Med Surg 1- Exam 3 with answers
The |nurse |instructs |a |client |about |how |to |increase |folic |acid |in |the |diet. |The |nurse |determines |
teaching |is |effective |if |the |client |makes |which |statement?
a) |"I |like |oatmeal |for |breakfast."
b) |"My |favorite |lunch |is |a |spinach |salad."
c) |"I |will |eat |more |grapes, |apples, |and |bananas |each |day."
d) |"I |will |eat |more |chicken." |- |correct |answer |-b) |"My |favorite |lunch |is |a |spinach |salad."
spinach |contains |108 |mg |of |folic |acid |per |half-cup |serving; |other |folate-rich |sources |include |organ |
meats, |broccoli, |asparagus, |milk, |orange |juice, |wheat |germ |and |Grape-Nuts
The |nurse |cares |for |a |client |with |a |nasogastric |tube |in |place. |The |client |reports |discomfort |in |the |
back |of |the |throat. |Which |action |by |the |nurse |is |BEST?
a) |Move |the |tube |out |2 |inches
b) |Change |feedings |to |full |liquids
c) |Reinsert |tube |into |other |nostril
d) |Spray |with |viscous |lidocaine |solution |- |correct |answer |-d) |Spray |with |viscous |lidocaine |solution
viscous |lidocaine |is |a |local |anesthetic; |spraying |it |on |the |irritated |surface |may |relieve |the |
discomfort |in |the |back |of |the |client's |throat; |tube |only |repositioned |if |the |tube |isn't |draining |after |
irrigation
The |nurse |gives |discharge |instructions |to |the |family |of |a |patient |diagnosed |with |hepatic |
encephalopathy. |The |nurse |determines |further |teaching |is |necessary |if |the |family |makes |which |of |
the |following |statements?
a) |We |should |contact |the |physician |if |Dad |is |restless |at |night."
b) |"Cephulac |will |cause |Dad |to |have |2-3 |stools |per |day."
,c) |"Dad |should |eat |meat |at |every |meal."
d) |"Cephulac |may |cause |bloating |and |cramps." |- |correct |answer |-c) |"Dad |should |eat |meat |at |every |
meal."
low-protein, |high-calorie |diet |for |clients |with |hepatic |encephalopathy; |instruct |family |to |observe |for
|and |report |any |mental |status |changes; |hepatic |encephalopathy |occurs |with |profound |liver |disease |
and |results |from |the |accumulation |of |ammonia |in |the |blood; |earliest |s/s |are |mental |changes, |such |
as |exhibiting |periods |of |lethargy |and |euphoria |and |progressing |to |coma
The |home |care |nurse |visits |a |client |with |a |diagnosis |of |ulcerative |colitis. |The |client |complains |of |
perineal |irritation |due |to |frequent |stools. |Which |suggestion |by |the |nurse |is |BEST?
a) |Apply |a |heat |lamp |to |the |perineal |area |three |times |per |day
b) |Use |protective |plastic |bed |pads
c) |Clean |the |perineal |area |with |soap |and |water |after |each |bowel |movement
d) |Increase |roughage |in |the |diet |to |prevent |the |frequent |stools |- |correct |answer |-c) |Clean |the |
perineal |area |with |soap |and |water |after |each |bowel |movement
keeps |the |skin |free |of |stool; |important |to |keep |perineal |area |clean |and |dry; |sitz |baths; |apply |
petroleum |jelly |or |vitamin |A |and |D |ointment; |low |residue |diet |recommended
The |nurse |instructs |a |client |about |appropriate |foods |for |a |high-protein |diet. |The |nurse |determines |
teaching |is |effective |if |the |client |chooses |which |menu?
