A client had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to be pale and cool, with a 1+ pedal pulse. What action would the nurse perform first?
Assess the neurovascular status of the right leg.
A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic intervention does the nurse recommend?
Ice packs
A client has a bone density score of -2.8. What intervention would the nurse anticipate based on this assessment?
Planning to teach about bisphosphonates
When administering alendronate (Fosamax) to a patient with osteoporosis, the nurse will
Assist the patient to sit up at the bedside
A client who had a partial gastrectomy 3 days ago begins experience vertigo sweating and tachycardia about 30 minutes after eating breakfast what postoperative complications would the nurse suspect
Dumping syndrome
After a patient has had a hemorrhoidectomy at an outpatient surgical center, which instructions will the nurse include in discharge teaching?
Take prescribed pain medications before you expect a bowel movement
Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient who has acute pancreatitis?
Muscle twitching and finger numbness
The nurse is assessing a client who has hepatitis C what extrahepatic complications would the nurse anticipate (SATA)
Polyarthritis
Heart disease
Myalgia
Which assessment finding is of most concern for a 46-year-old woman with acute pancreatitis?
Palpable abdominal mass
A woman receiving chemotherapy for breast cancer develops a Candida albicans oral infection. Which intervention should the nurse anticipate?
Nystatin tablets
A patient with knee pain who is diagnosed with bursitis asks the nurse to explain just what bursitis is. The nurse will respond that bursitis is an inflammation of
a small, fluid-filled sac found at some joints
The nurse is caring for a client who has pain during circumduction of the shoulder when the nurse moves the arm behind the client. Which of the following questions should the nurse ask?
Do you have difficulty putting on a jacket?"
The nurse admitting a patient with acute diverticulitis explains that the initial plan of care is to
administer IV fluids
A client had an open traditional Whipple procedure this morning. For what priority complication would the nurse assess?
Fluid and electrolyte imbalances
The nurse is performing an initial assessment and notes that the client weighs 186.4 Ib (84.7 kg). Six months ago, the client weighed 211.8 lb (96.2 kg). What action by the nurse is appropriate?
Ask the client if the weight loss was intentional
The nurse will be teaching self-management to patients after gastric bypass surgery. Which information will the nurse plan to include?
Drink fluids between meals but not with meals
Which assessment finding is of most concern for a patient with acute pancreatitis?
Palpable abdominal mass
The nurse is caring for a client who has cirrhosis of the liver. Which risk factor is the leading cause of cirrhosis?
Hepatitis C
The nurse notes that the primary health care provider documented the presence of mucosal erythroplasia in a client. What does the nurse understand that this most likely means for this client ?
Early sign of oral cancer
Which daily behavior of a client with GI problems requires further nursing assessment? Select all that apply.
Smokes a pack of cigarettes
Uses Fleet enemas frequently to assist with bowel movement
Takes 325 mg of aspirin at night for arthritic pain
Travels extensively across the world
A 26-yr-old patient with a family history of stomach cancer asks the nurse about ways to decrease the risk for developing stomach cancer. The nurse will teach the patient to avoid
Smoked foods such as ham and bacon
Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)?
Ranitidine decreases gastric acid secretion
The nurse is caring for a client who has been diagnosed with peptic ulcer disease. For which complication would the nurse monitor?
Upper gastrointestinal (GI) bleeding
A client has an open traditional hiatal hernia repair this morning. What is the nurse’s priority for client care at this time?
Preventing respiratory complications
The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (SATA)
Decreased hydrochloric acid production
Diminished sensation that can lead to constipation
Fat not digested as well in older adults
Pancreatic vessels become calcified
The nurse will plan to monitor a patient with an obstructed common bile duct for
Steatorrhea
A nurse is learning about different surgical procedures and their classifications. Which examples below does this include? (Select all that apply.)
Liver biopsy: diagnostic
Arthroscopy: preventative. Ileostomy: palliative. Total shoulder replacement: reconstructive
Body contouring: cosmetic
A client is scheduled to have a total hip arthroplasty. What preoperative teaching by the nurse is most important?
Remind the client to have all dental procedures completed at least 2 weeks prior to surgery.
A client who had a fractured ankle open reduction internal fixation (ORIF) 4 weeks ago, reports burning pain and tingling in the affected foot. For which potential complication would the nurse anticipate?
Complex regional pain syndrome
A nurse plans care for a client who is recovering from open reduction and internal fixation(ORIF) surgery for a right hip fracture. Which interventions would the nurse include in this plan of care? (Select all that apply.)
Elevate heels off the bed with a pillow.
Ambulate the client on the first postoperative day.
Reposition the client every 2 hours.
