Med Surg Practice Hesi Questions and Answers

Med Surg Practice Hesi Questions and Answers The nurse is assessing a client's lab values following admin of chemo. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)? Serum Ca+ of 5mg/dL TLS results in hyperkalemia, hypocalcemia, hyperuricemia, and hyperphosphatemia. A serum Ca+ level of 5 is low, is an indicator or possible tumor lyss syndrome. A client is admitted to the hospital w/ a dx of severe acute diverticulitis. Which assessment finding should the nurse expect this client to exhibit? Lower Left quadrant pain and a low grade fever LLQ pain occurs w/ diverticulitis because the sigmoid colon is the most common area for diverticula, and the inflammation of diverticula causes a low grad fever During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take 1st? Reposition the head to validate that the head is in the proper position to open the airway The most frequent cause of inadequate aeration of the client's lungs during CPR is improper positioning of the head resulting in occlusion of the airway A client is admitted to the hospital w/ a med dx of pneumococcal pneumonia. The nurse knows that the prognosis for gram-neg pneumonias (like E.coli, Klebsiella, Pseudomonas, and Proteus) is very poor because The gram-neg organisms are more resistant to abx therapy The gram-neg organisms are resistant to drug therapy A client is placed on a mechanical vent following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04mg/kg q 12h IV is prescribed. What is the priority nsg dx for this client? Impaired communication r/t paralysis of skeletal muscles To increase the client's tolerance of endotracheal intubation and / or mechanical ventilation, a skeletal-muscle relaxant, such as vecuronium, is usually prescribed. Impaired communication is a serious outcome because the client cannot communicate their needs due to intubation and diaphragmatic paralysis caused by the drug. When preparing a client who has had a total laryngectomy for DC, what instruction is most important for the nurse to include in the DC teaching? Tell the client to carry a med alert card stating that he is a total neck breather It is imperative that total neck breathers carry a med alert notice so that if they have a cardiac arrest, mouth to neck breathing can be done. Mouth to mouth resuscitation measures will not help them The nurse would be correct in w/holding a dose of Digoxin in a client w/ CHF w/out specific instruction for the HCP if the client's serum K+ is 3 Hypokalemia can precipitate digitalis toxicity in persons receiving Digoxin which will increase the chance of dangerous dysrhythmias. Normal K+ is 3.5-5mgEq/L. The therapeutic range for Digoxin is 0.8 - 2 ng/mL After the 4th dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to determine peak and trough levels. When are the best times to draw these samples? 5 minutes b/f and 30 minutes after the next dose Peak drug serum levels are achieved 30 minutes after IV admin of aminoglycosides. The best time to draw a trough is the closest time to the next administration A client has undergone insertion of a permanent PM. When dvp'g a DC teaching plan, the nurse writes a goal of "The client will verbalize sx of PM failure". Which sx are the most important to teach the client? Feelings of dizziness Feelings of dizziness may occur as the result of a decreased HR, leading to decreased CO The client w/ heart disease is on a continuous tele monitor and has dvp'd sinus bradycardia. In determining the possible causes of the bradycardia, the nurse assesses the client's med record. Which mid is most likely the cause of the bradycardia? Propanolol (Inderal) Inderal (Propanolol) is a beta adrenergic blocking agent, which causes decreased HR and decreased contractility. In preparing a DC plan for a 22 yr old male client dx'd w/ Bueger's disease (thromboangitis obliterans), which referral is most important? Smoking cessation program Buerger's disease is strongly r/t smoking. The most effective means of controlling sx and disease progression is trough smoking cessation. the cause is unknown Which sx's should the nurse expect a client to exhibit who is dx'd w/ a pheochromocytoma? HA, diaphoresis, and palpitations Pheochromocytoma is a catecholamine secreting tumor of the adrenal medulla, and these sx are the typical triad of sx depending upon the relative proportions of epi and norep secretion In assessing a client dx w/ primary hyperaldosteronism, the nurse expects the lab test results to indicate a decreased serum level of K+ Clients w/ primary aldosteronism exhibit a profound decline in the serum levels of K+. Hypokalemia hypertension is the most prominent and universal sign A middle-aged client w/ DM continues to eat an abundance of foods that are high is sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to b/c compliant w/ the prescribed diet? He visits his diabetic brother who just had surgery to amputate an infected foot The loss of a limb by a family