GI
A patient is about to undergo a diagnostic bowel procedure. The nurse expects which drug to be used to induce total cleansing of the bowel?
a.docusate sodium (Colace)
b.magnesium hydroxide (milk of magnesia)
c. mineral oil
d.polyethylene glycol (GoLYTELY)
ANS: D
Polyethylene glycol is a very potent laxative that induces total cleansing of the bowel and is most commonly used before diagnostic or surgical bowel procedures. The other options are incorrect.
A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take?
a. Document that the aspirin was refused by the patient.
b. Tell the patient that the aspirin is used to prevent a fever.
c. Explain that the aspirin is ordered to decrease stroke risk.
d. Call the health care provider to clarify the medication order.
C. Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains
When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is
a. vomiting.
b. headache.
c. change in level of consciousness (LOC).
d. sluggish pupil response to light.
Correct Answer: C
Rationale: LOC is the most sensitive indicator of the patient's neurologic status and possible changes in ICP. Vomiting and sluggish pupil response to light are later signs of increased ICP. A headache can be caused by compression of intracranial structures as the brain swells, but it is not unexpected after a head injury.
While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure.
Which action should the nurse take?
a.) Insert an oral airway during the seizure to maintain a patent airway.
b.) Restrain the patient's arms and legs to prevent injury during the seizure.
c.) Observe and record the details of the seizure and postictal state.
d.) Avoid touching the patient to prevent further nervous system stimulation.
c.) Observe and record the details of the seizure and postictal state.
Rationale:
Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.
In developing a care plan for a patient with an open reduction and internal fixation (ORIF) of an open, displaced fracture of the tibia, the priority nursing diagnosis is
a.
risk for constipation related to prolonged bed rest.
b.
activity intolerance related to deconditioning.
c.
risk for infection related to disruption of skin integrity.
d.
risk for impaired skin integrity related to immobility.
C
Rationale: A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis. After an ORIF, patients typically are mobilized starting the first postoperative day, so problems caused by immobility are not as likely.
A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the mid epigastric area along with a rigid, board-like abdomen. These clinical manifestations most likely indicate which of the following?
A. An intestinal obstruction has developed
B. Additional ulcers have developed
C. The esophagus has become inflamed
D. The ulcer has perforated
D
The body reacts to perforation of an ulcer by immobilizing the area as much as possible. This results in boardlike muscle rigidity, usually with extreme pain. Perforation is a medical emergency requiring immediate surgical intervention because peritonitis develops quickly after perforation. An intestinal obstruction would not cause midepigastric pain. Esophageal inflammation or the development of additional ulcers would not cause a rigid, boardlike abdomen.
Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address?
a. The patient is 25 pounds above the ideal weight.
b. The patient drinks a glass of red wine with dinner daily.
c. The patient's usual blood pressure (BP) is 170/94 mm Hg.
d. The patient works at a desk and relaxes by watching television
C. Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension.
A patient with a head injury has bloody drainage from the ear. To determine whether CSF is present in the drainage, the nurse
a. examines the tympanic membrane for a tear
b. tests the fluid for a halo sign on a white dressing
c. tests the fluid with a glucose identifying strip or stick
d. collects 5 mL of fluid in a test tube and sends it to the laboratory for analysis
B. Tests the fluid for a halo sing on a white dressing- Testing clear drainage for CSF in nasal or ear drainage may be done with a Dextrostik or Tes-Tape strip, but if blood is present, the glucose in the blood will produce and unreliable result. To test bloody drainage, the nurse should test the fluid for a halo or ring that occurs when a yellowish ring encircles blood dripped onto a white pad or towel
The classic symptoms of Parkinson's disease include (select all that apply)
A. tremor.
B. rigidity.
C. loss of balance.
D. bradykinesia.
E. nystagmus.
A,B,D
The classic manifestations of PD often include tremor, rigidity, and bradykinesia, which are often called the triad of PD.
When preparing a patient to ambulate the day after an ORIF for a hip fracture, which action is most important for the nurse to take?
a.
Administering the ordered oral opioid pain medication
b.
Instructing the patient about the benefits of ambulation
c.
Ensuring that the incisional drain has been discontinued
d.
Changing the hip dressing and document the appearance of the site
A
Rationale: The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not impact on ambulation.
The patient with chronic gastritis is being put on a combination of medications to eradicate H. pylori. Which drugs does the nurse know will probably be used for this patient?
a. Antibiotic(s), antacid, and corticosteroid
b. Antibiotic(s), aspirin, and antiulcer/protectant
c. Antibiotic(s), proton pump inhibitor, and bismuth
d.Antibiotic(s) and nonsteroidal antiinflammatory drugs (NSAIDs)
c. Antibiotic(s), proton pump inhibitor, and bismuth
To eradicate H. pylori, a combination of antibiotics, a proton pump inhibitor, and possibly bismuth (for quadruple therapy) will be used. Corticosteroids, aspirin, and NSAIDs are drugs that can cause gastritis and do not affect H. pylori.
A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first?
a. Complete blood count (CBC)
b. Chest radiograph (Chest x-ray)
c. 12-Lead electrocardiogram (ECG)
d. Noncontrast computed tomography (CT) scan
D. Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the less brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.
The nurse recognizes the presence of Cushing's triad in the patient with which vital sign changes?
a. Increased pulse, irregular respiration, increased BP
b. Decreased pulse, increased respiration, decreased systolic BP
c. Decreased pulse, irregular respiration, increased BP
d. Increased pulse, decreased respiration, widened pulse pressure
c. Cushing's triad consists of three vital sign measures that reflect ICP and its effect on the medulla, hypothalamus, pons, and thalamus. Because these structures are very deep, Cushing's triad is usually a late sign of ICP. The signs include an increasing SBP with a widening pulse pressure, a bradycardia with a full and bounding pulse, and irregular respirations.
