140 Unit 1

An insulin pump is instituted for a client with type 1 diabetes. The nurse plans discharge instructions. Which short-term goal is the priority for this client? "Adhere to the medical regimen." "Remain normoglycemic for 3 weeks." "Demonstrate correct use of the insulin pump." "List three self-care activities that help control the diabetes."

"Demonstrate correct use of the insulin pump." (Demonstrating correct use of the insulin pump is the short-term, client-oriented goal necessary for the client to manage the pump and avoid hypo- and hyperglycemia; this outcome can be measured by observing a return demonstration by the client. Adhering to the medical regimen is not a short-term goal. Remaining normoglycemic for 3 weeks is measurable but requires the client to manage the insulin pump. Although listing three self-care activities that help control the diabetes is a measurable short-term goal, it is not the priority when the client must master use of the insulin pump.)

A client with diabetes asks how exercise will affect insulin and dietary needs. What information does the nurse share about insulin and exercise? "Exercise increases the need for carbohydrates and decreases the need for insulin." "Exercise increases the need for insulin and increases the need for carbohydrates." "Regular physical activity decreases the need for insulin and decreases the need for carbohydrates." "Intensive physical activity decreases the need for carbohydrates but does not affect the need for insulin."

"Exercise increases the need for carbohydrates and decreases the need for insulin." (Exercise increases the uptake of glucose by active muscle cells without the need for insulin; carbohydrates are needed to supply energy for the increased metabolic rate associated with exercise. The need for insulin is decreased.)

A client with typically well controlled diabetes has a glycosylated hemoglobin (HbA1C) level of 9.4%. Which response by the nurse is most appropriate? "Keep up the good work." "This is not good at all." "Have you been doing something differently? "You need an increase in your insulin dose."

"Have you been doing something differently? (The most appropriate response by the nurse is telling the client that the level is high and then assessing the client's regimen or changes he or she may have made. This is the best format to formulate interventions to gain control of blood glucose. HbA1C levels for diabetic clients need to be less than 7%. A value of 9.4% shows poor control over the past 3 months.Telling the client to "keep up the good work" is incorrect. A(HbA1C) level of 9.4% is too high. Scolding the client by saying "this is not good," although true, does not take into account problems the client may be having with the regimen or an undiagnosed illness. Although it may be true that the client needs more insulin, an assessment of the client's regimen is needed before decisions are made about medications.)

A nurse is educating a preoperative client on how to cough effectively. What can the nurse tell the client to do to facilitate coughing? "Hold a pillow or folded bath blanket over the incision." "Get up and walk before you try to cough." "It would be best if you do not cough until you feel better." "When you cough, cover your nose and mouth with a tissue."

"Hold a pillow or folded bath blanket over the incision." (Because postoperative coughing is often painful, the client should be taught how to splint the incision by supporting it with a pillow or folded bath blanket.)

The nurse is providing discharge teaching to a client with type 2 diabetes and peripheral neuropathy. Which statement by the client indicates a need for further teaching about injury prevention? "I can break in my shoes by wearing them all day." "I need to monitor my feet daily for blisters or skin breaks." "I will never go barefoot." "I need to quit smoking."

"I can break in my shoes by wearing them all day." (Further teaching about injury prevention is needed when the client with diabetic peripheral neuropathy says that "I can break in my shoes by wearing them all day." Shoes need to be properly fitted and worn for a few hours a day to break them in, with frequent inspection for irritation or blistering.People with diabetes have decreased peripheral circulation, so even small injuries to the feet must be managed early. Going barefoot is contraindicated because if the client has diabetic neuropathy, stepping on something sharp or harmful would not be felt. Tobacco use further decreases peripheral circulation increasing the risk for vascular complications.)

Which of the following statements, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction? "I can have a hamburger and French fries as soon as I wake up." "The better I eat before surgery, the more likely I will heal." "I might be sick to my stomach and throw up after surgery." "When I can eat again, the best meal would be steak and orange juice."

"I can have a hamburger and French fries as soon as I wake up." (Oral fluid and food may be withheld until intestinal motility resumes.)

During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks? "I am taking vitamins." "I drink a glass of wine a night." "I had a heart attack 4 months ago." "I quit smoking 10 years ago."

"I had a heart attack 4 months ago." (The statement by the client that he or she had a heart attack 4 months ago requires further investigation. Cardiac problems increase surgical risks, and the risk for a myocardial infarction during surgery is higher in clients who have heart problems.The type of vitamins the client takes should be assessed, but this is not the highest risk. Moderate alcohol consumption is not considered high-risk behavior. A past history of smoking should be noted, but current or more recent smoking is of greater concern.)

The nurse reviews a routine discharge teaching plan concerning postoperative care with a client. Which statement by the client indicates that teaching about wound care was effective? "I may need to restrict my activities for several months." "I should remove the dressing if the wound is draining." "Some bleeding from the incision is normal for several weeks." "The wound will completely heal in about 2 months."

"I may need to restrict my activities for several months." (To protect the integrity of the wound, activities may need to be restricted.The wound is usually open to air for healing, but draining wounds need to be covered. Bleeding and serosanguineous drainage is not normal after 5 days. The length of time it takes for a wound to heal varies, and can take up to 2 years to heal.)

The nurse is teaching a client with diabetes about proper foot care. Which statement by the client indicates that teaching was effective? "I will go barefoot in my house so that my feet are exposed to air." "I must inspect my shoes for foreign objects before putting them on." "I will soak my feet in warm water to soften calluses before trying to remove them." "I must wear canvas shoes as much as possible to decrease pressure on my feet."

"I must inspect my shoes for foreign objects before putting them on." (The statement by the diabetic client that indicates that teaching was effective is, "I must inspect my shoes for foreign objects before putting them on." To avoid injury or trauma to the feet, shoes need to be checked for foreign objects before the feet are inserted in them.Clients with diabetes would not go barefoot because foot injuries can occur in those clients who lack sensation. To avoid injury or trauma, a callus needs to be removed by a podiatrist, not by the client. To prevent injury, the client with diabetes must wear protective shoes for support and not canvas shoes.)

Which client statement indicates the need for further teaching about antiemetic medications? "I may take Tylenol to treat the headache caused by ondansetron (Zofran)." "I will not drive while I am taking these medications because they may cause drowsiness." "I should take my prescribed antiemetic before receiving my chemotherapy dose." "I will apply the scopolamine patch to my right or left arm and rotate sites of application."

"I will apply the scopolamine patch to my right or left arm and rotate sites of application." (Transdermal scopolamine patches should be applied to nonirritated areas behind the ear, not on the arms.)