a) |Chef |salad, |crackers, |and |iced |tea
b) |Broiled |fish, |cream |of |tomato |soup |topped |with |grated |cheese, |and |custard
c) |Peanut |butter |and |jelly |sandwich, |chips, |and |fruit |drink
d) |Turkey |sandwich |with |lettuce |and |tomato, |potato |salad, |and |milk |- |correct |answer |-b) |Broiled |
fish, |cream |of |tomato |soup |topped |with |grated |cheese, |and |custard
all |foods |contain |protein; |increase |protein |by |adding |skim |milk |to |soup, |add |grated |cheese |to |
foods, |use |peanut |butter |as |spread |on |fruits |and |veggies, |use |yogurt |as |topping |for |fruit |and |cake
,The |nurse |performs |a |home |care |visit |on |a |client |with |a |diagnosis |of |right-sided |cerebrovascular |
accident. |The |client's |spouse |complains |about |having |frequent |loose |stools, |and |the |physician |
diagnosed |viral |gastroenteritis. |The |nurse |is |MOST |concerned |if |which |of |the |following |is |observed?
a) |The |spouse |washes |hands |frequently
b) |The |spouse |drinks |Gatorade
c) |The |spouse |uses |a |separate |tube |of |toothpaste
d) |The |spouse |prepares |lunch |for |the |client |- |correct |answer |-d) |The |spouse |prepares |lunch |for |the |
client
due |to |diarrhea, |should |not |prepare |foods |that |will |be |eaten |by |others; |gastroenteritis |is |
inflammation |of |the |mucous |membranes |of |the |small |bowel |- |s/s |include |N/V, |and |diarrhea
he |nurse |understands |the |MOST |common |reason |for |insertion |of |a |nasogastric |tube |in |a |postop |
client |diagnosed |with |a |duodenal |ulcer |includes |which |reason?
a) |Take |samples |of |gastric |acid
b) |Assess |the |stomach |for |bleeding
c) |Decompress |the |stomach
d) |Permit |saline |irrigations |- |correct |answer |-c) |Decompress |the |stomach
the |stomach |is |decompressed |postoperatively |to |prevent |distention |and |pressure |on |the |suture |
lines
The |nurse |preforms |preoperative |teaching |for |a |patient |scheduled |for |a |colostomy. |The |nurse |
explains |to |the |patient |that |24 |hours |after |the |surgery |the |colostomy |drainage |will |be |which |of |the
|following?
a) |A |large |amount |of |bloody |output
b) |A |large |amount |of |liquid |stool
c) |Formed |stool |with |water
, d) |A |scant |amount |of |bright |bloody |drainage |- |correct |answer |-d) |A |scant |amount |of |bright |bloody |
drainage
small |amount |of |bleeding |at |stoma |expected; |report |excessive |amounts |of |bleeding; |initial |stool |
will |be |liquid |after |colostomy |begins |functioning |and |if |colostomy |is |placed |in |the |ascending |colon, |
the |stool |will |always |be |liquid
The |nurse |obtains |a |history |from |a |client |suspected |of |having |a |duodenal |ulcer. |The |nurse |expects |
the |client |to |make |which |statement?
a) |"I |have |been |vomiting |bright |red |blood."
b) |"I |have |abdominal |pain |and |tenderness."
c) |"I |have |frequent |loose |stools |every |day."
d) |"I |have |increased |pain |after |eating." |- |correct |answer |-b) |"I |have |abdominal |pain |and |
tenderness."
duodenal |ulcer |is |erosion |of |the |mucosal |wall |of |the |duodenum; |epigastric |pain |is |the |most |
common |symptom; |pain |occurs |2-3 |hours |after |eating, |and |food |intake |relieves |the |pain
The |nurse |cares |for |a |client |with |a |Sengstaken-Blakemore |tube |to |treat |bleeding |esophageal |
varices. |The |client |suddenly |develops |respiratory |distress. |Which |action |should |the |nurse |take |
FIRST?
a) |Auscultate |breath |sounds
b) |Cut |the |balloon |port |on |the |Sengstaken-Blakemore |tube
c) |Obtain |and |record |blood |pressure |and |pulse
d) |Contact |the |health |care |provider |- |correct |answer |-b) |Cut |the |balloon |port |on |the |Sengstaken-
Blakemore |tube
keep |a |pair |of |scissors |at |bedside; |cutting |the |port |will |deflate |the |balloon |and |allow |the |nurse |to |
remove |the |tube
The |nurse |instructs |a |client |about |how |to |increase |folic |acid |in |the |diet. |The |nurse |determines |
teaching |is |effective |if |the |client |makes |which |statement?