member will be the strongest event or "cue to action" and is most likely to increase the perceived seriousness of the disease The nurse is taking a hx of a newly dx'd DM2 who is beginning tx. Which subjective info is most important for the nurse to note? An allergy to sulfa drugs An allergy to sulfa drugs may make the client unable to use some of the most common antihyperglycemic agents (sulfonylureas). The nurse needs to highlight this allergy for the HCP. A client w/ cirrhosis dvps increasing pedal edema and ascites. What dietary mods is most important for the nurse to teach this clients? Restrict salt and fluid intake Salt and fluid restrictions are the 1st dietary mods for a client who is retaining fluid as manifested by edema and ascites A female client rec'g IV vasopressin (Pitressin) for esophageal varice rupture reports to the nurse that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse initiate? Start an IV nitro infusion Vasopressin is used to promote vasoconstriction, thereby reducing bleeding. Vasoconstriction of the coronary arteries can lead to angina and MI, and should be counteracted by IV nitro per prescribed protocol A client who is HIV + asks the nurse "How will I know when I have AIDS?". which response is best for the nurse to provide? "AIDS is dx when a specific opportunistic infection is found in an otherwise healthy individual". AIDS is dx when 1 of several processes defined by the CDC is present in an individual who is not otherwise immunosuppressed. PCP, candidacies, cryptococcus, cryptosporidiosis, Kaposia sarcoma, CNS lymphomas Which description of sx is characteristic of a client dx w/ trigeminal neuroalgia (tic douloureux)? Sudden, stabbing, severe pain over the lip and chin Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by 1 or more branches of the trigeminal nerve (5th cranial) Which intervention would the nurse plan to implement when caring for a client who has just undergone a R AKA? Place a large tourniquet at the client's bedside A large tourniquet should be placed in plain sight at the bedside. If severe bleeding occurs, the tourniquet should be readily available and applied to the residual limb to control hemorrhage. The residual limb should not be placed on a pillow because a flexion cxn of the hip may result. you don't want to place direct pressure to the limb because it would compromise wound healing. Prone position should be encouraged to stretch the flexor muscles and to prevent flexion cxn of the hip The nurse is assessing a client who has a hx of Parkinson's disease for the past 5 yrs. What sx would this client most likely exhibit? Shuffling gait, mask-like facial expression, and tremors of the head These are common clinical features of Parkinsonism The nurse is completing an admission interview and assessment on a client w/ a hx of Parkinson's disease. Which question provides info relevant to the client's POC? "Have you ever been frozen in 1 spot, unable to move?" Clients w/ Parkinson's disease frequently exp difficulty in initiating, maintaining, and performing motor activities. They may even exp being rooted to the spot and unable to move. The nurse is interviewing a male client w/ HTN. Which additional med dx in the client's hx presents the greatest risk for dvp'g a CVA? Diabetes Mellitis A hx of DM poses the greatest risk for dvp'g a CVA The nurse notes that the only ECG for a 55 yr old male client scheduled for surgery in 2 hrs is dated 2 yrs ago. The client reports that he has a hx of "heart trouble", but has no problems at present. Hospital protocol requires that those over 50 yrs of age have a recent ECG prior to surgery. What nsg action is best for the nurse to implement? Call for an ECG to be performed immediately Clients over the age of 40 and/or w/ a hx of CV disease, should receive ECG eval prior to surgery, generally 24 hrs to 2 wks b/f surgery. The nurse is receiving report from surgery about a client w/ a penrose drain who is to be admitted to the post op unit. Before choosing a room for the client, which info is most important for the nurse to obtain? If the client's wound is infected Penrose drains provide a sinus tract or opening and are often used to provide drainage in abscesses. The fact that the client has a penrose drain should alert the nurse to the possibility that the client is infected. To avoid contamination of another pot op client, it is most important to place an infected client in a private room What is the correct procedure for performing an ophthalmoscopic exam on a client's right retina? From a distance of 21-15 inches and slightly to the side, shine the light into the client's pupil The client should focus on a distant object behind the examiner who should stand at 21-15 inches away and to the side of their line of vision. The examiner should hold the ophthalmoscope firmly against their face and then direct it at the client's pupil During lung assessment, the nurse places a stethoscope on a client's chest and instructs them