The nurse is teaching a client with newly diagnosed type 2 diabetes about the importance of weight control. Which comment by the client indicates a need for further teaching? "I will begin exercising for at least an hour a day." "I will monitor my diet and avoid empty calories." "If I lose weight, I may not need to use the insulin anymore." "Weight loss can be a sign of diabetic ketoacidosis."

"I will begin exercising for at least an hour a day." (Further teaching is needed when the client says that "I will begin exercising for at least an hour a day." The goal of weight control for Type 2 diabetes is to change sedentary behavior to active behavior. This is begun by starting low-intensity activities in short sessions (less than 10 minutes). The client may increase sessions to moderate or vigorous aerobic physical activity to lose and or sustain weight loss.Monitoring the diet and avoiding empty calories is essential to managing type 2 diabetes. Weight loss can minimize the need for insulin and can also be a sign of diabetic ketoacidosis due to osmotic diuresis.)

The nurse is teaching a client about the manifestations and emergency management of hypoglycemia. Which response by the client indicates a correct understanding of what to do if the client feels hungry and shaky? "I will drink a glass of water." "I will eat three graham crackers." "I will give myself 1 mg of glucagon." "I will sit down and rest."

"I will eat three graham crackers." (Correct understanding of what the client needs to do if the client feels hungry and shaky is to eat three graham crackers. This is the correct management strategy for mild hypoglycemia.Drinking a glass of water or sitting down and resting does not remedy hypoglycemia. Glucagon is generally administered for episodes of severe not mild hypoglycemia.)

In order to prevent the possibility of venous stasis, a nurse is teaching a surgical client how to perform leg exercises. Which of the client's following statements indicates a sound understanding of leg exercises? "I'll practice these now and try to start them as soon as I can after my surgery." "I'll try to do these lying on my stomach so that I can bend my knees more fully." "I'll make sure to do these, as long as my doctor doesn't tell me to stay on bed rest after my operation." "I'm pretty sure my stomach muscles are strong enough to lift both of my legs off the bed at the same time."

"I'll practice these now and try to start them as soon as I can after my surgery." (Leg exercises should be begun as soon as possible after surgery, unless contraindications exist. Bed rest does not preclude the performance of leg exercises and the legs should be lifted individually, not simultaneously. The client should perform leg exercises in a semi-Fowler's, not prone, position.)

The clinic nurse is providing teaching to a client with newly diagnosed diabetes. Which statement by the client indicates a correct understanding about the need to wear a MedicAlert bracelet? "If I become hyperglycemic, it is a medical emergency." "If I become hypoglycemic, I could become unconscious." "Medical personnel may need confirmation of my insurance." "I may need to be admitted to the hospital suddenly."

"If I become hypoglycemic, I could become unconscious." (The statement by the client that indicates a correct understanding about the need to wear a MedicAlert bracelet is, "If I become hypoglycemic, I could become unconscious." Hypoglycemia is the most common cause of medical emergency in clients with diabetes. A MedicAlert bracelet is helpful if the client becomes hypoglycemic and is unable to provide self-care.Hyperglycemia does not pose the same type of acute medical emergency as hypoglycemia unless it is severe and acidosis develops. Insurance information does not appear on a MedicAlert bracelet. Information on the MedicAlert bracelet may be helpful if a sudden hospitalization occurs when the client cannot communicate. However, it is standard procedure to assess blood glucose in that instance.)

The nurse is instructing a client about the use of antiembolism stockings. Which statement by the client indicates the need for further teaching? "I will take off my stockings one to three times a day for 30 minutes." "My stockings are too loose." "It's better if they are too tight rather than too loose." "These stockings help promote blood flow."

"It's better if they are too tight rather than too loose." (Antiembolism stockings should fit properly to achieve the desired result. Stockings that are too tight will impede blood flow.Frequent removal of the stockings is appropriate to allow for hygiene and a break from their wear. Stockings that are too loose are ineffective. Antiembolism stockings may be used during and after surgery to promote venous return.)

A client expresses fear and anxiety over the life changes associated with diabetes, stating, "I am scared I can't do it all and I will get sick and be a burden on my family." What is the nurse's best response? "It is overwhelming, isn't it?" "Let's see how much you can learn today, so you are less nervous." "Let's tackle it piece by piece. What is most scary to you?" "Many people live with diabetes and do it just fine."

"Let's tackle it piece by piece. What is most scary to you?" (The nurse's best response is to suggest that the client tackle it piece by piece and ask what is most scary to him or her. This is the best client centered response, and acknowledges the client's concern, letting the client master survival skills first.Referring to the illness as overwhelming may reflect the client's feelings, but is a closed-ended question and does not encourage the client to express his feelings about the underlying fear. Trying to see how much the client can learn in one day may add to his anxiety by overwhelming him with information and the need to "do it all" in one day. Suggesting that other people handle the illness just fine criticizes the client and does not recognize his concerns.)

Which statement by a nursing student indicates a need for further teaching about operating room (OR) surgical attire? "I must cover my facial hair." "I don't need a sterile gown to be in the OR." "If I go into the OR, I must wear a protective mask." "My scrubs will be sterile."

"My scrubs will be sterile." (Scrub attire is provided by the hospital and is clean, not sterile.All members of the surgical team must cover their hair, including any facial hair. Team members who are not scrubbed (e.g., anesthesia provider, student nurse) are not required to be sterile and may wear cover scrub jackets that are snapped or buttoned closed to prevent shedding of organisms from bare arms. Everyone who enters an OR in which a sterile field is present must wear a mask.)

A client with type 2 diabetes is taking one oral hypoglycemic tablet daily. The client asks whether an extra tablet should be taken before exercise. What is the best response by the nurse? "You will need to decrease your exercise." "An extra tablet will help your body use glucose correctly." "When taking medicine, your diet will not be affected by exercise." "No, but you should observe for signs of hypoglycemia while exercising."

"No, but you should observe for signs of hypoglycemia while exercising." (Exercise improves glucose metabolism; with exercise there is a risk of developing hypoglycemia, not hyperglycemia. Exercise should not be decreased because it improves glucose metabolism. An extra tablet probably will result in hypoglycemia because exercise alone improves glucose metabolism. Control of glucose metabolism is achieved through a balance of diet, exercise, and pharmacologic therapy.)

Which statement made by a client recently diagnosed with type 1 diabetes indicates that further education is necessary regarding the teaching plan? "I will need to have my eyes and vision examined once a year." "I will need to check my blood sugar at home to evaluate my response to my treatment plan." "I can improve metabolic and cardiac risk factors of this disease if I follow a low-calorie diet and lose weight." "Once I reach my target weight there is a good chance that I will be able to switch from insulin to an oral medication."

