RN Adult Medical Surgical Online Practice 2023 B Part 2

Answer: A, C, D, E, F, G, H
When recognizing cues, the nurse should identify the assessment findings that require follow-up include 12 % weight loss over 2 months, muscle guarding and tenderness in right lower quadrant of abdomen, abdominal firmness and rigidity, abdominal pain rate of 8, hypoactive bowel sounds, report of anorexia and temperature of 38.5 C (101.4 F) require follow up by the nurse. These are unexpected findings that should be assessed further by the nurse and may require further intervention.

When analyzing cues, the nurse should identify that the client's assessment findings of right lower quadrant pain, fever, and client report of anorexia indicates appendicitis.

When analyzing cues, the nurse should identify that the client's assessment findings of blood in stool, right lower quadrant pain, fever, and client report of anorexia indicates Crohn's disease.

Answer: After reviewing the findings in the client's medical record, the nurse should first address the client's ABDOMINAL FINDINGS followed by the client's PAIN RATING

- When prioritizing hypotheses and using the priority framework of urgent vs non-urgent approach to client care, the nurse first should address the client's abdominal findings followed by the client's pain rating. Abdominal distention is a manifestation of an inflammatory intestinal disorder. The nurse should address this finding first to reduce the risk of life-threatening complications, such as obstruction or infection. The nurse should next address the client's pain rate of 8 which indicates moderate pain which requires intervention by the nurse.

Anticipated:
- Obtain vital signs every hour.
- Obtain blood cultures.
- Insert a nasogastric tube.

Contraindicated:
- Administer an intermittent IV bolus of fluid within 1 hour.

Rationale:
- When generating solutions when planning the client's care, the nurse should anticipate that the provider prescriptions for obtaining blood cultures, obtaining vital signs ever hour and insert a nasogastric tube are prescriptions that could be indicated to manage the client's current condition. The anticipated provider prescription for administering a bolus of IV fluid is contraindicated for the client because the client's vital signs are within the expected reference range and the client is not experiencing findings that indicate a decrease in their fluid volume.

Answer: C. Administer client's PO medication with a sip of water.
E. Administer gentamicin 100 mg IV.
G. Ensure that the client has provided informed consent.
Rationale: - When taking actions after reviewing the client's EMR and provider prescriptions, the nurse should prepare the client for an exploratory laparotomy by ensuring that the client has provided informed consent, administer gentamicin 100 mg IV, and the client's prescribed PO phenytoin. The client has findings of peritonitis in which the provider evaluating further.

Answer: A, D - When evaluating outcomes, the nurse should identify that the client understands discharge teaching after stating "I will schedule several rest periods throughout the day" and "I will notify my provider if temperature is greater than 101 F." The client had an exploratory laparotomy procedure and has a closed incision; therefore, the client will require rest throughout the day and should monitor for manifestations of infection such as an elevated temperature and drainage from surgical wound.

Answer: B. Increase fiber intake to at least 30 g per day.
- Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.

Rationale:
A - Antacids are used to manage manifestations of gastric reflux and dyspepsia, not cramps and pain associated with diarrhea and constipation. Anticholinergic or antispasmodic agents can be prescribed to control cramping.
C - Ginger tea is useful for treating nausea, not cramping. Additionally, a client who has IBS should avoid dairy products, raw fruits, and grains that can cause bloating.
D - The client should consume at least 2 L of water daily to promote regular bowel function.

Answer: B. HR 55/min
- The client's heart rate of 55/min is a decrease from the client's baseline of 74/min, and it can indicate the development of digoxin toxicity. The nurse should report this finding to the provider.

Rationale:
A - The client's potassium level of 4.1 mEq/L is within the expected reference range (3.5 to 5 mEq/L).

C - The nurse should ensure that the client's SaO2 level remains at or above 90%. This finding is within the expected reference range.

D - The nurse should report a client's weight gain of 1.4 kg (3 lb) in a day or 2.3 kg (5 lb) or more in a week.

Answer: C. Use crutches with rubber tips.
- Using crutches with rubber tips prevents the client from slipping and decreases the risk of falls.

Rationale:
A - The surgeon applies the external fixation device directly to the client's bone to form a rigid structure around the affected extremity. Casts, boots, or splints are applied to the leg for internal fixation.

B - The client should wear external fixation devices continuously for a period of 4 to 6 weeks. The nurse should teach the client to perform care of the wound and pin sites at home.

D - Only the provider should adjust the client's external fixation device to maintain bone alignment.

Answer: D. Keep the client occupied with a manual activity.
- The nurse should provide the client with a manual activity such as a puzzle or an art project. This can help to distract the client from the IV catheter.

Rationale:
A - The nurse should check on the client at least once every hour.

B - The nurse should provide soft music to calm the client. If possible, the nurse should allow the client to choose the type of music they prefer.

C - If the client is agitated, the nurse should turn off the television in the client's room.

Answer: A. Suction Machine
- The nurse should ensure that a suction machine is at the bedside of a client who has dysphagia to clear the client's airway as needed and reduce the risk for aspiration.

Rationale:
B - The nurse should ensure wire cutters are at the bedside of a client who has an inner maxillary fixation to cut the wires in case the client vomits. This enables the client to clear their airway and reduce the risk for aspiration.

