Adult Health II (Med Surge) Nursing
A patron admitted to the health facility with a suspected analysis of acute pancreatitis is being
assessed by the nurse. Which evaluation findings would be steady with acute pancreatitis?
Select all that follow.
1.Diarrhea
2.Black, tarry stools
three.Hyperactive bowel sounds
4.Gray-blue coloration at the flank
5.Abdominal guarding and tenderness
6.Left higher quadrant ache with radiation to the back - ANS-four,five,6 (Rat) Grayish - blue
discoloration on the flank is called Grey-Turner's sign and takes place due to pancreatic enzyme
leakage.
A consumer has evolved hepatitis A after consuming infected oysters. The nurse assesses the
purchaser for which anticipated evaluation finding?
1.Malaise 2.Dark stools 3.Weight benefit 4.Left higher quadrant discomfort - ANS-1, Malaise
A customer has simply had a hemorrhoidectomy. Which nursing interventions are suitable for
this client? Select all that apply.
1.Administer stool softeners as prescribed. 2.Instruct the consumer to restrict fluid consumption
to avoid urinary retention. 3.Encourage a high-fiber food plan to sell bowel actions without
straining. 4.Apply bloodless packs to the anal-rectal area over the dressing until the packing is
removed. Five.Help the purchaser to a Fowler's position to place stress at the rectal vicinity and
decrease bleeding. - ANS-1, three,four Administer stool softness as prescribed, Encourage a
excessive - fiber eating regimen to promote BM w/o straining & Apply bloodless packs to the
anal-rectal location over the dressing till the packing is eliminated.
A client has simply had surgical operation to create an ileostomy. The nurse assesses the
consumer in the instantaneous postoperative period for which mostfrequent hardship of this kind
of surgical procedure?
1.Folate deficiency 2.Malabsorption of fat three.Intestinal obstruction four.Fluid and electrolyte
imbalance - ANS-4 FLuid and electrolyte imbalance
A purchaser is diagnosed with viral hepatitis, complaining of "no appetite" and "dropping my
flavor for food." What education must the nurse supply the customer to offer good enough
nutrients?
,1.Select ingredients high in fat.
2.Increase intake of fluids, together with juices.
3.Eat a terrific supper while anorexia is not as extreme.
4.Eat much less often, ideally simplest three huge meals day by day. - ANS-2, Increase intake
of fluids, inclusive of juices
A customer is readmitted to the sanatorium with dehydration after surgical procedure for
introduction of an ileostomy. The nurse assesses that the customer has lost three lb of weight,
has bad pores and skin turgor, and has concentrated urine. The nurse interprets the purchaser's
clinical photograph as correlating most carefully with latest intake of which remedy, which is
contraindicated for the ileostomy patron?
1.Folate
2.Biscodyl
three.Ferrous sulfate
4.Cyanocobalamin - ANS-2. Biscodyl (Rat) The affected person with an ileostomy is liable to
dehydration because of the area of the stony in the GI tract and should now not take laxatives.
A client visible inside the ambulatory care sanatorium has ascites and mild jaundice. The nurse
have to check the consumer for a records of continual use of which remedy?
1.Ibuprofen
2.Ranitidine
three.Acetaminophen
4.Acetylsalicylic acid - ANS-four, Tylenol (Rat) This medicine can motive hepatoxicity.
A client with acute pancreatitis is experiencing severe pain from the ailment. The nurse
determines that schooling approximately positioning to reduce ache turned into effective if the
consumer avoids which movement?
1.Sitting up
2.Lying flat
three.Leaning forward
four.Drawing the legs to the chest - ANS-2 Lying flat (Rat) The pain of acute pancreatitis is
irritated with the aid of lying supine or strolling.
A patron with cirrhosis has ascites and excess fluid quantity. Which assessment findings does
the nurse count on to word because of expanded abdominal stress? Select all that practice.
1.Orthopnea and dyspnea
2.Petechiae and ecchymosis
three.Inguinal or umbilical hernia
4.Poor frame posture and balance
, five.Abdominal distention and tenderness - ANS-1, 2, three, 5 Orthopnea and SOB, Petechiae
and ecchymosis, Inguinal or umbilical hernia and And distention and tenderness (Rat) Ascites
can reason physical problems because of the over distended stomach and resultant strain on
inner organs and vessels.