"Once I reach my target weight there is a good chance that I will be able to switch from insulin to an oral medication." (Type 1 diabetes mellitus (DM) is an autoimmune disorder in which beta cells are destroyed. No insulin or very little insulin is produced. Therefore a person with type 1 DM will need lifelong insulin injections to control blood sugar. Early detection of changes in the eye permits treatment plan adjustments that can slow or halt progression of retinopathy. Blood glucose monitoring should be done at home to evaluate the treatment plan. Disease risk factors can be improved with weight loss and a low-calorie diet.)

The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction? "I will wake up with a tube in my throat." "I will have a bandage on my chest." "My family will not be able to see me right away." "Pain medication will take away my pain."

"Pain medication will take away my pain." (The client's statement that, "Pain medication will take away my pain," indicates the need for further instruction. Pain medication will reduce pain, but will not take it away completely.The client statement about waking up with a tube in the throat is accurate, because the client will be intubated. Following heart surgery, a dressing is placed on the chest. The client will not be able to see family immediately because he or she will go to recovery first.)

A client has arrived in the same-day surgery suite. He states to the nurse, "I am so worried about being put to sleep and having the surgery." What would be the nurse's best response? "You don't have to worry. It will be fine." "Tell me what you are most worried about." "I will have the anesthesiologist talk to you." "Have you ever had surgery before?"

"Tell me what you are most worried about." (The nurse should first assess what the client is most worried about or fearful of and then provide emotional support.)

The adult male patient with significant body hair is being prepared for abdominal surgery. The patient states his dad had the same surgery many years ago and was shaved prior to the procedure. The nurse would explain to the patient: "That practice is no longer standard as shaving may cause breaks in the skin." "We no longer shave skin before procedures but we will apply a lotion that will remove the hair." "Your abdomen will be shaved in the operating room." "You will be shaved as well."

"That practice is no longer standard as shaving may cause breaks in the skin." (A surgical "prep," or shaving of the hair in the affected area, was a common preoperative procedure a decade ago. Current research indicates that preoperative shaving increases the risk for surgical site infection by causing tiny breaks in skin integrity.)

The nurse is caring for the postoperative patient in the PACU. The patient is concerned about the abdominal staples closing her wound for fear they will open and her "insides will fall out." Which of the following is the best response by the nurse? "Don't worry, the staples are properly placed and will not come out until they are removed by the physician." "If you are very careful and follow your postoperative instructions, there is no need to worry." "There are sutures in various levels below the staples that assist in keeping your wound intact." "Would you tell me why you are worried about that?" "That is possible, but we will keep a close eye on the staples."

"There are sutures in various levels below the staples that assist in keeping your wound intact." (A patient may have absorbable sutures closing the viscera and staples approximating the wound edges.)

A client is having an arthroscopy of the left knee and has just been moved to the surgical holding area. Which statement by the nurse properly identifies the client while the nurse checks the identification label? "Are you Mr. Smith?" "Good morning, Mr. Smith." "What is your name, and when were you born?" "What surgery are you having today?"

"What is your name, and when were you born?" (The nurse must verify the client's identity with two types of identifiers, such as name and birthdate. This practice prevents errors by drowsy or confused clients.When asked to verify his or her name, or respond to a greeting, the client may respond inappropriately if he or she is anxious or sedated. Asking the client about his or her surgery does help with identification. However, it is really done to ascertain that the client's perception of the procedure, the operative permit, and the operative schedule are the same.)

The nurse is interviewing a client admitted for uncontrolled diabetes after binging on alcohol for the past 2 weeks. The client states, "I am worried about how I am going to pay my bills for my family while I am hospitalized." Which statement by the nurse would best elicit information from the client? "You are worried about paying your bills?" "Don't worry; your bills will get paid eventually." "When was the last time you were admitted for hyperglycemia?" "You really shouldn't be drinking alcohol because of your diagnosis of diabetes."

"You are worried about paying your bills?" (Reflection can help the client to elaborate. The statement "Don't worry; your bills will get paid eventually" offers false assurance; the statement "When was the last time you were admitted for hyperglycemia?" uses professional jargon; and the statement "You really shouldn't be drinking alcohol because of your diagnosis of diabetes" is offering advice, all of which can all restrict the client's response.)

A patient arrives at the urgent care center complaining of leg pain after a fall when rock climbing. The x-rays show no broken bones, but he has a large bruise on his thigh. The patient says he drives a truck and does not want to take anything strong because he needs to stay awake. Which statement by the nurse is most appropriate? "It would be best for you not to take anything if you are planning to drive your truck." "We will discuss with your doctor about taking an opioid because that would work best for your pain." "You can take acetaminophen, also known as Tylenol, for pain, but no more than 1000 mg per day." "You can take acetaminophen, also known as Tylenol, for pain, but no more than 3000 mg per day."

"You can take acetaminophen, also known as Tylenol, for pain, but no more than 3000 mg per day." (Acetaminophen is indicated for mild-to-moderate pain and does not cause drowsiness, as an opioid would. Currently, the maximum daily amount of acetaminophen is 3000 mg/day. The 1000-mg amount per day is too low. Telling the patient not to take any pain medications is incorrect.)

A nurse is educating a surgical client on postoperative p.r.n. pain control. Which of the following should be included? "We will bring you pain medications; you don't need to ask." "Even if you have pain, you may get addicted to the drugs." "You won't have much pain so just tough it out." "You need to ask for the medication before the pain becomes severe."

"You need to ask for the medication before the pain becomes severe." (If medication for pain is ordered p.r.n., there is a time restriction between doses. The client needs to ask for the medication and should do so before the pain becomes severe.)

A nurse is educating a client about regional anesthesia. Which of the following statements is accurate about this type of anesthesia? "You will be asleep and won't be aware of the procedure." "You will be asleep but may feel some pain during the procedure." "You will be awake but will not be aware of the procedure." "You will be awake and will not have sensation of the procedure."

"You will be awake and will not have sensation of the procedure." (Regional anesthesia occurs when an anesthetic agent is injected near a nerve or nerve pathway in or around the operative site, inhibiting the transmission of sensory stimuli to central nervous system receptors. The client remains awake but loses sensation in a specific area or region of the body.)