to say "99" each time the chest is touched w/ the stethoscope. What would be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope? May indicate pneumonia The test (whispered pectoriloquy) demonstrates hyper-resonance and helps determine the clarity w/ which spoken words are heard upon auscultation. Normally, the spoken word is not well transmitted thru lung tissue, and is heard as a muffled or unclear transmission of the spoken word. Increased clarity of a spoken word is indicative of some sort of consolidation process (ie: tumor, pneumonia) A client has taken steroids for 12 yrs to help manage COPD. When making a home visit, which nsg fxn is of greatest importance to this client? Assess the client's Temp It is very important to check the temp. Infection is the most common factor precipitating respiratory distress. Clients w/ COPD who are on a maintenance doses of corticosteroids are particularly predisposed to infection. Even though HR and BP are important assessments, they are not as important as temp While working in the ER, the nurse is exposed to a client w/ active TB. When should the nurse plan to obtain a TB skin test? 4-6 wks after the exposure A TB skin test is effective 4-6 wks after exposure The nurse is planning to initiate a socialization grp for older residents of a long-term facility. Which info would be most useful to the nurse when planning activities for the grp? The usual activity patterns of each member of the grp An older person's level of activity is determining factor in adjustment to aging as described by the Activity Theory of Aging. The nurse knows that lab values sometimes vary for the older client. Which data would the nurse expect to find when reviewing lab values of an 80 yr old male? Increased protein in the urine, slightly increased serum glucose levels In older adults, the protein found in urine slightly rises probably as a result of kidney chgs or subclinical urinary tract infections. The serum glucose increases slightly due to chgs in the kidney. The specific gravity declines by age 80 from 1.032 to 1.024 A 77 yr old female client is admitted to the hospital. She is confused, has no appetite, is nauseated, vomiting, and c/o HA. Her pulse rate is 40. Which question is a priority for the nurse to ask this client or her family on admission? Does the client take digitalis? Elderly persons are particularly susceptible to digitalis intoxication - which manifests itself in such sx as anorexia, N/V/D, HA, and fatigue. Although it is important to obtain a complete med hx, the sx described are classic for digitalis toxicity and assessment of this problem should be made promptly A 67 yr old woman who lives alone tripped on a rug in her home and fx'd her hip. Which predisposing factor probably led to the fx in the proximal end of her femur? Osteoporosis resulting from hormonal chgs The most common cause of a fx hip in elderly women is osteoporosis, resulting from reduced Ca+ in the bones as a result of hormonal chgs in later life. During a health fair, a 72 yr old male client tells the nurse that he is experiencing SOB. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic sx would the nurse expect this client to have? Productive cough w/ grayish-white sputum Chronic bronchitis, 1 of the diseases comprising the dx of COPD, is characterized by a productive cough w/ grayish-white sputum, which usually occurs in the morning and is often ignored by smokers. An 81 yr old male client has emphysema. He lives at home w/ his cat and manages self-care w/ no difficulty. When making a home visit, the nurse notices that his tongue is somewhat cracked and his eyeballs are sunken into his head. What nsg intervention is indicated? Help the client to determine ways to increase his fluid intake the nurse should suggest creative methods to increase the intake of fluids, such as having disposable fruit juices readily available. Clients w/ COPD should have at least 3 liters of fluid/ day. These clients often reduce fluid intake because of SOB An elderly male client comes to the geriatric screening clinic c/o pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch as suspects it might be thrombophlebitis. Which type of pain would further confirm this suspicion? Pain in the calf upon exertion which is relieved by rest and elevating the extremity Thrombophlebitis pain is relieved by rest and elevation of the extremity. It typically occurs w/ exercise at the site of the thrombus, and is aggravated by placing the extremity in a dependent position, such as standing in 1 place An elderly client is admitted w/ a dx of bacterial pneumonia. The nurse's assessment of the client will most likely reveal which s/s? Confusion and tachycardia the onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased HR, or increased RR leukocytosis, febrile, polycythemia, crackles, pharyngitis, and sputum production are not present in the elderly w/ bacterial pneumonia A 58 yr old client, who has no health problems, asks the nurse about Pneumovax vaccine. The nurse's response to the client should be based on which info? The immunization is administered once to older adults or persons w/ a hx of chronic illness It is usually recommended that persons over 65 and those w/ a hx of chronic illness receive the vaccine once in a lifetime. some resources recommend obtaining the vaccine at 50 yrs old The influenza vaccine is given once / yr The nurse is assessing a client w/ bacterial meningitis. Which assessment finding indicates the client may have dvp'd septic emboli? Cyanosis of the fingertips Septic emboli secondary to meningitis commonly lodge in the small arterioles of the extremities, causing a decrease in circulation to the hands, which may lead to gangrene A client w/ MS has experienced an exacerbation of sx, including paresthesias, dipolia, and nystagmus. Which instruction should the nurse provide? Schedule extra rest periods exacerbations of the sx of MS occur most commonly as the result of fatigue and stress. Extra rest periods should be scheduled to reduce the sx A client has been taking oral corticosteroids for the past 5 days because of seasonal allergies. Which assessment finding is of most concern to the nurse? Purulent sputum Steroids cause immunosuppression, and a purulent sputum is an indication of infection, so this sx is of greatest concern. Oral steroids may increase WBCs and often cause excessive hunger. Glucose may remain normal, borderline, or increase while taking them The HCP prescribes aluminum and mg hydroxide (Maalox), 1 tab po prn, for a client w/ CKD who is c/o indigestion. What intervention should the nurse implement? Question the HCP's prescription Mg agents are not usually used for those w/ CKD due to the risk of hypermagnesemia, so this should be questioned by the nurse A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What action should the nurse implement? Advise the client to notify the HCP for immediate medical attn Calf pain is indicative of thrombophlebitis, a serious, life-threatening complication associated w/ the se of oral contraceptives which requires further assessment and possible immediate medical intervention. the nurse is preparing a teaching plan for a client who is newly dx'd w/ DM1. Which s/s should the nurse describe when teaching the client about hypoglycemia? Sweating, trembling, tachycardia These are signs of hypoglycemic reactions r/t the release of epinephrine as a compensatory response to the low blood sugar A client who is receiving chemo asks the nurse, "Why is so much of my hair falling out each day?" Which response by the nurse best explains the reason for alopecia? "Chemo affects the cells of the body that grow rapidly, both normal and malignant" The common adverse effects of chemo N/V, alopecia, bone marrow depression - are due to chemo's effect on the rapidly reproducing cells, both normal and malignant A client receiving cholestyramine (Questran) for hyperlipidemia should be evaluated for what vitamin deficiency? Vitamin K Clients should be monitored for an increased prothrombin time and prolonged bleeding times which would alert the nurse to a vitamin K deficiency. These drugs reduce absorption of the fat soluble vitamins A, D, E, K A client experiencing uncontrolled A-Fib is admitted to the tele unit. What initial med should the nurse anticipate administering to the client? Digoxin Digoxin is administered for uncontrolled, symptomatic A-Fib resulting is a decreased CO. Digoxin slows the rate of conduction by prolonging the refractory period of the AV node, thus slowing the ventricular response, decreasing the HR, and effecting CO A client taking a thiazide diuretic for the past 6 months has a serum K+ of 3. The nurse anticipates which chg in prescription for the client? A K+ supplement will be prescribed This client's K+ is too low. Normal is 3.5 - 5. Taking a thiazide diuretic often results in a loss of K+, so a supplement needs to be prescribed to restore a normal serum K+ levle A client taking furosemide (Lasix), reports difficulty sleeping. What question is important for the nurse to ask the client? "At what time do you take your meds" the nurse needs to 1st determine at what time of day the client takes the Lasix because of the diuretic effect of it. Clients should take the med in the a.m. to prevent nocturia The nurse assesses a client w/ advanced cirrhosis of the liver for signs of hepatic encephalopthy. Which finding would the nurse consider an indication of progressive hepatic encephalopthy? Difficulty in handwriting A daily record in handwriting may provide evidence of progression or reversal of hepatic encephalopathy leading to coma A client who was in a MVA was admitted to the hospital and the right knee was placed in skeletal traction. The nurse has documented this nsg dx in the client's med record: Potential for impairment of skin integrity r/t immobility from traction". Which nsg intervention is indicated based on this dx stmt? Provide back and skin care while