A customer with gastric hypersecretion is scheduled for surgical treatment. The nurse teaches
the purchaser that the method will reduce the belly's manufacturing of acid with the aid of
changing which structure?
1.Portal vein
2.Celiac artery
three.Vagus nerve
four.Pyloric valve - ANS-three, Vagus nerve (Rat) Note that the vagus nerve allows to
manipulate the complex methods in your digestive tract, such as signaling the. Muscle groups in
the belly to contract and push food into the small intestine. A broken vagus nerve or surgical
treatment that alters the vagus nerve function cannot ship indicators commonly for your belly
muscular tissues. A vagotomy is a procedure that could reduce innervation to the stomach,
thereby decreasing the production of gastric acid.
A vital care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in
Veterans who're being handled for shock. What interventions ought to be exact in the Veterans
plan of care even as the Veteran is ventilated?
A. Performing frequent oral care
B. Maintaining the Veteran in a supine function
C. Suctioning the Veteran every 15 mins except contraindicated
D. Administering prophylactic antibodies, as ordered - ANS-A. Performing frequent oral care
A gerontologic nurse is teaching a set of medical nurses approximately the high prevalence and
mortality of pneumonia in older adults. What is a contributing factor to this that the nurse have to
describe?
A. Older adults have much less compliant lung tissue than younger adults
B. Older adults are not typically applicants for pneumococcal vaccination
C. Older adults frequently lack the conventional symptoms and symtoms of pneumonia
D. Older adults often cannot tolerate the most common antibiotics used to deal with pneumonia.
- ANS-C. Older adults frequently lack the classic signs and symptoms and symtoms of
pneumonia
(RAT) Pneumonia - Assess for hypoxemia by way of applying the pulse oximetry and with the
aid of assessing ABG's.
Education/Teaching: Educate others that older adults are at extra hazard of getting pneumonia
due to the fact this patient population do no longer gift with the identical s/s as a more youthful
person would thus stopping early remedy that is lifesaving.
A patron admitted to the health facility with a suspected analysis of acute pancreatitis is being
assessed by the nurse. Which evaluation findings would be steady with acute pancreatitis?
Select all that follow.
1.Diarrhea
2.Black, tarry stools
three.Hyperactive bowel sounds
4.Gray-blue coloration at the flank
5.Abdominal guarding and tenderness
6.Left higher quadrant ache with radiation to the back - ANS-four,five,6 (Rat) Grayish - blue
discoloration on the flank is called Grey-Turner's sign and takes place due to pancreatic enzyme
leakage.
A consumer has evolved hepatitis A after consuming infected oysters. The nurse assesses the
purchaser for which anticipated evaluation finding?
1.Malaise 2.Dark stools 3.Weight benefit 4.Left higher quadrant discomfort - ANS-1, Malaise
A customer has simply had a hemorrhoidectomy. Which nursing interventions are suitable for
this client? Select all that apply.
1.Administer stool softeners as prescribed. 2.Instruct the consumer to restrict fluid consumption
to avoid urinary retention. 3.Encourage a high-fiber food plan to sell bowel actions without
straining. 4.Apply bloodless packs to the anal-rectal area over the dressing until the packing is
removed. Five.Help the purchaser to a Fowler's position to place stress at the rectal vicinity and
decrease bleeding. - ANS-1, three,four Administer stool softness as prescribed, Encourage a
excessive - fiber eating regimen to promote BM w/o straining & Apply bloodless packs to the
anal-rectal location over the dressing till the packing is eliminated.
A client has simply had surgical operation to create an ileostomy. The nurse assesses the
consumer in the instantaneous postoperative period for which mostfrequent hardship of this kind
of surgical procedure?
1.Folate deficiency 2.Malabsorption of fat three.Intestinal obstruction four.Fluid and electrolyte
imbalance - ANS-4 FLuid and electrolyte imbalance
A purchaser is diagnosed with viral hepatitis, complaining of "no appetite" and "dropping my
flavor for food." What education must the nurse supply the customer to offer good enough
nutrients?
