SOLVED

 Question 11 The nurse is caring for a patient diagnosed with an arteriovenous malformation of the ascending colon. The nurse would prepare to implement which intervention? 1. Administration of blood products 2. Administration of cytoprotective medication 3. Administration of H2 receptor blocking medication 4. Administration of antisecretory medication Question 12 A patient recovering from an open cholecystectomy 3 days prior has not passed any flatus since surgery. Which finding suggests to the nurse that the patient may be experiencing a life-threatening condition? 1. Anorexia 2. Falling blood pressure 3. Respiratory rate of 24 4. Hypoactive bowel sounds Question 13 A patient recovering from thyroid surgery is now experiencing numbness and tingling around the mouth with an increase in irritability. Which additional assessment finding would cause the nurse the most concern? 1. Decreased creatinine and BUN levels 2. Abdominal distention and pain 3. Hyperactive bowel sounds 4. Diarrhea Question 14 A patient with a history of coronary artery disease is admitted with vomiting, abdominal distention, and hypoactive bowel sounds. Which assessment would provide the nurse with the most accurate information about the patient’s fluid volume status? 1. Skin turgor assessment 2. Hourly urine output measurements 3. Daily weights 4. Pulmonary artery catheter Question 15 The conventional transducer method will be used to measure a patient’s intra-abdominal pressure. Which interventions will the nurse use in this measurement? 1. Connect the transducer to the patient’s peripheral intravenous line. 2. Place the head of the patient’s bed flat. 3. Inject 20-25 mL of saline into the indwelling urinary catheter port. 4. Calibrate the transducer at the level of the patient’s pubis. 5. Obtain the measurement at the beginning of respiration. Question 16 A trauma patient’s intra-abdominal pressure (IAP) measures 26 mm Hg. How would the nurse explain needed treatment to the patient’s family? 1. “This pressure reading is normal and will help to get oxygen to the damaged internal organs.” 2. “If we reduce the amount of IV fluid he is getting, the IAP will decrease.” 3. “We will raise the head of his bed and have him cough more frequently to reduce this pressure.” 4. “It is very likely that he will be taken back to surgery to relieve the pressure building in his abdomen.” Question 17 The nurse is assessing a patient recovering from surgery for abdominal compartment syndrome. Which findings could indicate a life-threatening condition may be developing in this patient? 1. Temperature 100.7° F 2. Complaint of dyspnea 3. Poor skin turgor 4. Blood pressure 146/88 mm Hg 5. Complaint of chest pain Question 18 A patient presents to the emergency department with reports of bloody diarrhea. During assessment, the patient becomes increasingly lethargic. The nurse’s emergency interventions are based upon which nursing diagnoses? 2. Impaired Gas Exchange 3. Risk for Infection 4. Nutrition, Less than Body Requirements 5. Altered Thought Processes Question 19 A patient vomiting bright red blood is scheduled for an endoscopy sclerotherapy. The patient asks the nurse what the procedure will do. The nurse would reinforce which teaching? 1. “The area of bleeding can be seen so surgery can be planned to remove it.” 2. “A chemical can be injected into the bleeding vessel to stop it from bleeding.” 3. “A cold material can be applied to the bleeding area to stop the bleeding.” 4. “A laser can be used on the bleeding areas to stop any possibilities of bleeding again.” Question 20 The nurse is providing care to a patient admitted with hematemesis, melena, and abdominal pain. Which nursing diagnosis is the highest priority for this patient? 1. Risk for Anxiety related to fear of bleeding 2. Risk for Aspiration related to potential changes in level of consciousness 3. Risk for Fatigue related to decreased oxygenation 4. Pain related to disruption of gastrointestinal tissues