Med/surg II Final exam

Med/surg II Final exam Priority action by nurse for client w/ compromised immune system? Correct Answer: Hand hygiene Client w/ wound is worried about drainage being present, best response by nurse? Correct Answer: Some drainage is to be expected & normal inflammatory response, if it smells foul or looks like pus that's a sign of infection Precautions for HIV patient? Correct Answer: Standard precautions What signifies advancement of HIV to AIDS? Correct Answer: Opportunistic infections -pneumonistic, C diff etc When ambulating client w/ anemia, what assessments to be done in order to check tolerance? Correct Answer: RR, HR, O2 sat/oxygenation- if any abnormals then not being tolerated well. What does it mean if someone is anemic? Correct Answer: Low iron & low oxygenation What to ask client w/ lots of bruising? Correct Answer: Are you taking any anticoagulant/anti platelet drugs? Client w/ platelet count of 30,000 is at risk for what? Correct Answer: LOW platelet count =bleeding risk What patient history info would correlate w/ diagnosis of iron deficient anemia? Correct Answer: Vegetarian- no meat=lack of iron in diet Normal platelet count? & risks associated w/ abnormal values? Correct Answer: 150,000-400,000 *low= thrombocytopenia/bleeding risk *high= thrombocythemia Normal hemoglobin levels? Correct Answer: Males=14-18g/dL Females=12-16g/dL **low Hgb may indicate anemia Normal hematocrit level? Correct Answer: Males=42-52% Females=37-47% What can high hematocrit level indicate? Correct Answer: Levels about 52%(M)/47%(F) can mean erythrocytosis, severe dehydration, polycythemia What can low Hct levels indicate? Correct Answer: Levels below 42%(M)/47%(F) can mean anemia, hemorrhage, bone marrow dysfunction, dietary deficiency What education to give for thrombocytopenia? Correct Answer: -soft bristle toothbrush -electric razor -avoid contact sports What manifestations to expect for someone whose releasing too many catecholamines? Correct Answer: **fight or flight mode -hot/flushed -increased vitals, high BP, HR, RR What hormone deficiency is of highest priority? Correct Answer: Thyroid/TSH deficiency is most critical (hypothyroidism) What is acromegaly? S&S? Correct Answer: Too much growth hormone being released from anterior pituitary. - What to teach someone undergoing hypovasectomy? Correct Answer: No need to buy new shoes, only soft tissue changes are reversible, not bone. What is SIADH? Appropriate teachings/interventions for client w/ sodium of 118? Correct Answer: SIADH=syndrome of inappropriate diuretic hormone **too low-restrict fluids What is Cushings disease? What precautions to take? Correct Answer: Too much cortisol being released, causing bone demineralization leading to osteoporosis. -move w/pull sheet when lifting in bed, fracture risk, fall precautions, non skids, yellow gown, bed in lowest position, assist to ambulate Client has been on corticosteroids, problem is solved & client states being ready to stop drug therapy. What is nurses best response? Correct Answer: Must slowly taper doses b/c when taken exogenously body has temporarily stopped making hormones. Need to allow body to begin producing again What is hyperaldosteronism? Correct Answer: Too much aldosterone= low creatinine, low urine output, H2O retention. Treat w/ spironolactone What to teach client on spironolactone? Correct Answer: Avoid salt/flavor substitutes, avoid foods rich in K+ What is proper hyperthyroidism diet? Correct Answer: High calorie, high protein Client had a subtotal thyroidectomy & now has tingling around lips-nursing intervention? Correct Answer: Check chovesks sign- to check for hypocalcemia Why does client w/ hypoglycemia need glucagon? Correct Answer: Raises blood sugar by stimulating release of glucagon from liver Diabetic of 15 years notes decrease in tactile sensation in foot, what is this an indicator of? Nurses next action? Correct Answer: Diabetic neuropathy- check feet for injuries Visually impaired diabetic asks if daughter came come fill his syringes