RN Adult Medical Surgical Online Practice 2019 B,100% CORRECT

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Medical Surgical ATI Lyme Disease A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Understanding of the patient teaching. ANS: My joints ache because I hav... e Lyme disease. Chronic complications memory problem and fatigue Musculoskeletal: Osteoporosis/Osteomyelitis A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings is a manifestation of this condition? ANS: Pain that increases with passive movement. Other s/s diminished pulse or pulselessness and capillary refill greater than 2 seconds in the affected extremity. Warmth indicates infection. A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include? Flex the foot every hour when awake. Avoid placing pillows under the knee. Elevate the leg when sitting in a chair to reduce edema and pain. Keep the operative leg in a neutral position when resting in bed Teaching external fixation device for fracture of lower extremity: use crutches with rubber tip. Casts/splints/boots applied. Continuous use for 4-6 weeks. Teach wound and pin care. Only provider can adjust. Post-op open reduction internal fixation of the ankle. What assessment report: extremity cool on palpation. Other findings to report: pallor, cool temp, paresthesia A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain? Alternate application of heat and cold to the affected joints. Diet high in nutrients, such as protein, vitamins, and iron, to promote tissue repair. Elevation of the affected extremities does not relieve the painful inflammation caused by rheumatoid arthritis. Elevation of the extremities can assist with managing the pain of a client who has peripheral vascular disease. Regular exercise is important to prevent stiffness. Caring for a client with hx of a compound fracture, 3 wks ago. Unexpected finding showing osteomyelitis? ANS: Sedimentation rate. An increased sedimentation rate occurs when a client has any type of inflammatory process, such as osteomyelitis. A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client which of the following medications can increase their risk of developing osteoporosis? ANS: Prednisone. The nurse should instruct the client that prednisone can increase the risk for developing osteoporosis due to suppression of bone formation, and an increase in bone resorption by osteoclasts. Prednisone can also reduce intestinal absorption of calcium. Conjugated estrogen reduces risk. Colchicine can cause aplastic anemia. A nurse is providing education to a client who is at risk for osteoporosis. Which of the following instructions should the nurse include? Walk for 30 mins four times per week. Other teaching: Glucosamine for pain, avoid exercises that cause jarring motions, such as jogging, take over-the-counter calcium supplements. Procedures Suctioning client tracheostomy tube. Signs of hypoxia: The client’s heart rate increases. Coughing is expected. Late signs are diaphoresis and a decrease in blood pressure and will not be seen now. An increase in blood pressure is an early sign. A nurse is caring for a client who has an arterial line. Nursing action to take? ANS: Place a pressure bag around the flush solution. Arterial line used for ABG samples and hemodynamic monitoring. Supine, HOB 60 degrees. A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse's priority to report to the provider? Restlessness. Expected: inc temp, dec BP, weight loss. A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide? Hemodialysis is sometimes required following surgery. Transplant can come from a living or deceased donor. Lifelong immunosuppressive therapy is necessary for the organ recipient. Following transplant, clients should follow dietary restrictions to prevent rejection. A nurse is caring for a client who had a nephrostomy tube inserted 12hrs ago. Report to the doc? ANS: The client complains of back pain. This indicates the tube may have clogged or is dislodged. Report decrease in UO. Red tinged urine expected post 12-24hrs Planning care for a client who is scheduled for a thoracentesis. Nursing interventions. ANS: Encourage the client to take deep breaths after the procedure. Other: upright position, arm resting overhead table, local anesthetic, npo not needed. Resumes activity within 1 hr post procedure. A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's inital vital signs were HR 80, BP 130/70, R 16, and temp 96.8. Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging? HR 110. one of the first signs of hemorrhage is an increase in the heart rate from the client's baseline, which occurs to compensate for blood loss. An early sign of hemorrhage is a slight increase in the diastolic blood pressure. As bleeding progresses, the systolic blood pressure will decrease. An increase in blood pressure postoperatively can indicate that the client is in pain. An increase in the respiratory rate from the client’s baseline is an indication of hemorrhage. An increase in temperature from the client’s baseline is an indication of infection, not hemorrhage. A nurse is caring for a client following extubation of an endotracheal tube 10 mins ago. Priority to report? ANS: Stridor. Expected findings: hoarseness, sore throat, oral secretions TURP post opp, clots in indwelling catheter: irrigate the catheter. Traction applied to reduce risk of bleeding. A nurse is planning for a client who is postoperative following a laparotomy and has a closed-suction drain. Which of the following actions should the nurse take to manage the drain? ANS: Compress the drain reservoir after emptying Compressing the reservoir creates a vacuum that draws fluid out of the wound, through the drain, and into the reservoir. A closed-suction drain uses a reservoir for collecting drainage and applies negative pressure, which allows the drainage to collect in the reservoir rather than relying on gravity, and does not require wall suction. A Penrose drain allows drainage to collect on a sterile gauze dressing. [Show More]

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