a) |"I |like |oatmeal |for |breakfast."
b) |"My |favorite |lunch |is |a |spinach |salad."
c) |"I |will |eat |more |grapes, |apples, |and |bananas |each |day."
d) |"I |will |eat |more |chicken." |- |correct |answer |-b) |"My |favorite |lunch |is |a |spinach |salad."
spinach |contains |108 |mg |of |folic |acid |per |half-cup |serving; |other |folate-rich |sources |include |organ |
meats, |broccoli, |asparagus, |milk, |orange |juice, |wheat |germ |and |Grape-Nuts
The |nurse |cares |for |a |client |with |a |nasogastric |tube |in |place. |The |client |reports |discomfort |in |the |
back |of |the |throat. |Which |action |by |the |nurse |is |BEST?
a) |Move |the |tube |out |2 |inches
b) |Change |feedings |to |full |liquids
c) |Reinsert |tube |into |other |nostril
d) |Spray |with |viscous |lidocaine |solution |- |correct |answer |-d) |Spray |with |viscous |lidocaine |solution
viscous |lidocaine |is |a |local |anesthetic; |spraying |it |on |the |irritated |surface |may |relieve |the |
discomfort |in |the |back |of |the |client's |throat; |tube |only |repositioned |if |the |tube |isn't |draining |after |
irrigation
The |nurse |gives |discharge |instructions |to |the |family |of |a |patient |diagnosed |with |hepatic |
encephalopathy. |The |nurse |determines |further |teaching |is |necessary |if |the |family |makes |which |of |
the |following |statements?
a) |We |should |contact |the |physician |if |Dad |is |restless |at |night."
b) |"Cephulac |will |cause |Dad |to |have |2-3 |stools |per |day."
,c) |"Dad |should |eat |meat |at |every |meal."
d) |"Cephulac |may |cause |bloating |and |cramps." |- |correct |answer |-c) |"Dad |should |eat |meat |at |every |
meal."
low-protein, |high-calorie |diet |for |clients |with |hepatic |encephalopathy; |instruct |family |to |observe |for
|and |report |any |mental |status |changes; |hepatic |encephalopathy |occurs |with |profound |liver |disease |
and |results |from |the |accumulation |of |ammonia |in |the |blood; |earliest |s/s |are |mental |changes, |such |
as |exhibiting |periods |of |lethargy |and |euphoria |and |progressing |to |coma
The |home |care |nurse |visits |a |client |with |a |diagnosis |of |ulcerative |colitis. |The |client |complains |of |
perineal |irritation |due |to |frequent |stools. |Which |suggestion |by |the |nurse |is |BEST?
a) |Apply |a |heat |lamp |to |the |perineal |area |three |times |per |day
b) |Use |protective |plastic |bed |pads
c) |Clean |the |perineal |area |with |soap |and |water |after |each |bowel |movement
d) |Increase |roughage |in |the |diet |to |prevent |the |frequent |stools |- |correct |answer |-c) |Clean |the |
perineal |area |with |soap |and |water |after |each |bowel |movement
keeps |the |skin |free |of |stool; |important |to |keep |perineal |area |clean |and |dry; |sitz |baths; |apply |
petroleum |jelly |or |vitamin |A |and |D |ointment; |low |residue |diet |recommended
The |nurse |instructs |a |client |about |appropriate |foods |for |a |high-protein |diet. |The |nurse |determines |
teaching |is |effective |if |the |client |chooses |which |menu?