You are counseling the family of a patient with Huntington's disease (HD) about the genetics involved in the disease. You would be correct in informing the family that the genetic risk for manifestation of the disease in genetic transmission is
A. 1 in every 4 pregnancies.
B. 1 in every 2 pregnancies.
C. only evident in male children.
D. impossible to predict.
B
HD is a genetically transmitted, autosomal dominant disorder that affects both men and women of all races. The offspring of a person with this disease have a 50% risk of inheriting it.
A patient is to be discharged from the hospital 4 days after undergoing a total hip arthroplasty. A statement by the patient that indicates a need for additional discharge instructions is
a.
"I should not cross my legs while sitting."
b.
"I can sleep in any position that is comfortable for me."
c.
"I will use a toilet elevator on the toilet seat."
d.
"I will have someone else put on my shoes and socks."
Correct Answer: B
Rationale: The patient needs to sleep in a position that allows excessive internal rotation or flexion of the hip. The other patient statements indicate that the patient has understood the teaching.
Which of the following tasks should be included in the immediate postoperative management of a client who has undergone gastric resection?
A. Monitoring gastric pH to detect complications
B. Assessing for bowel sounds
C. Providing nutritional support
D. Monitoring for symptoms of hemorrhage
D
The client should be monitored closely for signs and symptoms of hemorrhage, such as bright red blood in the nasogastric tube suction, tachycardia, or a drop in blood pressure. Gastric pH may be monitored to evaluate the need for histamine-2 receptor antagonists. Bowel sounds may not return for up to 72 hours postoperatively. Nutritional needs should be addressed soon after surgery
For a patient with a suspected stroke, which important piece of information should you obtain?
A. Time of the patient's last meal
B. Time at which stroke symptoms first appeared
C. Patient's hypertension history and management
D. Family history of stroke and other cardiovascular diseases
B
During initial evaluation, the single most important point in the patient's history is the time of onset of stroke symptoms. If the stroke is ischemic, recombinant tissue plasminogen activator (tPA) must be administered within 3 to 4.5 hours of the onset of clinical signs; tPA reestablishes blood flow through a blocked artery and prevents brain cell death in patients with an acute onset of symptoms.
A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. The nurse records the patients GCS score as
a. 6
b. 7
c. 9
d. 11
B. 7- no opening of eyes = 1; incomprehensible words= 2, flexion withdrawal = 4
Total = 7
Which nursing diagnosis is likely to be a priority in the care of a patient with myasthenia gravis?
A. Acute confusion
B. Bowel incontinence
C. Activity intolerance
D. Disturbed sleep pattern
C
The primary feature of MG is fluctuating weakness of skeletal muscle. Bowel incontinence and confusion are unlikely signs of MG, and while sleep disturbance is likely, activity intolerance is usually of primary concern.
A patient arrives in the emergency department with ankle swelling and severe pain after twisting the ankle playing soccer. All of the following orders are written by the health care provider. Which one will the nurse act on first?
a.
Administer naproxen (Naprosyn) 500 mg PO.
b.
Wrap the ankle and apply an ice pack.
c.
Give acetaminophen with codeine (Tylenol #3).
d.
Take the patient to the radiology department for x-rays.
B
Rationale: Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.
The nurse evaluates the client's stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician?
A. The stoma is slightly edematous
B. The stoma is dark red to purple
C. The stoma oozes a small amount of blood
D. The stoma does not expel stool
B
A dark red to purple stoma indicates inadequate blood supply. Mild edema and slight oozing of blood are normal in the early post-op period. The colostomy would typically not begin functioning until 2-4 days after surgery.
A 63-year-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol?
a. Obtain computed tomography (CT) scan without contrast.
b. Infuse tissue plasminogen activator (tPA).
c. Administer oxygen to keep O2 saturation >95%.
d. Use National Institute of Health Stroke Scale to assess patient.
C, D, A, B
The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.
You are providing care for a patient who has been admitted to the hospital with a head injury who requires regular neurologic vital signs. Which assessments are components of the patient's score on the Glasgow Coma Scale (select all that apply)?
A. Eye opening
B. Abstract reasoning
C. Best verbal response
D. Best motor response
E. Cranial nerve function
A,C,D
The three dimensions of the Glasgow Coma Scale are eye opening, best verbal response, and best motor response.
An unconscious patient receiving emergency care following an automobile crash accident has a possible spinal cord injury. What guidelines for emergency care will be followed?
Select all that apply.
A. Immobilize the neck using rolled towels or a cervical collar.
B. The patient will be placed in a supine position
C. The patient will be placed on a ventilator.
D. The head of the bed will be elevated.
E. The patient's head will be secured with a belt or tape secured to the stretcher.
Correct Answer: A,B,E
In the emergency setting, all patients who have sustained a trauma to the head or spine, or are unconscious should be treated as though they have a spinal cord injury. Immobilizing the neck, maintaining a supine position and securing the patient's head to prevent movement are all basic guidelines of emergency care. Placement on the ventilator and raising the head of the bed will be considered after admittance to the hospital.
Which discharge instruction will the emergency department nurse include for a patient with a sprained ankle?
a. Keep the ankle loosely wrapped with gauze.
b. Apply a heating pad to reduce muscle spasms.
c. Use pillows to elevate the ankle above the heart.
d. Gently move the ankle through the range of motion.
C
Elevation of the leg will reduce the amount of swelling and pain. Compression bandages are used to decrease swelling. For the first 24 to 48 hours, cold packs are used to reduce swelling. The ankle should be rested and kept immobile to prevent further swelling or injury.