ATI CAPSTONE ADULT MEDICAL SURGICAL ASSESSMENT 1

A nurse is caring for an adult client who asks about vaccinations against communicable diseases. The nurse should inform the client that which of the following vaccines are available? (Select all that apply) Hepatitis A vaccine Hepatitis B vaccine Pneumococcal vaccine Hepatitis C vaccine Helicobacter pylori vaccine Adult vaccines currently available to prevent contracting communicable diseases include those for hepatitis A & B influenza and pneumonia. No vaccine is currently available for hep C/H. pylori = A, B, C A nurse is providing discharge instructions to a client who has a peptic ulcer. Which of the following dietary modifications should the nurse include? Provide a snack at bedtime Choose decaffeinated coffee Restrict intake of fried foods Avoid drinking liquids with meals The nurse should instruct the client to avoid fried foods, spicy foods, and acid-producing foods, such as coffee and chocolate. Spicy foods, such as chili pepper, red pepper, and black pepper can cause mucosal damage. The nurse should instruct the client to avoid decaffeinated and caffeinated beverages and snacks at bedtime, which can stimulate gastric acid secretion. A client with dumping syndrome, rather than peptic ulcer should avoid liquids with meals = C A nurse is caring for a client who is postoperative immediately following a pheochromocytoma removal. Which of the following actions is the nurse’s priority? Increase hydration Monitor blood pressure Measure urine output Provide a calm environment The greatest risk to this client is injury from hypertension due to the release of catecholamines during surgery or hypotension from the sudden loss of catecholamines aker the tumor has been removed. Therefore, the priority intervention the nurse should take is to monitor the client's blood pressure = B A nurse is caring for a client who is using a ventilator when the low-pressure ventilator alarm sounds. Which of the following actions should the nurse take? Suction secretions from the endotracheal tube Check the ventilator tubing connections Administer intravenous sedation and analgesia Reassure the client and instruct them not to bite on the tube A low-pressure alarm indicates a loss of volume due to a disconnection, cuff link or tube displacement = B A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates the client might be experiencing a hemolytic transfusion reaction? Hypertension Report of urticaria Distended neck veins Report of chest pain Chest pain is a manifestation of a hemolytic transfusion reaction. Other manifestations include headache, low back pain, and hypotension = D A nurse is assessing a client who has right lower lobe pneumonia. Which of the following findings should the nurse expect? Dull percussion sounds Increased anteroposterior chest diameter Distended neck veins Pitting edema