C - The nurse should ensure a padded clamp is at the bedside of a client who has a chest tube to clamp the tube and prevent air from entering the client's chest if there is an interruption in the sealed drainage system.

D - The nurse should ensure a communication board is at the bedside of a client who has aphasia to assist the client with communicating.

Answer: D. Administer an opioid analgesic to the client.
- The nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite.

Rationale:
A - The nurse should apply ice for a bite from a black widow spider to reduce the action of the neurotoxin from the spider.

B - The nurse should expect a prescription for antihistamines and corticosteroids for stings from bees and wasps.

C - The nurse should keep the affected extremity at heart level, not above or below it.

Answer: B, C, E
B - Visual spatial deficits and loss of depth perception occur secondary to a right-hemispheric stroke.
C - Left hemianopsia, or blindness in the left half of the visual field, occurs secondary to a right-hemispheric stroke.
E - One-sided neglect, or an unawareness of the affected side, occurs secondary to a right-hemispheric stroke.

Rationale:
A - Expressive aphasia, or an inability to express what one wants to convey, occurs secondary to a left-hemispheric stroke.
D - One-sided neglect, or an unawareness of the affected side, occurs secondary to a right-hemispheric stroke.

Answer: B. Perform synchronized cardioversion
- Perform synchronized cardioversion.The nurse should perform synchronized cardioversion for a client who has supraventricular tachycardia.

Rationale:
A - The nurse should defibrillate the client's heart for ventricular tachycardia or ventricular fibrillation.
C - The nurse should initiate CPR for a client who is pulseless or not breathing.
D - The nurse should administer lidocaine IV bolus for a client who has a ventricular dysrhythmia.

Answer: A. Remain with the client for the first 15 min of the infusion.
- The nurse should remain with the client for the first 15 to 30 min of the infusion because hemolytic reactions usually occur during the infusion of the first 50 mL of blood.

Rationale:
B - The nurse should use 0.9% sodium chloride when transfusing blood to prevent clotting or hemolysis of the RBCs.

C - The client's room number is not an acceptable client identifier. The nurse should ensure that the name and number on the client's identification band matches the name and identification number on the blood label. The client's identification, the blood compatibility, and the expiration date of the blood should be verified by two nurses.

D - The nurse should transfuse the packed RBCs within 2 to 4 hr based upon the client's age and cardiovascular status. Longer infusion times increase the risk for bacterial contamination of the blood product.

Answer: C. Urine output 25 mL/hr
- Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing.

Rationale:
A - A decrease in weight of 4.54 kg (10 lb) in a short time period is a sign of a nutritional problem, which can delay wound healing.
B - BMI readings provide a means of determining a client's nutritional status. Clients who have a BMI less than 18.5 are considered at risk for complications, such as poor wound healing.
D - A well-managed pain level enhances a client's willingness to increase mobility.

Answer: C. Inject the medication into the anterolateral abdominal wall.
- The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to enhance medication absorption and prevent hematoma formation.

Rationale:
A - A client who is taking enoxaparin does not require a daily INR. The nurse should periodically compare the client's CBC with a baseline CBC.
B - The nurse should plan to follow the injection of the medication with the air bubble located at the site of the plunger in the prefilled syringe. The air bubble ensures that the client receives the whole dose of the medication.
D - The nurse should avoid massaging the client's injection site after administration to minimize bruising.

Answer: D. Urine specific gravity 1.045 (1.005 to 1.03)
- A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration.

Rationale:
A - A client who has hypertonic dehydration may experience a blood sodium level above the expected reference range because the kidneys would respond to loss of free body water by attempting to conserve the free body water which increases the blood concentration of sodium. A finding of 132 mEq/L is below the expected reference range and indicates an excess of free body water.

B - Skin turgor can be an unreliable indication of dehydration in older adult clients because of age-related changes to skin elasticity. The nurse should check an older adult client's skin turgor on the sternum, rather than on the limbs, for a more reliable indicator.

C - The nurse should expect the client's respiratory rate to increase if dehydration occurs because the decreased vascular fluid volume seen with dehydration decreases oxygenation and organ perfusion, requiring a compensatory increase in the respiratory rate.

Answer: C. "This identifies if the pacemaker cells of my heart are working properly."
- Telemetry detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the heart muscle.

Rationale:
A - Cardiac output, which is calculated by multiplying heart rate and stroke volume, measures the amount of blood ejected by the heart over 1 min.
B - An echocardiogram, a noninvasive ultrasound procedure, evaluates heart valve function and structure.
D - Cardiac catheterization allows for the measurement of coronary artery blood flow.

Answer: C. "You should cut the opening of the skin barrier one-eighth inch wider than the stoma."
- The client should cut the opening of the skin barrier 0.3 cm (1/8-in) wider than the stoma to minimize irritation of the skin from exposure to urine.

Rationale:
A - During the procedure, the client's bladder is removed and the ureters are brought to the skin surface of the abdomen to form a stoma, from which urine will flow into an external ostomy bag. Therefore, the client will not have an urge to void.
B - The client should not add an aspirin tablet to the pouch, because it can ulcerate the stoma.
D - The client should avoid using moisturizing soaps to clean the skin around the stoma because it will prevent the pouch from adhering to the skin.