The intensive care nurse is caring for a client admitted in a hyperglycemic-hyperosmolar state. Which of these prescriptions made by the primary health care provider will the nurse question? Add 20 mEq of KCl to each liter of IV fluid IV regular insulin at 2 units/hr IV normal saline at 100 mL/hr 1 ampule Sodium Bicarbonate IV now

1 ampule Sodium Bicarbonate IV now (Sodium Bicarbonate is given for the acid-base imbalance of diabetic ketoacidosis, not the hyperglycemic-hyperosmolar state that presents with hyperglycemia and absence of ketosis/acidosis.Insulin puts potassium into the cell. KCl 20 mEq for each liter of IV fluid will correct hypokalemia from osmotic diuresis and electrolyte shifts. IV regular insulin at 2 units/hr will help correct hyperglycemia. IV normal saline at 100 mL/hr will help correct dehydration.)

A client with type 1 diabetes receives regular insulin every morning at 8:00 AM. During what period of time does the nurse recognize the risk of hypoglycemia is greatest? 8:30 to 9:30 AM 8:00 PM to midnight 1:00 PM to 8:00 PM 10:00 AM to 1:00 PM

10:00 AM to 1:00 PM (Regular insulin peaks in 2 to 5 hours; therefore the greatest risk is between 10:00 AM and 1:00 PM. Although the onset of action occurs earlier, during the period from 8:30 to 9:30 AM, the level is not yet at its highest, so the risk of hypoglycemia is not at its greatest. NPH insulin's peak action is 4 to 12 hours; if hypoglycemia occurs, it will happen most likely between midnight and 8 PM.)

A client with type 1 diabetes mellitus received regular insulin at 7:00 a.m. The client will need to be monitored for hypoglycemia at which time? 7:30 a.m. 11:00 a.m. 2:00 p.m. 7:30 p.m.

11:00 a.m. (Regular insulin is a short-acting type of insulin. Onset of action to regular insulin is ½ to 1 hour. The peak effect time is when hypoglycemia may start to occur. Peak time for regular insulin is 2-4 hours. Therefore, 11:00 a.m. is the anticipated peak time for regular insulin received at 7:00 a.m.The other options for peak times for regular insulin are incorrect.)

The nurse is preparing to start an IV in the preoperative adult patient. The nurse would likely choose which gauge of IV catheter? 22 gauge 25 gauge 18 gauge 14 gauge

18 gauge (For any surgical patient, a large-gauge (e.g., 18-gauge) IV device should be used in case a blood transfusion is necessary during the surgical or postoperative period.)

A nurse prepares to administer prescribed regular and NPH insulin. Place the nurse's actions in the correct order to administer these medications. 1. Inspect bottles for expiration dates. 2. Gently roll the bottle of NPH between the hands. 3. Wash your hands. 4. Inject air into the regular insulin. 5. Withdraw the NPH insulin. 6. Withdraw the regular insulin. 7. Inject air into the NPH bottle. 8. Clean rubber stoppers with an alcohol swab.

3. Wash your hands. 1. Inspect bottles for expiration dates. 2. Gently roll the bottle of NPH between the hands. 8. Clean rubber stoppers with an alcohol swab. 7. Inject air into the NPH bottle. 4. Inject air into the regular insulin. 6. Withdraw the regular insulin. 5. Withdraw the NPH insulin. (After washing hands, it is important to inspect the bottles and then to roll the NPH to mix the insulin. Rubber stoppers should be cleaned with alcohol after rolling the NPH and before sticking a needle into either bottle. It is important to inject air into the NPH bottle before placing the needle in a regular insulin bottle to avoid mixing of regular and NPH insulin. The shorter-acting insulin is always drawn up first.)

The RN has just received reports about all of these clients on the inpatient surgical unit. Which client does the nurse care for first? A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing A 46-year-old who had a thoracotomy 5 days ago and needs discharge teaching before going home A 48-year-old who had bladder surgery earlier in the day and is reporting pain when coughing A 49-year-old who underwent repair of a dislocated shoulder this morning and has a temperature of 100.4°F (38°C)

A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing (The nurse would first care for the 7-day postoperative client who has new serosanguineous drainage. New drainage on the seventh postoperative day is unusual and suggests a complication that would require further assessment and possible immediate action.The client awaiting discharge teaching is not a priority. A temperature of 100.4°F (38°C) and pain upon coughing following bladder surgery are normal on the first postsurgical day.)

Which client is at greatest risk for slow wound healing? A 12-year-old healthy girl A 47-year-old obese man with diabetes A 48-year-old woman who smokes A 98-year-old healthy man

A 47-year-old obese man with diabetes (Obesity and diabetes would significantly put a client at greatest risk for slow wound healing.The healthy 12-year-old would likely heal quickly. The 48-year-old smoker will experience delayed wound healing, but is not as high a risk as an obese client who is diabetic. The healthy 98-year-old is not at risk for delayed wound healing.)

Which of these clients with diabetes will the endocrine unit charge nurse assign to an RN who has floated from the labor/delivery unit? A client with sensory neuropathy who needs teaching about foot care A client with diabetic ketoacidosis who has an IV running at 250 mL/hr A client who needs blood glucose monitoring and insulin before each meal A client who was admitted with fatigue and shortness of breath

A client who needs blood glucose monitoring and insulin before each meal (A nurse from the labor/delivery unit would be familiar with blood glucose monitoring and insulin administration because clients with type 1 and gestational diabetes are frequently cared for in the labor/delivery unit.The clients with sensory neuropathy, diabetic ketoacidosis, and the client with fatigue and shortness of breath all have specific teaching or assessment needs that are better handled by nurses more familiar with caring for adults with diabetes-related complications.)

A patient has chronic confusion secondary to dementia. As a result, he is unable to sign an informed consent for surgery. In this situation: An informed consent is not needed. Two nurses may sign the informed consent for the patient. The surgeon must sign the informed consent. A family member will be asked to sign the informed consent.

A family member will be asked to sign the informed consent. (In most states, a family member, conservator, or legal guardian may give consent for a procedure if a patient is not capable of giving an informed consent or if the patient is a minor.)

The nurse is assessing a patient for contraindications to drug therapy with acetaminophen (Tylenol). Which patient should not receive acetaminophen? A patient with a fever of 101° F (38.3° C) A patient who is complaining of a mild headache A patient with a history of liver disease A patient with a history of peptic ulcer disease

A patient with a history of liver disease (Liver disease is a contraindication to the use of acetaminophen. Fever and mild headache are both possible indications for the medication. Having a history of peptic ulcer disease is not a contraindication.)