,1.Select ingredients high in fat.
2.Increase intake of fluids, together with juices.
3.Eat a terrific supper while anorexia is not as extreme.
4.Eat much less often, ideally simplest three huge meals day by day. - ANS-2, Increase intake
of fluids, inclusive of juices
A customer is readmitted to the sanatorium with dehydration after surgical procedure for
introduction of an ileostomy. The nurse assesses that the customer has lost three lb of weight,
has bad pores and skin turgor, and has concentrated urine. The nurse interprets the purchaser's
clinical photograph as correlating most carefully with latest intake of which remedy, which is
contraindicated for the ileostomy patron?
1.Folate
2.Biscodyl
three.Ferrous sulfate
4.Cyanocobalamin - ANS-2. Biscodyl (Rat) The affected person with an ileostomy is liable to
dehydration because of the area of the stony in the GI tract and should now not take laxatives.
A client visible inside the ambulatory care sanatorium has ascites and mild jaundice. The nurse
have to check the consumer for a records of continual use of which remedy?
1.Ibuprofen
2.Ranitidine
three.Acetaminophen
4.Acetylsalicylic acid - ANS-four, Tylenol (Rat) This medicine can motive hepatoxicity.
A client with acute pancreatitis is experiencing severe pain from the ailment. The nurse
determines that schooling approximately positioning to reduce ache turned into effective if the
consumer avoids which movement?
1.Sitting up
2.Lying flat
three.Leaning forward
four.Drawing the legs to the chest - ANS-2 Lying flat (Rat) The pain of acute pancreatitis is
irritated with the aid of lying supine or strolling.
A patron with cirrhosis has ascites and excess fluid quantity. Which assessment findings does
the nurse count on to word because of expanded abdominal stress? Select all that practice.
1.Orthopnea and dyspnea
2.Petechiae and ecchymosis
three.Inguinal or umbilical hernia
4.Poor frame posture and balance
, five.Abdominal distention and tenderness - ANS-1, 2, three, 5 Orthopnea and SOB, Petechiae
and ecchymosis, Inguinal or umbilical hernia and And distention and tenderness (Rat) Ascites
can reason physical problems because of the over distended stomach and resultant strain on
inner organs and vessels.
A customer with gastric hypersecretion is scheduled for surgical treatment. The nurse teaches
the purchaser that the method will reduce the belly's manufacturing of acid with the aid of
changing which structure?
1.Portal vein
2.Celiac artery
three.Vagus nerve
four.Pyloric valve - ANS-three, Vagus nerve (Rat) Note that the vagus nerve allows to
manipulate the complex methods in your digestive tract, such as signaling the. Muscle groups in
the belly to contract and push food into the small intestine. A broken vagus nerve or surgical
treatment that alters the vagus nerve function cannot ship indicators commonly for your belly
muscular tissues. A vagotomy is a procedure that could reduce innervation to the stomach,
thereby decreasing the production of gastric acid.
A vital care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in
Veterans who're being handled for shock. What interventions ought to be exact in the Veterans
plan of care even as the Veteran is ventilated?
A. Performing frequent oral care
B. Maintaining the Veteran in a supine function
C. Suctioning the Veteran every 15 mins except contraindicated
D. Administering prophylactic antibodies, as ordered - ANS-A. Performing frequent oral care
A gerontologic nurse is teaching a set of medical nurses approximately the high prevalence and
mortality of pneumonia in older adults. What is a contributing factor to this that the nurse have to
describe?
A. Older adults have much less compliant lung tissue than younger adults
B. Older adults are not typically applicants for pneumococcal vaccination
C. Older adults frequently lack the conventional symptoms and symtoms of pneumonia
D. Older adults often cannot tolerate the most common antibiotics used to deal with pneumonia.
- ANS-C. Older adults frequently lack the classic signs and symptoms and symtoms of
pneumonia
(RAT) Pneumonia - Assess for hypoxemia by way of applying the pulse oximetry and with the
aid of assessing ABG's.
Education/Teaching: Educate others that older adults are at extra hazard of getting pneumonia
due to the fact this patient population do no longer gift with the identical s/s as a more youthful
person would thus stopping early remedy that is lifesaving.