A nurse teaches a client with a fractured tibia about external fixation. Which advantages of external fixation for the immobilization of fractures would the nurse share with the client? (Select all that apply.)
It leads to minimal blood loss.
It allows for early ambulation.
It promotes healing.
A nurse cares for a client with a recently fractured tibia. Which assessment would alert the nurse to take immediate action?
Numbness and tingling in the extremity………….Report to the doctor immediately
A nurse cares for a client who had a bronchoscopy/post endoscopy 2 hours ago. The client asks for a drink of water. What action would the nurse take next?
Assess the gag reflex before giving any food or water.
A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is appropriate?
Assess the gag reflex
A nurse cares for an older adult who is admitted to the hospital with complications of diverticulitis. Which actions should the nurse include in the plan of care?(Select all that apply.)
Administer pain medications as prescribed.
Palpate the abdomen for distention.
Assess for sudden changes in mental status.
Evaluate stools for occult blood.
Which finding in the mouth of a patient who uses smokeless tobacco is suggestive of oral cancer?
Red, velvety, patches on the buccal mucosa
Which statement to the nurse from a patient with jaundice indicates a need for teaching?
“I use acetaminophen (Tylenol) every 4 hours for back pain.”
What action(s) by the nurse is (are) appropriate to promote nutrition in a client who had a partial gastrectomy? (SATA)
Administer vitamin B12 injections
Ask the primary health care provider about folic acid replacement
Provide iron supplements for the client
When caring for a patient with a history of a total gastrectomy, the nurse will monitor for
cobalamin (vitamin B12) deficiency
A nurse teaches a client who is at risk for carpal tunnel syndrome. Which health promotion activities would the nurse include in the health teaching? (SATA)
“Frequently assesses the ergonomics of the equipment being used.”
“Take breaks to stretch fingers and wrists during working hours.”
“Adjust chair height to allow for good posture.”
When assessing for Tinel’s sign in a patient with possible right carpal tunnel syndrome, the nurse will ask the patient about
Tingling in the right thumb and index finger
The nurse who notes that a 59-yr-old female patient has lost 1 inch in height over the past 2 years will plan to teach the patient about
dual-energy x-ray absorptiometry (DXA)
Which information in a 67-yr-old woman’s health history will alert the nurse to the need for a more focused assessment of the musculoskeletal system?
The patient’s mother became shorter with aging
The nurse reviews a list of drugs that can cause secondary osteoporosis. Which drugs are most commonly associated with this health problem? (SATA)
Barbiturates
Corticosteroids
Loop Diuretics
Which medication information will the nurse identify as a potential risk to a patient’s musculoskeletal system?
The patient has severe asthma requiring frequent therapy with oral corticosteroids.
A nurse assesses a client who has cirrhosis of the liver. Which laboratory findings would the nurse expect in clients with this disorder?
Elevated international normalized ratio (INR)
Elevated serum ammonia
Elevated prothrombin time (PT)
The nurse is reviewing the laboratory profile for a client who has muscular dystrophy. Which laboratory value(s) would the nurse expect to be elevated? (SATA)
Creatine Kinase (CK)
Lactic dehydrogenase (LDH)
Aspartate aminotransferase (AST)
lase (ALD)
The nurse is caring for several clients with osteoporosis. For which client would bisphosphonates not be a good option?
Client with a spinal cord injury who cannot tolerate sitting up.
What abnormality on the skin of an older patient is the priority to discuss immediately with the health care provider?
Petechiae on the chest and abdomen
Pt post op teaching of gastric bypass
Teach hydration
Pain in back or shoulders abdomen flank pain call dr
Small frequent meals
A nurse is caring for a client who has been diagnosed with a small bowel obstruction which assessment findings will the nurse correlate with this diagnosis SATA
Serum potassium 2.8
Abdominal pain in upper quadrants
Serum sodium of 121
High pitched bowel sounds
A client is admitted with acute pancreatitis. What priority problem would the nurse expect the client to report?
Severe boring abdominal pain
A client is receiving adefovir for management of hepatitis B. What health teaching will the nurse provide for the client about this drug? Select all that apply.
"Avoid places with crowds and individuals who have infection."
"Get your lab work done regularly because the drug can affect your kidneys."
The nurse is caring for a patient who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern?
The patients hands flap back and forth when the arms are extended
A patient with acute pancreatitis is NPO and has a nasogastric tube (NG) to suction. Which information obtained by the nurse indicates that these therapies have been effective?
Abdominal pain is decreased
A patient has been admitted with acute liver failure. Which data are most important for the nurse to communicate to the health care provider?
Asterixis and lethargy