At what point would the patient sign the consent form for a surgical procedure? A. After the surgeon explains the procedure B. During the preoperative consultation at the surgeon's office C. After receiving preoperative medication D. At the completion of the physical examination

A. After the surgeon explains the procedure (Rationale: The consent form for a surgical procedure is signed after the surgeon explains the procedure. The patient does not always have a preoperative consultation at the surgeon's office. Even when such a consultation occurs, it is too early for the patient to be asked to sign a surgical consent form. The consent form for a surgical procedure could be considered invalid if the patient signs it after receiving preoperative medication. The consent form for a surgical procedure is signed after the surgeon explains the procedure. This occurs before a physical examination is completed.)

What will the nurse do when discontinuing PCA? A. Ensure that the main intravenous line is intact. B. Pull the intravenous access device from the patient. C. Tell the patient that pain medication has been discontinued. D. Change the PCA pump infusion rate to keep vein-open status.

A. Ensure that the main intravenous line is intact. (Rationale: The main intravenous infusion should remain intact when discontinuing PCA. Pain medication has not been discontinued. The PCA delivery approach has been discontinued. Changing the PCA pump infusion rate to keep the vein open is not discontinuing the medication.)

Which action will help support the postsurgical patient's respiratory status? A. Extending the patient's head when not contraindicated B. Maintaining the patient in a supine position C. Frequently calling the patient by name in a moderate tone D. Reporting to the health care provider a systolic drop of 10 points or more from the baseline blood pressure

A. Extending the patient's head when not contraindicated (Rationale: Extending the neck helps to ensure a patent airway. The supine position does not support the patient's respiratory status or best facilitate oxygenation. Calling the patient's name may help to rouse him or her from anesthesia during the immediate postoperative period, but doing so would not help support the patient's respiratory status. Reporting a significant drop in the patient's systolic blood pressure is appropriate, but doing so would not help support the patient's respiratory status.)

A diabetic client is undergoing surgery to amputate a gangrenous foot. This procedure would be considered which of the following categories of surgery based on purpose? Diagnostic Ablative Palliative Reconstructive

Ablative (Ablative surgery is performed to remove a diseased body part. Diagnostic surgery is performed to make or confirm a diagnosis. Palliative surgery involves relieving or reducing intensity of an illness. Reconstructive surgery restores function to traumatized or malfunctioning tissue.)

While admitting a patient for treatment of an acetaminophen (Tylenol) overdose, the nurse prepares to administer which medication to prevent toxicity? Methylprednisolone (Solu-Medrol) Acetylcysteine (Mucomyst) Naloxone (Narcan) Phytonadione (vitamin K)

Acetylcysteine (Mucomyst) (Acetylcysteine is the antidote for acetaminophen overdose. It must be administered as a loading dose followed by subsequent doses every 4 hours for 17 additional doses and started as soon as possible after the acetaminophen ingestion (ideally within 12 hours).)

Surgeries are commonly classified by which of the following? Choose all that apply. Acuity Level of urgency Length of surgery Organ involved

Acuity Level of urgency (Surgeries can be classified by body systems, purpose, level of urgency, and degree of seriousness. The length of surgery and organ involved are not used for classifying surgeries.)

A client with abdominal incisions experiences excruciating pain when he tries to cough. What should the nurse do to reduce the client's discomfort when coughing? Administer prescribed pain medication just before coughing. Ask the client to drink plenty of water before coughing. Ask the client to lie in a lateral position when coughing. Administer prescribed pain medication 30 minutes before deliberately attempting to cough.

Administer prescribed pain medication 30 minutes before deliberately attempting to cough. (Coughing is painful for clients with abdominal or chest incisions. Administering pain medication approximately 30 minutes before coughing, or splinting the incision when coughing, can reduce discomfort. Making the client lie in a lateral position or asking the client to drink plenty of water is not helpful because it will make breathing and coughing even more difficult for the client.)

A 57-year-old woman being treated for end-stage breast cancer has been using a transdermal opioid analgesic as part of the management of pain. Lately, she has been experiencing breakthrough pain. The nurse expects this type of pain to be managed by which of these interventions? Administering NSAIDs Administering an immediate-release opioid Changing the opioid route to the rectal route Making no changes to the current therapy

Administering an immediate-release opioid (If a patient is taking long-acting opioid analgesics, breakthrough pain must be treated with an immediate-release dosage form that is given between scheduled doses of the long-acting opioid. The other options are not appropriate actions.)

The nurse is preparing an intraoperative care plan for a client. Which intervention should be excluded from the care plan? Ensuring the client's skin integrity Reviewing the preoperative instructions Administering general anesthetic to the client Placing the client in the correct position on the operating table

Administering general anesthetic to the client (Only anesthesiologists who are specially trained can administer anesthesia. Therefore, the nurse should exclude this intervention from the nursing care plan. In the operating room, the nurse should ensure the client's skin integrity to prevent complications such as pressure sores. The nurse should review the preoperative care plan to establish or amend the plan if changes are required. The nurse should place the client in the correct position to prevent the client from injury during the operation.)

A 78-year-old patient is in the recovery room after having a lengthy surgery on his hip. As he is gradually awakening, he requests pain medication. Within 10 minutes after receiving a dose of morphine sulfate, he is very lethargic and his respirations are shallow, with a rate of 7 per minute. The nurse prepares for which priority action at this time? Assessment of the patient's pain level Immediate intubation and artificial ventilation Administration of naloxone (Narcan) Close observation of signs of opioid tolerance

Administration of naloxone (Narcan) (Naloxone, an opioid-reversal agent, is used to reverse the effects of acute opioid overdose and is the drug of choice for reversal of opioid-induced respiratory depression. This situation is describing an opioid overdose, not opioid tolerance. Intubation and artificial ventilation are not appropriate because the patient is still breathing at 7 breaths/min. It would be inappropriate to assess the patient's level of pain.)

Which of the following nursing interventions occurs in the postoperative phase of the surgical experience? Airway/oxygen therapy/pulse oximetry Teaching deep breathing exercises Reviewing the meaning of p.r.n. orders for pain medications Putting in IV lines and administering fluids

Airway/oxygen therapy/pulse oximetry (Airway/oxygen therapy/pulse oximetry occur in the postanesthesia unit in the postoperative phase. Teaching deep-breathing exercises and reviewing the meaning of p.r.n. orders for medications occur in the preoperative phase. Putting in IV lines and administering fluids occurs in the intraoperative phase.)

The nurse is caring for a patient admitted for an outpatient surgical procedure. Which of the following will the nurse include in the care? Select all that apply. Begin discharge teaching as soon as the procedure is completed. Allow family members to be present during discharge teaching. Begin discharge teaching in the preoperative period. Investigate the patient's home care and discharge transportation following the procedure. Discuss discharge transportation during the preoperative period.