maintaining the traction This indicates that back care is performed while traction is left intact, which is the correct intervention for maintaining skin integrity. Maintaining skin integrity and providing back care is difficulty when a client is in traction, but it cannot be delayed until the client is removed from traction A splint is prescribed for nighttime use by a client w/ rheumatoid arthritis. Which stmt by the nurse provides the most accurate explanation for use of the splints? Prevention of deformities Splints may be used at night by clients w/ RA to prevent deformities caused by muscle spasms and contractures The nurse is assessing a client who smokes and has been dx'd w/ emphysema. Which finding would the nurse expect this client to exhibit? Normal skin coloring The differentiation b/w the "pink puffer" and the "blue bloater" is a well-known method of differentiating clients exhibiting sx of emphysema (normal color but puffing respirations) from those exhibiting sx of chronic bronchitis (edematous, cyanotic, shallow respirations). Total lung capacity is increased in emphysema since these clients have hyper-inflated lungs A client is admitted to the med ICU w/ a dx of MI. The client's hx indicates the infarction occurred 10 hrs ago. Which lab test result would the nurse expect this client to exhibit? Elevated CK-MB The cardiac isoenzyme CK-MB is the most sensitive and most reliable indicator of myocardial damage of all the cardiac enzymes. It peaks w/in 12-20 hrs after MI LDH cardiac enzyme that peaks about 48 hr after MI An adult client is admitted to the hospital burn unit w/ partial -thickness and full-thickness burns over 40% of the BSA. In assessing the potential for skin regeneration, what should the nurse remember about full-thickness burns? Regenerative fxn of the skin is absent because the dermal layer has been destroyed full-thickness burns destroy the entire dermal layer, included in this destruction is the regenerative tissue. For this reason, tissue regeneration does not occur, and skin grafting is necessary In assessing cancer risk, the nurse identifies which woman as being at greatest risk of dvp'g breast cancer? a 50 yr old whose mom had unilateral breast cancer the most predictive risk factors for dvpmt of breast cancer are over 40, a + family hx. other risk factors include nulliparity, no hx of breastfeeding, early menarche and late menopause. A 51 yr old truck driver who smokes 2 pks / day and is 30 # overwt is dx'd w/ having a gastric ulcer. what content is most important for the nurse to include in the DC teaching for him? Info on smoking cessation Smoking has been associated w/ ulcer formation, and stopping or decreasing the # of cigarettes smoked / day is an important aspect of ulcer mgmt HC workers must protect themselves against becoming infected w/ HIV. The CDC has issued guidelines for HC workers in r/t protection from HIV. These guidelines include which recommendation? Wear gloves when coining in contact w/ the blood or body fluids of any pt The CDC guidelines recommend that HCW use gloves when coming into contact w/ blood or body fluids from any client since HIV is infectious b/f the client becomes aware of sx 2 days post op, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. What intervention would be most helpful to this client? Advise the client to remain in bed w/ the leg elevated The client is exhibiting sx of DVT, a complication of immobility. The initial care includes BR and elevation of the extremity. A 46 yr old female client is admitted for acute renal failure secondary to DM and HTN. Which test is the best indicator of adequate glomerular filtration? Serum creatinine Creatinine is a product of muscle metabolism that is filtered by the glomerulus, and blood levels of this substance are not affected by dietary or fluid intake. An elevated creatinine strongly indicates nephron loss, reducing filtration. Although BUN is also an indicator or renal activity, it can be affected by non-renal factors such as hypovolemia and increased protein intake What types of meds should the nurse expect to administer to a client during an acute respiratory distress episode? Bronchodilators and steroids Besides supplemental O2, this client w/ ARDS needs meds to widen air passages, increase air space, and reduce alveolar membrane inflammation, such as bronchodilators and steroids Despite several eye surgeries, a 78 yr old client who lives alone has persistent vision problems. The visiting nurse is discussing home safety hazards w/ the client. The nurse suggests that the edges of the steps be painted which color? Medium yellow Yellow is the easiest for a person w/ failing vision to see Which intervention should the nurse implement for a female client dx'd w/ pelvic relaxation DO? Encourage the client to perform Kegal exercises 10 X day Pelvic relaxation DO's resulting from weakening support tissues of the pelvis. Kegel exercises helps strengthen the surrounding muscles. The nurse working