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7 Cards in this Set
A male client had abdominal surgery and the nurse suspects he has peritonitis. Which assessment data support the diagnosis of peritonitis?
1. Absent bowel sounds & potassium level of 3.9 mEq/L
2. Abdominal cramping & hemoglobin of 14 g/dL
3. Profuse diarrhea & stool specimen shows Campylobacter.
4. Hard, rigid abdomen & white blood cell count 22,000/mm^3
4. A hard, rigid abdomen indicates an inflamed peritoneum (abdominal wall cavity) resulting from an infection, which results in an elevated WBC level.
(1. absent bowel sounds indicate paralytic ileus, not peritonitis. K level is normal)
(2. abdominal cramping is not peritonitis. hgb is normal)
(3. this bug does cause acute diarrhea - not peritonitis)
from MedSurg Success pg 268
A client with abdominal surgery tells the nurse, "I felt something give way in my stomach." Which intervention should the nurse implement first?
1. Notify the surgeon immediately.
2. Instruct the client to splint the incision.
3. Assess the abdominal wound incision.
4. Administer pain medication intravenously.
3. Assessing the surgical incision is the first intervention because this may indicate the wound has dehiscence.
(1. the nurse may notify the surgeon, but this is not the first intervention)
(2. the nurse should instruct the client to splint the incision when coughing, then take further action)
(4. the nurse should never admin pain meds without assessing for potential complications)
MedSurg Success pg 268
Client is one day post op major abdominal surgery. Which problem is priority?
1. Impaired skin integrity
2. Fluid and Electrolyte imbalance
3. Altered bowel elimination
4. Altered body image
2. After abdominal surgery, the body distributes fluids to the affected area as part of the healing process. These fluids are shifted from the intravascular compartment to the interstitial space, which causes potential fluid & electrolyte imbalance.
(1 the client has a surgical incision, which impairs the skin integrity, but it is not the priority bc it is sutured undered sterile conditions.)
(3. Bowel elimination is a problem, but after general anesthesia wears off, the bowel sounds will return and this is not a life threatening problem.)
(4. Psychosocial problems are not priority over actual physiological problems.)
from MedSurg Success pg 269
The client has an eviscerated abdominal wound. Which intervention should the nurse implement?
1. Apply sterile normal saline dressing.
2. Use sterile gloves to replace protruding parts.
3. Place the client in reverse Trendelenburg position.
4. Administer intravenous antibiotic STAT
1. Evisceration is a life-threatening condition in which the abdominal contents protrude through the ruptured incision. The nurse must protect the bowel from the environment by placing a sterile normal saline gauze on it, which prevents the intestines from drying out and necrosing.
(2. the nurse should not attempt to replace the protruding bowel.)
(3. this position places the client with the head of bed elevated, which will make the situation worse.)
(4. Antibiotics will not protect the protruding bowels, which must be priority. Antibiotics will be administed at a later time to prevention infection, but this is not urgent. MedSurg Success pg 269
The client is diagnosed with peritonitis. Which assessment data indicate to the nurse the client's condition is improving?
1. The client is using more pain medication on a daily basis.
2. The client's nasogastric tube is draining coffee-ground material.
3. The client has a decrease in temperature and a soft abdomen.
4. The client has had two soft, formed bowel movements.
3. Because the signs of peritonitis are elevated temp & rigid abdomen, a reversal of these signs indicates the client is getting better.
(1. more pain meds means he is getting worse)
(2. Coffee ground material indicates od blood from the GI system)
(4. Two soft formed bowel movements are normal; but this does not have anything to do with peritonitis) MedSurg Success pg 269
The client developed a paralytic ileus after abdominal surgery. Which intervention should the nurse include in the plan of care?
1. Administer a laxative of choice.
2. Encourage client to increase oral fluids.
3. Encourage client to take deep breaths.
4. Maintain a patent nasogastric tube.
4. A paralytic ileus is the absence of peristalsis; therefore the bowel will be unable to process any oral intake. A nasogastric tube is inserted to decompress the bowel until surgical intervention or until bowel sounds return spontaneously.
(1. the client is NPO - no medication will be administered)
(2. The client is NPO- no food or fluids are allowed)
(3. Deep breathing will help prevent pulmonary complications but does not address the client's paralytic ileus) MedSurg Success pg 269
The client who had an abdominal surgery has a Jackson Pratt drainage tube. Which assessment data warrant immediate intervention by the nurse?
1. The bulb is round and has 40 mL of fluid
2. The drainage tube is taped to the dressing.
3. The insertion site is pink and has not drainage.
4. The bulb has suction and is sunken in.
1. The JP bulb should be depressed, which indicates suction is being applied. A round bulb indicates the bulb is full and needs to be emptied and suction reapplied.
(2. The tube should be taped to the dressing to prevent accidentally pulling the drain out of the insertion site)
(3. The insertion site should be pink and without any sign of infection, which include drainage, warmth, and redness.)
(4. the bulb should be sunken in or depressed, indicating suction is being applied)