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Advanced Nursing Final Keiser
University Questions With
Accurate Answers
1 day post op trantonoidal hyposisectomy with clear drainage coming from nose what is nurses action? correct answer check drainage for glucose 72 HOURS AFTER ABOVE KNEE AMPUTATION correct answer have patient lay prone every 4 hours for 20-30 minutes A client being discharged after ineffective endocarditis discharge teaching correct answer Finish antibiotics until complete. A client who has pneumothorax experiences correct answer experiences severely diminished or absent breath sounds on the affected side. A client who is MPL and has a nasal drip gastric tube to suction. When the client reports nausea which of the following actions should the nurse take? correct answer Irrigate the tube with normal saline A client with a diagnosis of colon cancer is two days post op following a reception and Anastomosis. The nurse plans what should the nurse prioritize? correct answer Frequent abdominal auscultation A client with a Q information of diverticulitis should maintain a what diet? correct answer A diet very low in fiber
the client can consume low fiber foods like white bread low fat milk yogurt with active cultures poached eggs canned soft fruit A client with an infection will have an increased what? correct answer Temperature A client with continuous tube feeding through a pump at 75 mL per hour. When the nurse assesses a client at 8:00 AM following find findings requires intervention? correct answer The head of the bed is elevated at 20°. The head of the bed should be Élevage at least 30° semi Fowler's position while the two fitting is administered this position is a scrubby to help the feeding move through the digestive system unless there's a possibility of regurgitation A community health nurse is preparing an initial visit to a client that is being discharged following a total Gastroectomy from gastric cancer. what should they anticipate the plan of care to include? correct answer Injections of B 12 A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should alert the nurse to a serious adverse effect? correct answer midsternal chest pain A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse?
A nurse in the ER has a patient with myasthenia gravis patient in crisis which of the following causes of crisis? correct answer infection A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect? correct answer Anorexia is a early manifestation of hepatitis A and is often severe. A nurse is assessing a client with a head injury in a brief level of consciousness which of the following should the nurse report? correct answer Small drop of clear fluid in left ear. A nurse is assessing a client with meningitis possibly flexing neck and bringing legs up what sign is this? correct answer Bruzinski's sign A nurse is caring for a client in late stage esophageal cancer what assessments are characterics of this disease? correct answer Perforation of the mediastinum erosion great vessels obstruction obstruction of esophagus A nurse is caring for a client who had a gastric resection to treat adenocarcinoma of the stomach. The client tells the nurse in the PACU that he does not remember why the surgeon said he had to have a tube in his nose. The nurse should explain that the NG tube service which of the following purposes? correct answer Prevents excessive pressure on suture lines
A nurse is caring for a client who has a Trumatic brain injury which of the following findings for indications of ICP? correct answer The greatest risk to this client is injury from increased intracranial pressure. Therefore, the nurse's priority action is to maintain the PaCO2 at approximately 35 mm Hg to prevent hypercarbia and subsequent vasodilation effects that lead to increase in intracranial pressure. A nurse is caring for a client who has acute diverticulitis. While the client has active information the nurse should instruct the client to include which of the following foods in her diet? correct answer White bread and plain yogurt A nurse is caring for a client who is a quadriplegic who has severe headache and a blood pressure of 210/108 and suspects autonomic dysreflexia what should the nurse do? correct answer Please client high Fowlers a nurse is caring for a patient following treatment for supraventorial brain tumor which of the following interventions should the nurse do? correct answer Raise the head of the bed 30° A nurse is planning care for a client with cirrhosis of the liver to prevent ascites diet? correct answer a low sodium diet administration of furosemide or spilactrone - diuretics measurements of abdominal girth daily A patient is having a tonic clonic seizure what action should the nurse take? correct answer Turn the clients head to the side.
Admitted with pheochromocytoma after adrenalectomy. assessment that is most concerning correct answer bp 169/98, tumors on adrenal gland increases blood pressure alcohol use and frequent bruises and nose bleeds are caused by what? correct answer cirrhosis Allen's test procedure correct answer Measures arterial blood flow Allens test correct answer The nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery. Always keep the chest tube below the level of what body part correct answer waist ARDS (acute respiratory distress syndrome) correct answer admin vecuronium to facilitate ventilation ARDS (acute respiratory distress syndrome) correct answer respiratory insufficiency marked by progressive hypoxia aspirin correct answer anti platelet drug
aspririn and quinine correct answer ototoxicity = irreversible hearing loss Atelectasis/Post -op complication correct answer increased dyspnea atrial fibrillation correct answer occurs when the normal rhythmic contractions of the atria are replaced by rapid irregular twitching of the muscular heart wall atrial fibrillation correct answer rapid, random, ineffective contractions of the atrium atrial graft venous infusscency correct answer cold and numbness distal to site auditory receptive correct answer temporal lobe Autonomic Dysreflexia correct answer (potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure) basal skin carcinoma assessment correct answer pearly skinny nodule basal skin carcinoma correct answer skin cancer; frequent contact with sun, chemicals, radiation treatment; most common on face and upper trunk, favorable outcome with early detection
cardiac labs correct answer tropionin 1 = 1 week troponin T= 2 weeks Caring for a patient with questions on treatment options for new diagnosis of basal carcinoma what treatment should be included? correct answer gyro therapy electrotherapy radiation micrographic surgery cath interventions correct answer peripheral pulses in hip and leg extended remain in bed for 6hoursz keep affected leg straight and extended Cephalexin (Keflex) correct answer reduces intestinal bacterial levels chest pain lead over infarcted are with elevation correct answer elevated ST segment chest tube is dislodged correct answer put end of tube in normal saline basin cover other hole with saline soaked gauze Cholecystitis correct answer inflammation of the gallbladder
Cholecystitis findings ` correct answer blumbergs sign Chronic pancreatitis or pancreatic cancer you should expect to find what? correct answer Ascites-Abdominal swelling caused by accumulation of fluid, most often related to liver disease. Cirrhosis correct answer Obtain the clients PT and INR measurements admin lactose 30 mL four times a day and abdominal girth measurements daily multivitamin Cisplatin (Platinol) correct answer tintus report
- Treatment for cancer.