in a post op surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for dvp'g lymphedema? She sustained an insect bit to her left arm yesterday A radical mastectomy interrupts lymph flow, and the increased lymph flow that occurs in response to the insect bite increases the risk for the occurrence of lymphedema In preparing to administer IV albumin to a client following surgery, what is the priority nsg intervention? a. Set the infusion pump to infuse the albumin w/in 4 hrs because it does not contain any preservatives. Any fluid remaining after 4 hrs should be discarded d. Administer through a large gauge catheter, this allows for fast infusion rate, which may be necessary. e. monitor Hgb and Hct levels. H/H levels may decrease as hemodilution may occur f. Assess for increased bleeding after administration; while increased blood vol and BP may cause bleeding The nurse working on a tele unit finds a client unconscious and in pulseless V-Tach. The client has an implanted auto defibrillator. What action should the nurse implement? Shock the client w/ 200 joules per hospital policy The client must be externally shocked to restore an effective cardiac rhythm. The automatic defibrillator is obviously malfunctioning A 57 yr old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130 he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client? "The test you are having tomorrow requires that you have nothing by mouth tonight." This is the most therapeutic stmt because the nurse is responding to the client's question How should the nurse position the electrodes for modified lead one telemetry monitoring? Negative polarity Left shoulder, Positive polarity Right chest nipple line, Ground Left Chest nipple line In MCL 1 monitoring, the + electrode is placed on the client's mid-chest to the R of the sternum, and the - electrode is placed on the upper L part of the chest. The ground may be placed anywhere, but is usually placed on the lower Left portion of the chest A client is admitted for further testing to confirm sarcoidosis. Which dx test provides definitive info that the nurse should report to the HCP? Lung tissue bx Sarcoidosis is an inflammatory condition that is characterized by the formation of widespread granulomatous lesions involving a pulmonary site. Although chest radiography identifies sarcoidosis, lung tissue bx obtained by bronchoscopy or bronchoalveolar lavage provides definitive confirmation During sxn'g , a client w/ an uncuffed tracheostomy tube begins to cough violently and dislodges the tracheostomy tube. Which action should the nurse implement 1st? Attempt to reinsert the tracheostomy tube The nurse should attempt to reinsert the tracheostomy tube by using a hemostat to open the tracheostomy or by grasping the retention sutures (if present) to spread the opening in insert a replacement tube w/ its obturator into the stoma. Once in place, the obturator should immediately be removed. When teaching diaphragmatic breathing to a client w/ COPD, which info should the nurse provide? Place a small book or magazine on the abd and make it rise while inhaling deeply Diaphragmatic or abd'l breathing uses the diaphragm instead of accessory muscles to achieve maximum inhalation and to slow the RR. The client should protrude the abd on inhalation and contract it w/ exhalation, so placing a book or magazine on the abd helps the client visualize the rise and fall of the abd The nurse is planning care to prevent complication for a client w/ multiple myeloma. Which intervention is most important for the nurse to include? Maintain a fluid intake of 3-4 liters/ day Multiple myeloma is a malignancy of plasma cells that infiltrate bone causing demineralization and hypercalcemia, so maintaining a urinary output of 1.5 - 2 liters / day requires an intake of 3-4 liters/day to promote excretion of serum Ca+ The nurse is caring for a client w/ a continuous feeding through a PEG tube. Which intervention should the nurse include in the POC? Check for placement and residual volume q4h Tube placement and residual volume should be checked b/f each feeding. Tube placement is checked by aspiration if stomach contents and measurement of pH. It is important to check for residual volume because gastric emptying is often delayed during illness. There is an increased risk for aspiration of the feeding w/ increased residual volume A client w/ a 16 yr hx of DM is having renal fxn tests because of recent fatigue, weakness, elevated BUN, and serum creatinine levels. Which finding should the nurse conclude as an early sx of renal insufficiency? Nocturia As the glomerular filtration rate decreases in early renal insufficiency, metabolic waste products, including urea, creatinine, and other substances, such as phenols, hormones, electrolytes, accumulate in the blood. In early stage of renal insufficiency, polyuria results from the inability of the kidneys to concentrate urine and contribute to nocturia A client w/ DM is experiencing polyphagia. Which