Med Surg II Hesi (2) Flashcards

1
Q

stroke and dysphagia

A

Put pt in the upright position to prevent aspiration

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2
Q

A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding?

A

Persistent coughing while drinking

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3
Q

A client with Addison’s disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client’s laboratory values include; sodium 129 mEq/l (129mmol/l SI), glucose 54 mg/dl (2.97mmol/l SI) and potassium 5.3 mmol/l SI). When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medications?

A

hydrocortisone

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4
Q

The nurse is preparing a client for discharge who was recently diagnosed with Addison’s disease. Which instruction is most important for the nurse to include in the client’s discharge teaching plan?

A

Take prescribed cortisone accurately

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5
Q

A client admitted to the telemetry unit is having unrelieved chest pain after receiving 3 sublingual nitroglycerin tablets and morphine 8 mg IV. The electrocardiogram reveals sinus bradycardia with ST elevation. In what order should the nurse implement the nursing actions? (Arrange first to last)

A
  1. Call the rapid response team to assist
  2. Move the crash cart to the client room
  3. Notify the client’s healthcare provider
  4. Inform the family of the critical situation
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6
Q

The nurse is obtaining a health hx from a new pt with a hx of kidney stones. What statement by the pt indicates an incr risk of renal calculi?

A

Answer: eats a vegetarian diet with cheese 2-3x daily

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7
Q

In teaching a client newly diagnosed with multiple sclerosis (MS), which approach should the nurse emphasize as most likely to prevent an exacerbation of symptoms?

A

develop pre planned mechanisms to avoid or minimize the effects of triggers

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8
Q

ABG’s PE

A

a. Hypoxemia and hypocapnia, and respiratory alkalosis (this makes sense bc you are hyperventilating)

b. Arterial blood gas (ABG) results reflect respiratory alkalosis.

c. pH - 7.5 PaCO2 - 32

d. HCO3 - 24 PaO2 - 60

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9
Q

ARDS - COPD

A

Compensation occurs over time in clients with COPD and ABGs are altered. As COPD worsens, the amount of O2 decrease in the blood (hypoxemia) and the amount of CO2 increases (hypercapnia) causing chronic respiratory acidosis

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10
Q

How are the pathophysiological mechanisms responsible for ascites related to liver failure? (Select all that apply)

A

a. Fluid shifts from intravascular to interstitial area due to decreased serum protein

b. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen

c. Increased circulating aldosterone levels that increase sodium and water retention

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11
Q

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.)

A

-Monitor abdominal girth

-Report serum albumin and globulin levels.

-Note signs of swelling and edema

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12
Q

A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first?

A

evaluate swallow

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13
Q

The nurse is caring for a postoperative pneumonectomy client. Which finding on assessment of the client is an adverse sign or symptom indicating pulmonary edema?

A

Lung crackles in the remaining lung

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14
Q

The nurse is caring for a client with heart failure who develops respiratory distress and coughs up pink frothy sputum. Which action should the nurse take first?

A

Position in a high Fowler’s position with the legs down.

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15
Q

Atrial Flutter

A

Atrial flutter is a common abnormal heart rhythm similar to atrial fibrillation, the most common abnormal heart rhythm, both conditions are a type of supraventricular tachycardia. In AFL the upper chambers of the heart beat too fast, which results in atrial muscle contractions that are faster than and out of sync with the lower chambers

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16
Q

A-flutter

A

a. Description is a saw-toothed waveform, fluttering in the chest, and ventricular rhythm stays regular.

b. Treatment is cardioversion to treat atrial dysrhythmias, antidysrhythmic drugs, radiofrequency catheter ablation.

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17
Q

A client with ARF has been treated with sodium polystyrene sulfonate (Kayexalate) by mouth. The nurse would evaluate this therapy as effective if which of the following lab values was noted on a follow-up lab testing?

A

Potassium: 2.9 mEq/L

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18
Q

A client with acute renal injury (AKI) who weighs 50 kg had a potassium level of 6.7 mEq/L Is admitted to the hospital. Which prescribed medication should the nurse administer 1st?

A

Sodium polystyrene sulfonate 15 grams PO

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19
Q

Client has not been taking cortisone for either 2 weeks or 2 months and husband brings her into the ED. Husband states that she has not been feeling well and that she needed help getting ready today. (Patient has SIADH). What should you do?

A

Initiate fall precautions

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20
Q

Guillain Barre- swallow

A

a. Paresthesia (tingling and numbness)

b. Muscle weakness of legs progressing to the upper extremities, trunk, and face

c. Paralysis of the ocular, facial, and oropharyngeal muscles, causing marked difficulty in talking, chewing, and swallowing.