- If a client has reported fatigue it is important to check the pts most recent CBC. The client I likely to be anemic as a result of myelosuppression (bone marrow suppression) from the chem. The pt may require tx for the anemia (transfusion, medications) and further chemo may be need to be delayed until the blood counts are higher. close chest tube water seal suction check for correct answer continuous bubbling in seal chamber Complete intestinal obstruction what should the nurse expect? correct answer Hyper active bowel sounds around the obstruction Cushing diet correct answer RESTRITED SODIUM
elastic bandage of a stump with RBK amputation complications correct answer pitting edema around stump dressing wrap from distal to proximal change every 4-6 hours elective surgery with Addisons disease correct answer hyperpigmentation end stage liver failure ammonia levels correct answer increased with ESLF End stage liver failure what to expect? correct answer Increase pro thrombin time related to the in adequate supply of clotting factors in an increased or prolong thrombin time end-stage kidney disease (ESKD) patient has shortness of breath and swelling in extremities, crackles in lungs, and elevated blood pressure correct answer hypERvOlemia Esophageal cancer early prevention? correct answer Early treatment of gastric reflux disease esophageal cancer late stage correct answer perforation of the mediastinum erosion great vessels obstruction of esophagus expressive speaking correct answer inferior posterior frontal area expressive writing correct answer posterior frontal area
Heart mumur documented by? correct answer Quality Location Radiation Posture Timing Loudness Pitch Pattern hemolytic reaction to blood transfusion correct answer BACK PAIN hemolytic reaction to blood transfusion correct answer Caused by incompatibility. S/S include N/V, pain in lower back, hypotension, hematuria. hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first? correct answer d. Assess the client for airway patency. hyp0parathyroidism correct answer pathological fracture Hyper glycemia patient will exhibit what? correct answer Excessive thirst hyperactive reflexes correct answer clonus like my boyfriends dog foot that bouncing like crazy rt nerve damage `
lacerated spleen osculate decrease breath sounds in lower lobes correct answer atelectasis lactate dehydrogenase correct answer converts pyruvate to lactate lactate dehydrogenase in end stage liver failure correct answer indicative of Lactulose is what? correct answer A laxative that decreases ammonia levels laryngeal cancer correct answer hoarseness Late manifestations of hepatitis A correct answer Jaundice dark urine pale feces liver failure correct answer prothrombin prolonged Management of happy includes? correct answer Frequent rest periods throughout the day. mechanical heart valve teaching correct answer I will have my prothrombin time checked on a normal bases
metabolic acidosis correct answer low pH, low HCO metabolic acidosis correct answer ph below 7. metabolic alkalosis correct answer high pH, high HCO mi manifestations correct answer nausea tachycardia diaphoresis MITRAL STENOSIS aviod activities that increase correct answer HR valve replacement =long term mitral stenosis correct answer abnormal narrowing of the opening of the mitral valve Mitral stenosis murmur correct answer "early to mid diastolic low pitch rumble murmur best heard at apex in left lateral decubitus position. May also have presystolic murmur." mona b correct answer morphine oxygen nitro aspirin beta blockers most common sign of colorectal cancer correct answer #1 change of bowel habits
no bubbling in chest tube chamber correct answer check for suction leaks 1 p wave correct answer depolarization Pain above umbilicus when assessing the client the nurse notices sister Mary St. Joseph's Najwa what health problems does this patient present with? correct answer Gastro intestinal malignancy patient has dyspnea, pink and frothy sputum correct answer pulmonary embolism patient was stabbed in chest and the nurse suspects development of cardiac tamponade correct answer muffled heart sounds =FLUID ACCUMMULATION patient with colorectal cancer are prescribed cephalexin (kelfex) to reduce what correct answer intestinal bacterial levels ` pericarditis with new onset of palpitation and shortness of breath is a sign of AFIB correct answer different atrial and radial pulses =afib irregular peritoneum dialysis correct answer purulent dualist
Play Pasa with a peg tube is receiving intermittent feedings. Prior to initiating the feeding which of the following actions should the nurse take first? correct answer Place the client in semi Fowler's position. pleurisy correct answer scratch sound in lungs poly correct answer alot polyuria, polydipsia, polyphagia correct answer 3 Ps of diabetes post op to prevent pulmonary embolism correct answer incentive spirometry post operative care correct answer get up and ambulate ASAP use incentive spirometer SCD's leg exercises passive and active range motion Postulation of pleurisy is what type of breath sound? correct answer Loud scratching sound rubbing Prevention of have a transmission is? correct answer Good hand hygiene.
