HESI Med Surg Level Three Questions and Answers

HESI Med Surg Level Three Questions and Answers List four common symptoms of pneumonia the nurse might note on physical examination - Tachypnea, shallow respirations with use of accessory muscles - abrupt onset of fever with shaking and chills (not reliable in older adults) - productive cough with pleuritic pain - rapid, bounding pulse State four nursing interventions for assisting the client to cough productively - deep breathing q2 hours (may use incentive spirometer) - use humidity to loosen secretions (may be used with O2) - suctioning the airway if necessary, also helps with coughing - chest physiotherapy -increase fluids to 3L/day What symptoms of pneumonia might the nurse expect to see in an older client? - confusion - lethargy/malaise - anorexia - rapid respiratory rate - tachycardia How does the nurse prevent hypoxia when suctioning? oxygenate with 100% O2 for 1-2 minutes before and after suctioning During mechanical ventilation, what are three major nursing interventions? - verify that the alarms are on - maintain settings, and check often to ensure that they are specifically set as prescribed by the HCP - verify functioning of ventilator at least q4 hours -keep airway clear by coughing and suctioning When examining a client with emphysema, what physical findings is the nurse most likely to see? - bronchospasm and dyspnea - change in breathing pattern - over inflation of lungs... barrel chest - generalized cyanosis - either dry or productive cough - higher CO2 than average - low O2, usually between 90-92% - decreased breath sounds - coarse crackles in lungs that tend to disappear after coughing - orthopnea - poor nutrition, weight loss - activity intolerance -anxiety from not being able to breath What is the most common risk factor associated with lung cancer? cigarette smoking/marijuana describe why preop care is important for a pt going for a laryngectomy - involve family and client in manipulation of trach equipment before surgery - plan acceptable communication methods - refer to speech pathologist - discuss rehab program List 5 nursing interventions after chest tube insertion. - keep all tubing loosely coiled below chest level, ensure connections are tight and taped - keep water seal and suction control at appropriate levels - monitor fluid drainage and mark times of measurement and the fluid level - observe for bubbling in water seal chamber - monitor clients clinical status - check position of chest drainage system - encourage client to deep breath periodically - do not empty collection chamber container of chest tube, replace whole unit when full - do not strip or milk chest tubes - chest tubes are not clamped, if drainage system breaks, place distal end of tube in sterile water as an emergency water seal - maintain dry occlusive dressing What immediate action should the nurse take when a chest tube becomes disconnected from a bottle or suction apparatus? What should the nurse do if a chest tube is accidentally removed from the client? place the end of the tube in at least 2 cm of sterile water, apply an occlusive dressing, and notify HCP stat what instructions should be given to a client after radiation therapy? - do not wash off lines - wear soft cotton clothes - avoid use of powder and cream on radiation site what precautions are required for clients with TB when placed on respiratory isolation? - mask for anyone entering the room - private room for client - client must wear mast when leaving the room what are four components for teaching clients with TB? - cough into tissues and dispose of immediately in special bags - long-term need for daily meds - good hand-washing - report symptoms of deterioration, such as blood in secretions differentiate between ARF and CRF ARF: often reversible, abrupt deterioration of kidney fxn CRF: irreversible, slow deterioration of kidney fxn characterized by increasing BUN and creatinine. Eventually dialysis is required. During the oliguric phase of renal failure, protein should be severely restricted. What is the rationale for this restriction? toxic metabolites that build up in the blood (urea&creatinine) are derived mainly from protein catabolism Identify two nursing interventions for the client on hemodialysis. do not take BP or perform venipuncture on arm with AV shunt, fistula, or graft - assess site for thrill and bruit a client with renal failure asks why antacids are being given... what should the nurse say calcium and aluminum antacids bind phosphates and help keep phosphates from being absorbed into bloodstream, thereby preventing rise of phosphate levels in blood - must be taken with meals list 4 essential elements of a teaching plan for a pt with frequent UTI's - fluid intake of 3L/day - good hand washing - void q2-3 hours while awake - take all prescribed meds - wear cotton underwear what are the most important nursing interventions for clients with possible renal calculi -straining urine is the most important - accurate I&O and administer analgesics prn What discharge instructions should be given to a client who has had urinary calculi? - maintain high fluid intake to 3-4L/day - follow up care, stones tend to reoccur - follow prescribed diet based on calculi content - avoid supine position after TURP, hematuria should subside after how many days? 4 days After the urinary catheter is removed in the TURP client, what are 3 priority nursing actions? - strict I&O - continued observation for hematuria - inform pt that burning and frequency is a possible outcome for up to a week After kidney surgery, what are the primary assessments the nurse should make? - respiratory status (breathing is guarded from pain) - circulatory status (kidney is vascular and bleeding may occur) - pain assessment - urinary assessment (most important, assessment of urinary output) How do clients experiencing angina describe that pain? described as squeezing, heavy, burning, radiates to L arm or shoulder, transient or prolonged Develop a teaching plan for a client taking nitroglycerin. - take at first sign of anginal pain - take no more than 3 five minutes apart - call 911 if no relief in 10 minutes parameters of BP for diagnosing HTN 140/90 differentiate between essential and secondary HTN Essential HTN has no known cause; secondary HTN develops in response to an identifiable mechanism. Develop a teaching plan for a client taking antihypertensive medications. explain how and when to take meds; reason for meds; necessity of compliance; need for follow up visits while on meds; need for lab testing; VS parameters while initiating therapy Describe intermittent claudication Pain related to PVD; the pain occurs with exercise and disappears with rest. Describe the nurse's discharge instructions to a client with venous PVD. keep extremities elevated when sitting; rest at first sign of pain; keep extremities warm, but do not use heating pads; change position often; avoid crossing legs; do not wear tight clothing what is the underlying cause of AAA Atheroscloerosis what lab values should be monitored daily for a pt with thrombophlebitis who is on anticoag therapy PTT, PT, Hgb, Hct, platelets When do PVCs present a grave danger? When they begin to occur more often than once in 10 beats, occur in twos or threes, land near the T wave, or take on multiple configurations differentiate between the symptoms of left sided heart failure and right sided - L sided results in pulmonary failure due to backup of circulation in the left ventricle - R sided results in peripheral congestion due to backup of circulation in the R ventricle list 3 symptoms of digitalis toxicity Dysrhythmias, headache, nausea, and vomiting what condition increases the chance that dig toxicity will occur hypokalemia (which is more common when dig and diuretics are given together) what lifestyle changes can the pt who is at risk for HTN initiate to reduce the likelihood of becoming hypertensive? cease cigarette smoking; control weight; exercise regularly; maintain low-fat, low-cholesterol diet what immediate action should the nurse implement when a pt is having an MI - administer O2 by nasal cannula at 2-5L/min - ensure patent IV is started to deliver emergency meds - take measures to alleviate pain and anxiety - pt put on immediate bed rest to decrease amount of O2 demands on heart What symptoms should the nurse expect to find in a client with hypokalemia? dry mouth and thirst; drowsiness and lethargy; muscle weakness and aches; tachycardia bradycardia is defined as a HR below _____, and tachycardia is defined as a HR above ______ 60 bpm; 100 bpm what precautions should a client with valve disease take before invasive procedures such as dental work take prophylactic antibiotics List four nursing interventions for the client with a hiatal hernia. sit up while eating and for 1 hour after eating; eat frequent, small meals; eliminate foods that are problematic list three categories of meds that are used in the tx of peptic ulcer disease - antacids - H2 receptor blockers - mucosal healing agents - proton pump inhibitors List the symptoms of upper and lower GI bleeding Upper GI: melena, hematemesis, tarry stools; Lower GI: bloody stools, tarry stools; Common to both: tarry stools What bowel sound disruptions occur with an intestinal obstruction? early mechanical obstructions: high pitched sounds late mechanical obstruction: diminished or absent bowel sounds list four nursing interventions for postop care of a pt with a colostomy - irrigate daily at the same time - use warm water for irrigations - wash around stoma with mild soap and water after each ostomy bag change -ensure pouch opening extends at least 1/8 inch around the stoma List the common clinical manifestations of jaundice. scleral icterus (yellow sclera) dark urine chalky, clay-colored stools what are the common food intolerances for a pt with cholelithiasis fried, spicy, and fatty foods List five symptoms indicative of colon cancer Rectal bleeding, change in bowel habits, sense of incomplete evacuation, abdominal pain with nausea, weight loss in a client with cirrhosis, it is imperative to prevent further bleeding and observe for bleeding tendencies. list 6 relevant nursing interventions - avoid injections - use small-bore needles for IV insertions - maintain pressure on all injection sites for 5 