outcome stmt is the priority for this client? Adequate cellular nourishment DM type 1 is characterized by hyperglycemia that precipitates glucosuria and polyuria (frequent urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). Polyphagia is a consequence of cellular malnourishment when insulin deficiency prevents utilization of glucose for energy, so the outcome stmt should include stabilization of adequate cellular nutrition A client w/ a completed ischemic stroke has a BP of 180/90 mmHg. Which should the nurse implement? Give an antihypertensive med Most ischemic strokes occur during sleep when baseline BP declines or blood viscosity increases due to minimal fluid intake. Completed strokes usually produce neurologic deficits w/in an hr and the client's current elevated BP requires antihypertensive med the nurse is caring for a client w/ stroke resulting in R sided paresis and aphasia. The client attempts to use the L hand for feeding and other self-care activities. The spouse becomes frustrated and insists on doing everything for the client. Based on this data, which ngs dx should the nurse document for this client? Disabled family coping r/t dissonant coping style of significant person A stroke affects the whole family and in this case the spouse probably thinks that she is helping and needs to feel that she is contributing to his care. Her help is noted as being incongruent w/ attempts of self-care by the client, thereby disabling family coping The nurse formulates the nsg dx of "Urinary retention r/t sensorimotor deficit" for a client w/ MS. Which nsg intervention should the nurse implement? Teach the client techniques of intermittent self-catheterization Bladder control is a common problem for clients w/ MS. A client w/ urinary retention should receive instructions about self-catheterization to prevent bladder distention. A 58 yr old client who has been post-menapausal for 5 yrs is concerned about the risk for osteoporosis because her mother has the condition. Which info should the nurse offer? Ca+ loss from bones can be slowed by increasing Ca+ intake and exercise Post-menapausal females are at risk for osteoporosis due to the cessation of estrogen secretion, but a regimen including Ca+, vitamin D, and wt bearing exercise can prevent further bone loss. Osteoporosis can be managed w/ conservative therapy, such as bone metabolism regulators and estrogen replacement therapy to improve bone density, but it is not a genetic disease The nurse is working w/ a 71 yr old obese client w/ bilateral osteoarthritis (OA) of the hips. What recommendation should the nurse make that is most beneficial in protecting the client's joints? Initiate a wt-reduction diet to achieve a healthy body wt. Achieving a healthy wt is critical to protect the joints of clients w/ OA. A 20 yr old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide? "Most lumps are benign, but it is always best to come in for an examination." This response provides the best response because it addresses the client's anxiety most effectively and encourages prompt and immediate action for a potential problem A 32 yr old female client c/o severe abd'l pain each month b/f her menstrual period, painful intercourse, and painful defecation. Which additional hx should the nurse obtain that is consistent w/ the client's complaints? Inability to get pregnant Dysmenorrhea, dyspareunia, and difficulty or painful defecation are common s of endometriosis, which is the abnormal displacement of endometrial tissue in the dependent areas of the pelvic peritoneum. A hx of infertility is another common finding associated w/ endometriosis A female client requests info about using the calendar method of contraception. Which assessment is most important for the nurse to obtain? An accurate menstrual cycle diary for the past 6-21 months The fertile period, which occurs 2 wks prior to the onset of menses, is determined using an accurate record of the number of days of the menstrual cycles for the past 6 months, so it is most important to emphasize to the client that accuracy and compliance of a menstrual diary is the basis of the calendar method A client who is sexually active w/ several partners requests an intrauterine device (IUD) as a contraceptive method. which info should the nurse provide? Using an IUD offers no protection against STD, which increases the risk for pelvic inflammatory disease (PID) the use of an IUD provides the client w/ no protection from STDs. While preg rates w/ the use of an IUD are somewhat higher, it is not therapeutic for avoiding other problems The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which info should the nurse include? D. Do not leave the diaphragm in place longer than 8 hrs after intercourse E. Replace the old diaphragm every 3 months the diaphragm needs to remain against the cervix for 6-8 hrs to prevent pregnancy but should not remain longer than 8 hrs to avoid the risk of TSS. The diaphragm should be replaced q3 months to