ATI CAPSTONE ADULT MEDICAL SURGICAL ASSESSMENT 1

A nurse is caring for an adult client who asks about vaccinations against communicable diseases. The nurse should inform the client that which of the following vaccines are available? (Select all that apply) Hepatitis A vaccine Hepatitis B vaccine Pneumococcal vaccine Hepatitis C vaccine Helicobacter pylori vaccine Adult vaccines currently available to prevent contracting communicable diseases include those for hepatitis A & B influenza and pneumonia. No vaccine is currently available for hep C/H. pylori = A, B, C A nurse is providing discharge instructions to a client who has a peptic ulcer. Which of the following dietary modifications should the nurse include? Provide a snack at bedtime Choose decaffeinated coffee Restrict intake of fried foods Avoid drinking liquids with meals The nurse should instruct the client to avoid fried foods, spicy foods, and acid-producing foods, such as coffee and chocolate. Spicy foods, such as chili pepper, red pepper, and black pepper can cause mucosal damage. The nurse should instruct the client to avoid decaffeinated and caffeinated beverages and snacks at bedtime, which can stimulate gastric acid secretion. A client with dumping syndrome, rather than peptic ulcer should avoid liquids with meals = C A nurse is caring for a client who is postoperative immediately following a pheochromocytoma removal. Which of the following actions is the nurse’s priority? Increase hydration Monitor blood pressure Measure urine output Provide a calm environment The greatest risk to this client is injury from hypertension due to the release of catecholamines during surgery or hypotension from the sudden loss of catecholamines aker the tumor has been removed. Therefore, the priority intervention the nurse should take is to monitor the client's blood pressure = B A nurse is caring for a client who is using a ventilator when the low-pressure ventilator alarm sounds. Which of the following actions should the nurse take? Suction secretions from the endotracheal tube Check the ventilator tubing connections Administer intravenous sedation and analgesia Reassure the client and instruct them not to bite on the tube A low-pressure alarm indicates a loss of volume due to a disconnection, cuff link or tube displacement = B A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates the client might be experiencing a hemolytic transfusion reaction? Hypertension Report of urticaria Distended neck veins Report of chest pain Chest pain is a manifestation of a hemolytic transfusion reaction. Other manifestations include headache, low back pain, and hypotension = D A nurse is assessing a client who has right lower lobe pneumonia. Which of the following findings should the nurse expect? Dull percussion sounds Increased anteroposterior chest diameter Distended neck veins Pitting edema The consolidation that occurs with pneumonia will result in dull chest percussion over the involved lobes = A A nurse is providing teaching to a newly licensed nurse about caring for a client who is receiving a sealed radioactive implant. Which of the following information should the nurse include in the teaching? Place soiled linens in a lead container Allow children who are over 10 years old to visit Limit visitors to 1 hr per day Wear a lead apron during care The nurse should wear a lead apron at all times during care of a client who has a sealed radioactive implant = D A nurse is caring for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse include in the plan of care to prevent autonomic dysreflexia? Monitor bowel movement regularity Use a fan to promote air circulation to the client’s room Tuck the top bedsheet tightly around the client’s torso Monitor for cerebral spinal fluid leakage Autonomic dysreflexia occurs secondary to the stimulation of the sympathetic nervous system and inadequate compensatory response by the parasympathetic nervous system. Common causes of autonomic dysreflexia include distended bladder, fecal impaction, cold stress, tight clothing, and undiagnosed injury or illness. The nurse should monitor the client's bowel movements to reduce the risk of fecal impaction which can lead to autonomic dysreflexia = A A nurse is assessing a client who has tension pneumothorax following blunt chest trauma. Which of the following findings should the nurse expect? Tracheal deviation to the unaffected side Pleural friction rub