Allow family members to be present during discharge teaching. Begin discharge teaching in the preoperative period. Discuss discharge transportation (Patient teaching begins during the preoperative period and continues throughout all perioperative phases of care. In the preoperative phase, assess the patient's and family's readiness to learn and their knowledge base so that teaching can be individualized. If the patient will be discharged on the day of surgery, be sure to identify someone who can take the patient home and assist during the postoperative recovery period.)

The removal of a toddler's clothing and application of monitoring equipment after anesthesia is administered will Minimize blood loss Ensure temperature control Provide baseline vital signs Allow sufficient relaxation

Allow sufficient relaxation (Relaxation can be enhanced by removing the child's clothing, applying the grounding pad, and applying monitoring devices after the child is anesthetized.)

Which is the best referral that the community health nurse can suggest to a client who has been newly diagnosed with diabetes? American Diabetes Association (ADA) Centers for Disease Control and Prevention Primary health care provider office Pharmaceutical representative

American Diabetes Association (ADA) (The American Diabetes Association is the best agency to refer the diabetic client to. The ADA provides national and regional support and resources to clients with diabetes and their families.The Centers for Disease Control and Prevention does not specifically focus on diabetes. The client's primary health care provider's office is limited in the resources available to the client with diabetes. A pharmaceutical representative is not an appropriate resource for diabetes information and support.)

Surgery can lead to hypothermia. Of the following clients, who is at greatest risk for hypothermia? A woman delivering by C-section An adolescent for arthroscopic surgery A young adult with a fractured leg An elderly man with a fractured hip

An elderly man with a fractured hip (The risk of hypothermia increases in the very young and the very old.)

Identify the desired effects of general anesthesia. Choose all that apply. Reduction of risk Analgesia Amnesia Muscle relaxation

Analgesia Amnesia Muscle relaxation (General anesthesia is used to control pain (analgesia), relax muscles, and promote amnesia. Anesthesia is not used for the purpose of obtaining a reduction in risk potential; however, surgical risk is influenced by the type of anesthesia used.)

A postoperative home care client has developed thrombophlebitis in her right leg. What category of medications will probably be prescribed for this cardiovascular complication? Anticoagulants Antibiotics Antihistamines Antigens

Anticoagulants (Thrombophlebitis is an inflammation of a vein associated with thrombus formation. Thrombophlebitis from venous stasis is most commonly seen in the legs of postoperative clients. Nursing interventions include administering ordered medications, most often anticoagulants.)

Antidopaminergic drugs are useful to treat not only nausea and vomiting but also which other conditions? Select all that apply. Anxiety Bone marrow suppression Seizures Intractable hiccups Schizophrenia

Anxiety Intractable hiccups Schizophrenia (Antidopaminergic drugs are used to treat psychotic disorders (mania, schizophrenia, anxiety), intractable hiccups, nausea, and vomiting.)

A nurse is providing ongoing postoperative care to a client who has had knee surgery. The nurse assesses the dressing and finds it saturated with blood. The client is restless and has a rapid pulse. What should the nurse do next? Document the data and apply a new dressing. Apply a pressure dressing and report findings. Reassure the family that this is a common problem. Make assessments every 15 minutes for four hours.

Apply a pressure dressing and report findings. (Hemorrhage is an excessive internal or external loss of blood. Common indications of hemorrhage include a rapid, thready pulse. If bleeding occurs, the nurse should apply a pressure dressing to the site, report findings to the physician, and be prepared to return the client to the operating room if bleeding cannot be stopped or is massive.)

A patient is to have a sequential compression device (SCD) applied on the postoperative unit. The patient is wearing knee-high elastic (antiembolism) stockings. When applying the SCD, what should the nurse do? Remove the antiembolism stockings and not replace them. Replace the knee-high stockings with thigh-high stockings. Notify the surgeon that the patient is wearing antiembolism stockings. Apply the SCD over the knee-high antiembolism stockings.

Apply the SCD over the knee-high antiembolism stockings. (If elastic stockings have been ordered with the sequential compression device, leave them in place; if the patient is not yet wearing them, obtain them and put them on the patient. Knee-high stockings do not need to be replaced with thigh-high stockings. Some research has shown knee-high stockings to be equally effective. There is no need to notify the surgeon, as patients commonly return from surgery wearing antiembolism stockings, as prescribed.)

A preoperative client wears a hearing aid and is extremely hard of hearing without it. What does the nurse do to help reduce this client's anxiety? Actively listen to this client's concerns. Allow the client to wear the hearing aid to surgery. Ask if the client may wear the hearing aid until anesthesia is given. Explain that it is hospital policy to remove a hearing aid before surgery.

Ask if the client may wear the hearing aid until anesthesia is given. (The nurse needs to ask if the client can wear the hearing aid to the operating room (OR). In some facilities, clients may wear eyeglasses and hearing aids until after anesthesia induction.Listening isn't always enough; more intervention is needed. Sending the client to the OR with the hearing aid without checking first is inappropriate. The OR staff may have a different policy, considering that the hearing aid may get lost. Telling the client that a policy precludes the client's needs is not therapeutic.)

A client with type 2 diabetes who is taking metformin (Glucophage) is seen in the diabetic clinic. The fasting blood glucose is 108 mg/dL (6.0 mmol/L), and the glycosylated hemoglobin (HbA1C) is 8.2%. Which action will the nurse take next? Instruct the client to continue with the current diet and metformin use. Discuss the need to check blood glucose several times every day. Talk about the possibility of adding rapid-acting insulin to the regimen. Ask the client about current dietary intake and medication use.

Ask the client about current dietary intake and medication use. (The nurse's next action would be to assess the client's adherence to the currently prescribed diet and medications. The nurse would also check for any stressors or undocumented illnesses. Glycosylated hemoglobin (HbA1C) levels >8% indicate poor diabetes control and need for adherence to regimen or changes in therapy.Instructing the client to continue with current diet and metformin use is inappropriate without further assessment. Checking blood glucose more frequently and/or using rapid-acting insulin may be appropriate, but this will depend on the assessment data. The HbA1C indicates that the client's average glucose level is higher than the target range, but discussing the need to check blood glucose several times every day assumes that the client is not compliant with the therapy and glucose monitoring. The nurse would not assume that adding insulin, which must be prescribed by the primary health care provider, is the answer without assessing the underlying reason for the treatment failure.)

A nurse is assisting a postoperative client with deep-breathing exercises. Which of the following is an accurate step for this procedure? Place the client in prone position, with the neck and shoulders supported. Ask the client to place the hands over the stomach, so he or she can feel the chest rise as the lungs expand. Ask the client to exhale rapidly and completely, and inhale through the nose rapidly and completely. Ask the client to hold his or her breath for three to five seconds and mentally count "one, one thousand, two, one thousand" and so forth.

Ask the client to hold his or her breath for three to five seconds and mentally count "one, one thousand, two, one thousand" and so forth. (The nurse should place the client in semi-Fowler's position, with the neck and shoulders supported, and ask the client to place the hands over the rib cage, so he or she can feel the chest rise as the lungs expand. Then, ask the patient to exhale gently and completely, inhale through the nose gently and completely, hold his or her breath for three to five seconds, and mentally count "one, one thousand, two, one thousand" etc., then exhale as completely as possible through the mouth with lips pursed (as if whistling).)

As the unit nurse is about to give a preoperative medication to a client going into surgery, it is discovered that the surgical consent form is not signed. What does the nurse do after verifying the procedure with the client? Calls the surgeon Calls the anesthesiologist Gives the medication as ordered Asks the client to sign the consent form

Asks the client to sign the consent form (The unit nurse will ask the client to sign the consent form, after which the medication can be administered.Calling the surgeon or the anesthesiologist is not necessary. It is illegal for the client to sign the permit after being sedated.)

Which of the following interventions are recommended guidelines for meeting client postoperative elimination needs? Assess abdominal distention, especially if bowel sounds are audible or are low pitched. Assess for the return of peristalsis by auscultating bowel sounds every four hours when the client is awake. Encourage food and fluid intake when ordered, especially dairy products and low-fiber foods. Assess for bladder distention by Palpating below the symphysis pubis if the client has not voided within eight hours after surgery.

Assess for the return of peristalsis by auscultating bowel sounds every four hours when the client is awake. (Assess for the return of peristalsis by auscultating bowel sounds every four hours when the client is awake. Assess abdominal distention, especially if bowel sounds are inaudible or are high pitched. Encourage food and fluid intake when ordered, especially fruit juices and high-fiber foods. Assess for bladder distention by palpating above the symphysis pubis if the client has not voided within eight hours after surgery.)

Which nursing action will the home health nurse delegate to a home health aide who is making daily visits to a client with newly diagnosed type 2 diabetes? Assist the client's spouse in choosing appropriate dietary items. Evaluate the client's use of a home blood glucose monitor. Inspect the extremities for evidence of poor circulation. Assist the client with washing the feet and applying moisturizing lotion.

Assist the client with washing the feet and applying moisturizing lotion. (The nursing action that the home health nurse can delegate to a home health aide who is making daily visits to a newly diagnosed type 2 diabetic client is assisting with personal hygiene. This action is included in the role of home health aides.Assisting with appropriate dietary selections, evaluating the effectiveness of teaching, and performing assessments are complex actions that would be performed by licensed nurses.)

A patient had a colon resection for removal of a cancerous tumor. Postoperatively, on the surgical floor which of the following activities would the nurse perform for the purpose of decreasing the risk of postoperative complications? Choose all that apply. Assist the patient to turn, breathe deeply, and cough every 2 hours. Teach the patient about the type of tumor removed. Assess the drainage from the surgical site. Monitor vital signs on a regular basis.

Assist the patient to turn, breathe deeply, and cough every 2 hours. Assess the drainage from the surgical site. Monitor vital signs on a regular basis. (The nurse assists the patient to turn, breathe deeply, and cough every 2 hours in order to decrease the risk of postoperative atelectasis or pneumonia. The nurse assesses the wound drainage to monitor for signs of bleeding, infection, or wound complications. Vital signs are monitored to detect the potential for infection or hemorrhage, not to prevent them. The nurse may teach the patient about cancerous tumors; however, this intervention will not decrease the risk of postoperative complications.)

A client returning to the floor after orthopedic surgery is complaining of nausea. The nurse is aware that an appropriate intervention is to do which of the following? Avoid strong smelling foods. Provide clear liquids with a straw. Avoid oral hygiene until the nausea subsides. Hold all medications.

Avoid strong smelling foods. (Nursing care for a client with nausea includes avoiding strong smelling foods, providing oral hygiene, administering prescribed medications (especially medications ordered for nausea and vomiting), and avoiding use of a straw.)

What instruction might the nurse give to nursing assistive personnel (NAP) regarding postoperative exercises? A. "Find out if the patient has any language barriers." B. "Let me know when the patient actually begins exercising." C. "Please review a copy of the preoperative literature with the patient." D. "Assess the method of learning the patient would prefer."

B. "Let me know when the patient actually begins exercising." (Rationale: NAP may let the nurse know if the patient is exercising. No aspect of patient assessment may be delegated to NAP. Patient education may not be delegated to NAP. Because assessment of learning preferences is part of patient education, NAP may not carry out this responsibility.)

When a patient returns to the unit from the PACU, how would the nurse assess possible urinary retention? A. Straight-catheterize the patient. B. Complete a bladder scan. C. Encourage the patient to void. D. Check the chart for lab values specific to urinary function.

B. Complete a bladder scan. (Rationale: Performing a bladder scan identifies how much fluid is present in the bladder, accurately identifying the retention. Before straight catheterization could be considered, a bladder scan would need to be completed to see how much retention is present. It is correct to encourage the patient to void, but doing so will not assess if urinary retention is occurring. Although it is good to monitor kidney function after surgery, such lab values will not specifically show urinary retention.)

Before teaching a patient postsurgical exercises, the nurse premedicates the patient for pain. What benefit does this have specific to the patient's learning? A. Reduced pain B. Improved focus C. Decreased relaxation D. Decreased irritability

B. Improved focus (Rationale: When pain is controlled, the patient is better able to concentrate. Although reduced pain is a desired outcome, this answer fails to address a specific effect on patient learning. To decrease relaxation would mean that the patient would be less relaxed and, with pain relief, the patient would be more relaxed. This option is also unrelated to a patient's learning. Although reduced pain may make the patient less irritable, this outcome is not directly related to learning.)

Which patient outcome best reflects adequate management for pain originally rated as 8 out of 10 on a pain scale? A. The patient is observed quietly watching television. B. The patient rates current pain as 4 out of 10. C. The patient tells NAP that he is "not hurting as much." D. The patient is observed sleeping, with a respiratory rate of 20 breaths/min.

B. The patient rates current pain as 4 out of 10. (Rationale: This self-rated improvement is the best sign that pain management is adequate. The patient quietly watching TV is not the most definitive indicator of good pain management. The patient may be using distraction as a way to manage pain. The patient telling the NAP that he is "not hurting as much" is too ambiguous to indicate good pain management. Sleep is not always an indication that a patient is pain free.)