maintain integrity. A male client receives a local anesthetic during surgery. During the post op assessment, the nurse notices the client is slurring his speech. Which action should the nurse take? Evaluate his BP, Pulse, and Respiratory status Slurred speech in this situation is an atypical finding and may indicate neurological deficits that require further assessment. During an interview w/ a client planning elective surgery, the client asks the nurse "What is the advantage of having a preferred provider organization insurance plan?" Which response is best for the nurse to provide? Insurance coverage of employees is less expensive to employers The financial advantage of this is the feature of a PPO that is most relevant to the avg consumer. The nurse must have knowledge about PPO's, which provide discounted rates to large employers who provide ins coverage for their employees. In return, the ins co. receives a large pool of clients for their facilities A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority? Check W the client's gag and swallow reflexes Following a gastroscopy, a client should remain NPO until the effects of the anesthesia have dissipated and the airway's protective reflexes, gag, and swallow reflexes, have returned After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hrs. What priority nsg action should be implemented? Report the findings to the surgeon An adult who weighs 132 pounds (60kg) should produce about 60 ml of urine hourly (1mL/kg/hr). Dark, concentrated, and low volume of urine output should be reported to the surgeon The nurse is assisting a client out of bed for the 1st time after surgery. What action should the nurse do 1st? Allow the client to sit w/ the bed in a high Fowler's position The 1st step is to raise the HOB to a high Fowlers position which allow venous return to compensate from lying flat and vasodilating effects of the perioperative drugs A female client is brought to the clinic by her daughter for a flu shot. she has lost significant wt since the last visit. She has poor personal hygiene and inadequate clothing for the weather. the client states that she lives alone and denies problems or concerns. What action should the nurse implement? Collect further data to determine whether self-neglect is occurring Chgs in wt and hygiene may be indicators of self-neglect or neglect by family members. Further assessment is needed b/f notifying social services or discussing a need for counseling A client w/ GERD has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client? Raising the HOB on blocks Raising the HOB on blocks to reduce reflux and subsequent aspiration is the most effective recommendation for a client experiencing severe GERD during sleep When providing DC teaching for a client w/ osteoporosis, the nurse should reinforce which home care activity? Elimination of hazards to home safety Discussion about fall prevention strategies is imperative for the DC'd client w/ osteoporosis so that advice about safety measures can be given. Another instruction can be wt bearing exercises The nurse is planning care for a client w/ newly dx'd DM that requires insulin. Which assessment should the nurse ID b/f beginning the teaching session? Willingness of the client to lean the injection sites. If a client is incapable or does not want to learn, it is unlikely that learning will occur, so motivation is the 1st factor the nurse should assess b/f teaching. Which finding should the nurse ID as most significant for client dx'd w/ polycystic kidney disease (PKD)? 3+ bacteria in the urine UTI for a client w/ PKD require prompt antibiotic therapy to prevent renal damage and scarring which may cause further progression of the disease, so bacteria in the urine is the most significant finding at this time The nurse is assessing a client w/ CKD. Which finding is most important for the nurse to respond to 1st? K+ of 6.0 mEq Hyperkalemia is a serious electrolyte disorder that can cause fatal arrhythmias, so this level of K+ is the nsg priority What DC instruction is most important for a client after a kidney transplant? Use daily reminders to take immunosuppressants After renal transplantation, acute rejection is a risk for several months, so immunosuppressive therapy, such as corticosteroids and azathioprine (Imuran), is essential in preventing rejections, so the priority instruction includes measures, such as daily reminders, to ensure the client takes meds regularly. Daily wts provides a better indicator or wt gain r/t rejections. It is important to ensure medication compliance to prevent rejection. A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. What response is best for the nurse to provide? Estrogen deficiency causes the vaginal tissues to become dry and thinner Estrogen deprivation decreases the moisture-secreting capacity of vaginal cells to vaginal tissues tend to b/c thinner, drier, and the rugae b/c smoother which reduces vaginal stretching that contributes to dyspareunia