2- MED SURG III - EXAM #3

The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated?

Semi-Fowler position is maintained for at least which timeframe following completion of an intermittent tube feeding?

The nurse identifies which type of jaundice in an adult experiencing a transfusion reaction?

Which position should be used for a client undergoing a paracentesis?

Clients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which is a sign of potential hypovolemia?

A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal?

A client reporting shortness of breath is admitted with a diagnosis of cirrhosis. A nursing assessment reveals an enlarged abdomen with striae, an umbilical hernia, and 4+ pitting edema of the feet and legs. What is the most important data for the nurse to monitor?

A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition?

The nurse is assessing a client with hepatic cirrhosis for mental deterioration. For what clinical manifestations will the nurse monitor? Select all that apply.

When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately?

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices?

The nurse working with a client after an ileal conduit notices that the pouching system is leaking small amounts of urine. What is the appropriate nursing intervention?

A client is to undergo a TURP for BPH. Which statement is accurate with regard to a TURP?

A client with bladder cancer has undergone surgical removal of the bladder with creation of an ileal conduit. Which assessment findings indicate that the client is developing complications? Select all that apply.

A cystectomy is performed for a client with a diagnosis of bladder cancer, and a Kock pouch is created for urinary diversion. In creating a discharge teaching plan for the client, the nurse would include which instruction in the plan?

A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which problem?

A client states that the physician said the tidal volume is slightly diminished and asks the nurse what this means. The nurse explains that the tidal volume is the amount of air:

Which of the following conditions can you safely administer metoclopramide (Reglan)?

Which of the following drugs will reduce the effectiveness of sucralfate?

A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit. Preoperatively, the nurse reinforces the client’s understanding of the surgical procedure by explaining that an ileal conduit:

Your patient with cirrhosis has severe splenomegaly. As the nurse you will make it priority to monitor the patient for signs and symptoms of? Select all that apply:

Jam is under chemotherapy in which nausea is an expected side effect. Which of the following drugs is indicated to prevent such side effects?

A patient is admitted with hepatic encephalopathy secondary to cirrhosis. Which meal option selection below should be avoided with this patient?

You are receiving shift report on a patient with cirrhosis. The nurse tells you the patient’s bilirubin levels are very high. Based on this, what assessment findings may you expect to find during your head-to-toe assessment? Select all that apply:

While providing mouth care to a patient with late-stage cirrhosis, you note a pungent, sweet, musty smell to the breath. This is known as: