed antiemetic.
Assess the client's bowel sounds.
Notify the primary health care
provider.
, Identifying the concerns and helping the client explore feelings
After a myocardial infarction, a client
asks the nurse, "What's the chance of
me having another heart attack if I
watch my diet and stress levels
carefully?" What is the most
appropriate initial response by the
nurse?
Identifying the concerns and helping
the client explore feelings
Telling the client that it is important
to be especially careful with diet and
stress
Suggesting that the client discuss the
feelings of vulnerability with the
primary health care provider
Understanding that the client is
frightened and suggesting a talk with
the psychiatric nurse
, fever, tachypnea, abdominal rigidity
The metabolic rate will be increased, and the temperature-regulating center
in the hypothalamus resets to a higher-than-usual body temperature because
A client develops peritonitis and of the influence of pyrogenic substances related to the peritonitis.
sepsis after the surgical repair of a Tachypnea results as the metabolic rate increases and the body attempts to
ruptured diverticulum. Which signs meet cellular oxygen needs. With increased intra-abdominal pressure, the
would the nurse expect when abdominal wall will become rigid and tender. Hypovolemia and
assessing the client? Select all that hypotension, not hypertension, results because of a loss of fluid,
apply. One, some, or all responses electrolytes, and protein into the peritoneal cavity. Peristalsis and associated
may be correct. bowel sounds will decrease or be absent in the presence of increased intra-
abdominal pressure.
Fever
Tachypnea
Hypertension
Abdominal rigidity
Increased bowel sounds
, Palpating the neck or face
Subcutaneous emphysema refers to the presence of air in the tissue that
surrounds an opening in the normally closed respiratory tract; the tissue
A client develops subcutaneous appears puffy, and a crackling sensation is detected when trapped air is
emphysema after the surgical creation compressed between the nurse's palpating fingertips and the client's tissue.
of a tracheostomy. Which assessment Gas exchange and thus blood gases are not affected. The lungs are not
by the nurse most readily detects this affected.
complication?
Palpating the neck or face
Evaluating the blood gases
Auscultating the lung fields
Reviewing the chest x-ray film
