MED SURGICAL NCLEX - 1. Call the health care provider to reinsert th...

MED SURGICAL NCLEX

The client coughs and the tube is dislodged. What is the initial nursing action?

• Call the health care provider to reinsert the tube.
• Ventilate the client using a manual resuscitation bag and face mask.
• Cover the tracheostomy site with a sterile dressing to prevent infection.
• Call the respiratory therapy department to reinsert the tracheostomy tube. -

ANSWER 2. Ventilate the client using a manual resuscitation bag and face mask The nurse is changing the tapes on a tracheostomy tube.The clinic nurse instructs an adolescent with iron deficiency anemia about the administration of oral iron preparations. The nurse should tell the adolescent that it is best to take the iron with which item?

• Cola
• Soda
• Water
• Tomato juice - ANSWER 4. Tomato juice

The home care nurse visits a client with chronic obstructive pulmonary disease (COPD) who is on home oxygen at 2 L per minute. The client's respiratory rate is 22 breaths per minute, and the client is complaining of increased dyspnea. The nurse should take which initial action?

• Determine the need to increase the oxygen.
• Call emergency services to come to the home.
• Reassure the client that there is no need to worry.
• Collect more information about the client's respiratory status - ANSWER
• Collect more information about the client's respiratory status

The nurse should implement which measures to prevent infection in a hospitalized immunocompromised client? Select all that apply.

• Use strict aseptic technique for all invasive procedures. 1 / 4

• Use good hand-washing technique before touching the client.
• Insert a urinary catheter to eliminate the need to use a bedpan.
• Keep fresh flowers and potted plants out of the client's room.
• Place the client in a semiprivate room with another client who is

immunocompromised.

• Keep frequently used equipment such as a blood pressure cuff in the client's

room for use by the client. - ANSWER 1. Use strict aseptic technique for all invasive procedures.

• Use good hand-washing technique before touching the client.
• Keep fresh flowers and potted plants out of the client's room.
• Keep frequently used equipment such as a blood pressure cuff in the client's

room for use by the client.For a diabetic male client with a foot ulcer, the physician orders bed rest, a wet-to- dry dressing change every shift, and blood glucose monitoring before meals and bedtime. Why are wet-to-dry dressings used for this client?

• They contain exudate and provide a moist

wound environment.

• They protect the wound from mechanical

trauma and promote healing.

• They debride the wound and promote

healing by secondary intention.

• They prevent the entrance of

microorganisms and minimize wound discomfort. - ANSWER 3. They debride the wound and promote healing by secondary intention.Alvin has a history of peptic ulcer disease and vomits coffee ground emesis. What does this indicate?

• He has fresh, active upper GI bleeding.
• He needs immediate saline gastric

lavage.

• His gastric bleeding occurred 2 hours earlier.
• He needs a transfusion of packed 2 / 4

RBC's. - ANSWER C. His gastric bleeding occurred 2 hours earlier.Anna is 45 y.o. and has a bleeding ulcer. Despite multiple blood transfusions, her HGB is 7.5g/dl and HCT is 27%. Her doctor determines that surgical intervention is necessary, and she undergoes partial gastrectomy. Postoperative nursing care

includes:

• Giving pain medication Q6H.
• Flushing the NG tube with sterile water.
• Positioning her in high Fowler's

position.

• Keeping her NPO until the return of peristalsis. - ANSWER
• Keeping her NPO until the return of peristalsis.

Nurse Gemma is teaching a group of middle-aged men about peptic ulcers. When

discussing risk factors for peptic ulcers, the nurse should mention:

• a sedentary lifestyle and smoking.
• a history of hemorrhoids and smoking.
• alcohol abuse and a history of acute renal failure.
• alcohol abuse and smoking. - ANSWER D. alcohol abuse

and smoking.Who is suspected of having peptic ulcer disease?

• History of side effects experienced from all medications
• Use of non steroidal anti inflammatory drugs (NSAIDs)
• Any known allergies to drugs and environmental factors
• Medical histories of at lease 3 generations - ANSWER B.

Use of non steroidal anti inflammatory drugs (NSAIDs) The nurse has been assigned to care for a client diagnosed with peptic ulcer disease. Which assessment data require further intervention?

• Bowel sour s auscultated 15 times in1minute 3 / 4

• Belching after eating a heavy and fatty meal late at night
• A decrease in systolic BP of 20 mmHg from lying to sitting
• A decreased frequency of distress located in the epigastric region -

ANSWER C. A decrease in systolic BP of 20 mmHg from lying to sitting The nurse is caring for a female client with active upper GI bleeding due to a peptic ulcer. What is the appropriate diet for this client during the first 24 hours after admission?

• Regular diet
• Skim milk
• Nothing by mouth
• Clear liquids - ANSWER C. Nothing by mouth

Which assessment data indicate to the nurse the clients gastric ulcer has perforated?

• Complaints of sudden, sharp, substernal pain
• Rigid, boardlike abdomen with rebound tenderness
• Frequent, clay-colored, liquid stool
• Complaints of vague abdominal pain in the right upper quadrant -

ANSWER B. Rigid, boardlike abdomen with rebound tenderness Which expected outcome should the nurse include for a client diagnosed with peptic ulcer disease?

• The clients pain is controlled with the use of NSAIDs
• The client maintains lifestyle modifications
• The client has no signs and symptoms of hemoptysis
• The client take s antacids with each meal - ANSWER B.

The client maintains lifestyle modifications

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