a) |Chef |salad, |crackers, |and |iced |tea
b) |Broiled |fish, |cream |of |tomato |soup |topped |with |grated |cheese, |and |custard
c) |Peanut |butter |and |jelly |sandwich, |chips, |and |fruit |drink
d) |Turkey |sandwich |with |lettuce |and |tomato, |potato |salad, |and |milk |- |correct |answer |-b) |Broiled |
fish, |cream |of |tomato |soup |topped |with |grated |cheese, |and |custard
all |foods |contain |protein; |increase |protein |by |adding |skim |milk |to |soup, |add |grated |cheese |to |
foods, |use |peanut |butter |as |spread |on |fruits |and |veggies, |use |yogurt |as |topping |for |fruit |and |cake
,The |nurse |performs |a |home |care |visit |on |a |client |with |a |diagnosis |of |right-sided |cerebrovascular |
accident. |The |client's |spouse |complains |about |having |frequent |loose |stools, |and |the |physician |
diagnosed |viral |gastroenteritis. |The |nurse |is |MOST |concerned |if |which |of |the |following |is |observed?
a) |The |spouse |washes |hands |frequently
b) |The |spouse |drinks |Gatorade
c) |The |spouse |uses |a |separate |tube |of |toothpaste
d) |The |spouse |prepares |lunch |for |the |client |- |correct |answer |-d) |The |spouse |prepares |lunch |for |the |
client
due |to |diarrhea, |should |not |prepare |foods |that |will |be |eaten |by |others; |gastroenteritis |is |
inflammation |of |the |mucous |membranes |of |the |small |bowel |- |s/s |include |N/V, |and |diarrhea
he |nurse |understands |the |MOST |common |reason |for |insertion |of |a |nasogastric |tube |in |a |postop |
client |diagnosed |with |a |duodenal |ulcer |includes |which |reason?
a) |Take |samples |of |gastric |acid
b) |Assess |the |stomach |for |bleeding
c) |Decompress |the |stomach
d) |Permit |saline |irrigations |- |correct |answer |-c) |Decompress |the |stomach
the |stomach |is |decompressed |postoperatively |to |prevent |distention |and |pressure |on |the |suture |
lines
The |nurse |preforms |preoperative |teaching |for |a |patient |scheduled |for |a |colostomy. |The |nurse |
explains |to |the |patient |that |24 |hours |after |the |surgery |the |colostomy |drainage |will |be |which |of |the
|following?
a) |A |large |amount |of |bloody |output
b) |A |large |amount |of |liquid |stool
c) |Formed |stool |with |water
, d) |A |scant |amount |of |bright |bloody |drainage |- |correct |answer |-d) |A |scant |amount |of |bright |bloody |
drainage
small |amount |of |bleeding |at |stoma |expected; |report |excessive |amounts |of |bleeding; |initial |stool |
will |be |liquid |after |colostomy |begins |functioning |and |if |colostomy |is |placed |in |the |ascending |colon, |
the |stool |will |always |be |liquid
The |nurse |obtains |a |history |from |a |client |suspected |of |having |a |duodenal |ulcer. |The |nurse |expects |
the |client |to |make |which |statement?
a) |"I |have |been |vomiting |bright |red |blood."
b) |"I |have |abdominal |pain |and |tenderness."
c) |"I |have |frequent |loose |stools |every |day."
d) |"I |have |increased |pain |after |eating." |- |correct |answer |-b) |"I |have |abdominal |pain |and |
tenderness."
duodenal |ulcer |is |erosion |of |the |mucosal |wall |of |the |duodenum; |epigastric |pain |is |the |most |
common |symptom; |pain |occurs |2-3 |hours |after |eating, |and |food |intake |relieves |the |pain
The |nurse |cares |for |a |client |with |a |Sengstaken-Blakemore |tube |to |treat |bleeding |esophageal |
varices. |The |client |suddenly |develops |respiratory |distress. |Which |action |should |the |nurse |take |
FIRST?
a) |Auscultate |breath |sounds
b) |Cut |the |balloon |port |on |the |Sengstaken-Blakemore |tube
c) |Obtain |and |record |blood |pressure |and |pulse
d) |Contact |the |health |care |provider |- |correct |answer |-b) |Cut |the |balloon |port |on |the |Sengstaken-
Blakemore |tube
keep |a |pair |of |scissors |at |bedside; |cutting |the |port |will |deflate |the |balloon |and |allow |the |nurse |to |
remove |the |tube