min - use electic razor - use soft-brstile toothbrush - check stools and emesis for occult blood what is the main side effect of lactulose; which is used to reduce ammonia levels in clients with cirrhosis diarrhea how should the nurse administer pancreatic enzymes give with meals or snacks powder forms should be mixed with fruit juices List four groups who have a high risk for contracting hepatitis homosexual males; IV drug users; those who have had recent ear or tattoos; health care workers what diagnostic test is used to determine thyroid activity T3 & T4 what condition results from all tx for hyperthyroidism hypothyroidism; requiring thyroid replacement State three symptoms of hyperthyroidism and three symptoms of hypothyroidism. hyperthyroidism: weight loss, heat intolerance, diarrhea hypothyroidism: fatigue, cold intolerance, weight gain List five important teaching aspects for clients who are beginning corticosteroid therapy - continue medication until weaning plan has begun by HCP - monitor potassium, glucose, and sodium frequently - weigh daily; report a gain of 5 lb/week - monitor BP and pulse - teach S&S of cushings describe the physical appearance of a pt who has cushings moon face obesity of trunk buffalo hump in back muscle atrophy thin skin What type of diabetes is insulin dependent? Type 1 what type of diabetes sometimes requires no meds type 2 list 5 symptoms of hyperglycemia Polydipsia, polyuria, polyphagia, weakness, weight loss list 5 symptoms of hypoglycemia Hunger, lethargy, confusion, tremors or shakes, sweating Name the necessary elements to include in teaching a new diabetic: - the underlying pathophys - management and tx regimen - meal planning - exercise program - insulin admin - sick-day management - symptoms of hyperglycemia (not enough insulin) -symptoms of hypoglycemia (too much insulin, too much exercise, not enough food) - foot care Identify the peak action time of the following types of insulin; rapid-acting regular insulin; intermediate-acting insulin; long- acting insulin. rapid acting insulin: 2-4 hours intermediate: 6-12 hours long acting: 14-20 hours when preparing a client with diabetes for discharge, the nurse teaches the relationship between stress, exercise, bedtime snacking, and glucose balance. state the relationship among each of these stress and stress hormones usually increase glucose production and increase insulin need exercise may increase the chance of hypoglycemia, the client must always carry a fast-acting source of carb, such as a glucose tablet when exercising the nurse is in a situation where there is no premixed insulin. describe the method of drawing up a mixed dose of insulin - identify prescribed dose and type of insulin - store unopened insulin in fridge - open insulin has to be kept at room temp - draw up R insulin first - rotate injection sites - may reuse syringe by recapping and storing in fridge when making rounds at night, the nurse notices a pt prescribed insulin is complaining of a headache, nausea and slight trembling, and their hand is cool and moist. what is this pt most likely having? hypoglycemia/insulin reaction Identify 5 foot care interventions that should be taught to the client with diabetes check feet daily report any breaks, sores or blisters wear well fitted shoes never go barefoot or wear sandals never personally remove corns or calluses cut/file nails straight across wash feet daily with mild soap and water differentiate between rheumatoid arthritis and OA in terms of joint involvement RA occurs bilaterally and OA occurs asymmetrically Identify the categories of drugs commonly used to treat arthritis. NSAIDs, of which salicylates are the cornerstone of tx, and corticosteroids (used when S&S are severe) Identify pain-relief interventions for clients with arthritis. warm, moist heat (compresses, baths and showers), diversionary activities (imaging, self-distraction, self-hypnosis, biofeedback), meds What measures should the nurse encourage female clients to take to prevent osteoporosis? possible estrogen replacement therapy after menopause high calcium and Vit D intake beginning in early adulthood calcium supplements after menopause weight-bearing exercises what are common side effects of salicylates GI irritation, tinnitus, thrombocytopenia, mild liver enzyme elevation. what is the priority nursing intervention used with clients using NSAIDs admin or teach pt to take meds with food or milk List three of the most common joints that are replaced? hip, knee, finger Describe postop residual lib care after amputation for the first 48 hours? elevate stump for first 24 hours do not elevate after 48 hours keep stump in extended position and turn client prone three times a day to prevent flexion contracture Describe nursing care for the client who is experiencing phantom pain after amputation. be aware that phantom pain is real and will eventually disappear admin pain meds; phantom pain responds to pain meds What are the immediate nursing actions if fat embolization is suspected in a client with a fracture or other orthopedic condition? notify HCP stat draw ABGs assist with endotrach intubation and tx of respiratory failure