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21
Q

What is the first few s/sx of ARDS

A

confusion, restlessness, agitation

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22
Q

Chest pain ACS algorithm

A

Beta-Blocker: this will lower the workload of the heart. ↓HR↓BP↓Contractility.

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23
Q

A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client’s EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, “I feel like an elephant just stepped on my chest” The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform?

A

Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula.

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24
Q

The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain. Which assessment data is most important for the nurse to obtain?

A

Eating patterns and dietary intake

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25
Q

Which symptom of chronic pancreatitis also occurs with acute pancreatitis?

A

Abdominal pain

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26
Q

Nursing assessment: Chronic pancreatitis

A

a. Continuous burning or gnawing abdominal pain

b. Recurring attacks of severe upper abdominal and back pain

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27
Q

Renal diet CKD

A

a. Avoid salt substitutes.

b. A client with CKD should restrict sodium and potassium dietary intake, and salt substitutes usually contain potassium

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28
Q

After teaching a male client with chronic kidney disease (CKD) about therapeutic diet…which menu of foods indicates that the teaching was effective? Select all that apply

A

a. A slice of whole grain toast

b. A bowl of cream of wheat

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29
Q

Postop circulation after hip replacement

A

a. Post hip replacement complication → swelling/inflammation

b. check for the distal circulation: neurovascular circulation

c. color, sensation, warmth

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30
Q

A pt arrives at the ED with pain. Which description should prompt the nurse to suspect an MI?

A

Produces chest heaviness with left arm pain

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31
Q

An elderly female is admitted because of a change in her level of sensorium. During the evening shift, the client attempts to get out of bed and falls, breaking her left hip. Buck’s skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client’s plan care?

A

Ensure proper alignment of the leg in traction.

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32
Q

Stroke/TIA

A

-tinnitus

-diplopia

-dysarthia

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33
Q

Acute MI activity

A

How to prevent further MI → oxygen, morphine, rest

34
Q

A client with coronary artery disease is hospitalized with unstable angina. To reduce cardiac workload, what should the nurse introduce in the plan of care ?

A

Provide a bedside commode for toileting

35
Q

MI plan of care

A

Administer medications as prescribed For pain and to increase O2 perfusion,

IV morphine Sulfate

Nitrates

ACE inhibitors

Beta Blockers

Calcium Channel Blockers

Aspirin

Antiplatelet aggregates

Obtain vital signs and EKG

Administer O2 at 2-6 L per NC

Obtain cardiac enzymes

Provide quiet restful environment

Assess breath sounds for rales

Maintain patent IV line

Monitor fluid balance

Keep in semi-fowler’s position

Maintain bed rest for 24 hours

Consider medical interventions

Thrombolytic agents within 1-4 hours of MI but not more then 12 hours of MI

Intra Aortic balloon pump- improves myocardial perfusion

Surgical repair with CABG

36
Q

A client with angina pectoris is being discharged from the hospital. What instruction should the nurse plan to include in this discharge teaching?

A

Avoid all isometric exercises, but walk regularly

37
Q

Before a client’s discharge after mitral valve replacement surgery, the nurse should evaluate the client’s understanding of post surgery activity restrictions. Which of the following should the client not engage in until after the 1-month post discharge appointment with the surgeon?

A

Lifting anything heavier than 10 lb (4.5 kg).

38
Q

vascular compromise

A

blockage of blood flow leading to the death of tissues or organs

39
Q

Pericarditis pain

A

Relieved by sitting upright and leaning forward

When is pericarditis pain the worst?

breathing in

bed rest is recommended until pain is gone

40
Q

A client with acute pancreatitis is complaining of pain and nausea. Which interventions should the nurse implement (Select all that apply)

A
  • Monitor heart, lung, and kidney function.
  • Notify healthcare provider of serum amylase and lipase levels.
  • Review client’s abdominal ultrasound findings.
41
Q

secondary tumor

A

A term that is used to describe either a new primary cancer or a metastasis.

42
Q

Renal diet restrictions

A

Restrict Na, K, and protein.

43
Q

Patho fracture complications

A

-hemorrhage

-hypovolemic shock

44
Q

The nurse is assessing a client’s arteriovenous (AV) fistula. Which finding provides evidence of its normal function?

A

Enlarged vein

45
Q

Myasthenia gravis cold

A

avoid extreme temps

46
Q

A client tells the nurse I just received good news about my tumor I have a neoplasm but it is benign. How should the nurse respond?

A

Ask the client if the diagnostic tests indicated any secondary metastasis

47
Q

Which assessment finding indicates to the nurse that the desired outcome of the calcium acetate (PhosLo) has been acheived?

A

Serum phosphorus 4.0 mg/dL

48
Q

ABGs hypoxia

A

The PO2 should be maintained between 50 to 90 mmHg.PO2 <50 signifies hypoxia,

49
Q

ARDS priority lab

A

Low arterial PaO2

50
Q

Macular degeneration patho

A

a. related to the deterioration of macula as evidenced by verbal complaint of vision problems such as blurry or distorted vision and inability to see properly at night night blindness

b. leading cause of blindness

51
Q

Chemotherapy Teaching

A

Pt on chemo, and is vomiting - give ondansetron (antiemetic)

52
Q

A client with Cushing’s syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse?

A

Irregular apical pulse

53
Q

While completing an admission assessment for a client with unstable angina, which closed questions should the nurse ask about the client’s pain?

A

Does your pain occur when walking short distances?

54
Q

A nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate intervention by the nurse?

A

Serum sodium of 185 mEq/L

55
Q

A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse?

A

hypernatremia

56
Q

Pancreatitis Lipase

A

a. Elevated amylase, lipase, triglycerides, and glucose levels

b.may not occur until 24-36 h after illness onset

57
Q

Peritoneal dialysis first step

A

a. Obtain And record client’s vital signs

c.monitor I&O

58
Q

A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client’s plan of care?

A

Evaluate daily blood clotting factor

59
Q

SIADH findings

A

weight gain due to water retention

60
Q

A nurse is caring for a client with syndrome of inappropriate antidiuretic hormone secretion (SIADH). The nurse should monitor the client closely for

A

loss of thirst, weight gain

61
Q

Fibromyalgia patho

A

a. disorder of pain processing

b. The pathophysiology of fibromyalgia involves the autonomic nervous​ system, somatic peripheral nervous​ system, and endocrine system.

62
Q

Atrial Flutter Treatment

A

a. Cardioversion to treat atrial dysrhythmia

b. Antidysrhythmic drugs

calcium channel blocker, beta-adrenergic blockers, or antiarrhythmic

-anticoagulant will be prescribed if there’s blood pooling in the atria

c. Radiofrequency catheter ablation

63
Q

Chemotherapy- renal failure

A

Chemotherapy and immunotherapy drugs and biological therapies can all cause kidney damage. 1 Chemotherapy causes renal dysfunction by damaging the blood vessels or structures of the kidneys.

64
Q

Hemodialysis- BP

A

Do not take BP or perform venipunctures on the arm with the AV shunt, fistula, or graft.

65
Q

Pt has L grand toe amputation and states that he is having toe pain. What should the nurse do?

A

check the incision

66
Q

A nurse is caring for a client with acute pancreatitis. Which elevated laboratory test result is most indicative of acute pancreatitis?

A

Serum amylase

67
Q

The nurse is caring for a client with chronic renal failure (CRF) who is receiving dialysis therapy. Which nursing intervention has the greatest priority when planning this client’s care?

A

Monitor serum potassium levels.

68
Q

Pt has a long history of smoking. Pt comes in with sob. These are the ABG’s: pH 7.25, PCO2 50, anD HCO3 24. What does the patient have

A

Acidosis

69
Q

The nurse is caring for a client with respiratory distress whose arterial blood gas (ABG) results are as follows: pH, 7.33; Pco2,50 mm Hg; Po2, 70 mm Hg; HCO3, 26 mEq/L. How should the nurse interpret these results?

A

Respiratory acidosis

70
Q

ABGs- WNL

A

The nurse should continue to prepare the client for surgery because this is a normal finding.

71
Q

pancreatitis electrolytes

A

hypercalcemia 40 ~ 75% = positive trousseau sign = carpal spasm

72
Q

A client with Gullian Barre is not blinking. What intervention to implement?

A

apply lubricant

73
Q

Guillain Barre syndrome, what to report to HCP →

A

injury below T8?weakness in legs?

74
Q

The nurse suspects that the client has a pulmonary embolism and immediately sets about:

A

administer oxygen

75
Q

The nurse admits a client who has a medical diagnosis of bacterial meningitis to the unit. Which intervention has the highest priority in providing care for this client?

A

Assess the client for symptoms of hyponatremia

76
Q

A nurse provides home care instructions to a client with multiple sclerosis. The nurse tells the client to:

A

avoid taking hot baths and shower

77
Q

A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action?

A

Admin a topical analgesic per PRN protocol

78
Q

A client diagnosed with stable angina secondary to ischemic heart disease has a prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which instructions if chest pain is not relieved after taking 3 NTG tables 5 min apart?

A

a. Call 911 if pain is unrelieved and chew a tablet of aspirin 325 mg.

.

b. Store the medication in its original container and protect it from light.

79
Q

Mitral valve prolapse- 2d echo

A

used as a dx tool

80
Q

Sublingual nitroglycerin is administered to a male client with unstable angina who complains of crushing chest pain. Five minutes later the client becomes nauseated and his blood pressure drops to 60/40. Which intervention should the nurse implement?

A

infuse a rapid IV normal saline bolus