Why might a nurse teach a patient scheduled for surgery how to do postoperative exercises? A. To maximize a sense of well-being B. To minimize postoperative complications C. To identify cultural factors that reflect the patient's perception of pain D. To evaluate the patient's ability to participate in postoperative activities

B. To minimize postoperative complications (Rationale: Teaching postoperative exercises can minimize the patient's risk for injury. Promoting a sense of well-being is not why patients are taught postoperative exercises, although doing so may have that effect. Cultural factors are unrelated to postoperative exercise teaching. There is no link between teaching postoperative exercises and evaluating the patient's ability to participate in postoperative activities.)

Why does the nurse place a patient on bed rest after administering preoperative medication? A. To ensure that the surgical site is not injured B. To protect the patient from injury C. To maintain a calm environment D. To maintain the intravenous infusion

B. To protect the patient from injury (Rationale: A patient is placed on bed rest after receiving preoperative medication to ensure that he or she is not injured in a fall. Bed rest is not specifically required to prevent injury to the surgical site. A patient is not placed on bed rest after receiving preoperative medication in order to maintain a calm environment, although doing so might have that effect. Bed rest is not required in order to maintain an intravenous infusion.)

Which instruction might a nurse give a patient in order to protect a surgical incision when turning in bed? A. Hold your breath when turning. B. Use a pillow to splint the incision. C. Take pain medication 30 minutes before turning. D. Keep both legs straight when turning.

B. Use a pillow to splint the incision. (Rationale: Using a pillow to splint the incision will protect the incision when turning in bed. Holding one's breath when turning in bed is not appropriate technique and will not protect the incision. Taking pain medication before turning in bed will not protect the incision. Keeping both legs straight when turning in bed is not appropriate technique and will not protect the incision.)

During a diabetes mellitus campaign, the community nurse is assessing different clients. Which client should be treated first? A: A1C% 5.6, fasting BG 110, post-prandial BG 150 B: A1C% 6.8, fasting BG 130, post-prandial BG 200 C: A1C% 6.0, fasting BG 120, post-prandial BG 130 D: A1C% 6.1, fasting BG 100, post-prandial BG 140

B: A1C% 6.8, fasting BG 130, post-prandial BG 200 (The client with an A1 C % level of less than 7%, fasting plasma glucose > 126 mg/dL, and 2-hour plasma glucose > 200 mg/dL indicates diabetes mellitus. Client B has increased values for A1 C %, fasting plasma glucose, and 2-hour plasma glucose. Therefore client B should be treated first. Clients A, C, and D have normal values for diabetes mellitus and, therefore, can be treated after client B.)

The nurse is providing education to a client regarding pain control after surgery. What time does the nurse inform the client is the best time to request pain medication? Before the pain becomes severe When the client experiences a pain rating of "10" on a 1-to-10 pain scale When there is no pain, but it is time for the medication to be administered After the pain becomes severe and relaxation techniques have failed

Before the pain becomes severe (If a pain medication is ordered p.r.n., the client should be instructed to ask for the medication before the pain becomes severe.)

The nurse knows the term perioperative phase refers to care given to the client Before, during, and after the operative phase From the start of surgery until its conclusion Immediately before an operative procedure Immediately after the operative phase

Before, during, and after the operative phase (Perioperative nursing includes three distinct phases: preoperative, intraoperative, and postoperative.)

A nurse is caring for a client who has a 20-year history of type 2 diabetes. The nurse should assess for what physiologic changes associated with a long history of diabetes? Blurry, spotty, or hazy vision Arthritic changes in the hands Hyperactive knee and ankle jerk reflexes Dependent pallor of the feet and lower legs

Blurry, spotty, or hazy vision (Blurry, spotty, or hazy vision; floaters or cobwebs in the visual field; and cataracts or complete blindness can occur as a result of diabetes. Diabetic retinopathy is characterized by abnormal growth of new blood vessels in the retina (neovascularization). More than 60% of clients with type 2 diabetes have some degree of retinopathy after 20 years. Arthritic changes of the hands are not a usual complication associated with diabetes mellitus. Clients who are diabetic have peripheral neuropathy, which is characterized by hypoactive, not hyperactive, reflexes. Peripheral vascular disease is indicated by dependent rubor with pallor on elevation, not dependent pallor.)

In conducting a postoperative assessment of a client, what is important for the nurse to examine first? Breathing pattern Level of consciousness Oxygen saturation Surgical site

Breathing pattern (Respiratory assessment is the first and most important.Assessing level of consciousness, oxygen saturation, and the surgical site are important, but not the priority.)

What instruction might the nurse give to nursing assistive personnel (NAP) caring for a postsurgical patient? A. "Assess his urine output, and compare it to intake." B. "Please reassure the family, and explain to them what is going on." C. "Let me know when the patient's family arrives on the floor." D. "Please teach him about the incentive spirometer while I speak with the physician."

C. "Let me know when the patient's family arrives on the floor." (Rationale: The task of notifying the nurse of the family's arrival may be delegated to NAP. The skill of assessment may not be delegated to NAP. Education of a postsurgical patient may not be delegated to NAP. Education may not be delegated to NAP for even a short period of time.)

When a patient is using PCA, which statement is appropriate for the nurse to make to nursing assistive personnel (NAP)? A. "Let me know if the patient has any problems using the PCA pump." B. "Let me know when the patient's vital signs indicate that he has pain." C. "Tell me if the patient is in too much pain to assist with his bath." D. "The patient is confused and will need your help operating the PCA pump."

C. "Tell me if the patient is in too much pain to assist with his bath." (Rationale: NAP may assist with the bath and should report to the nurse if the patient is in too much pain to help. The responsibility of assessing if the patient has problems using the PCA pump or assessing the patient's vital signs to indicate pain may not be delegated to NAP. Neither NAP nor anyone other than the patient may routinely assume responsibility for a PCA pump.)

What is one step the nurse would take if a patient receiving patient-controlled analgesia (PCA) were difficult to arouse? A. Assess the infusion tubing to make sure it has not become occluded. B. Check the infusion site for infiltration and any symptoms of infection. C. Assess respiration, and then notify the health care provider immediately. D. Check the infusion of maintenance fluid to make sure the correct rate is running.

C. Assess respiration, and then notify the health care provider immediately. (Rationale: If a patient on PCA were difficult to arouse, a possible sign of life-threatening respiratory depression, the nurse would assess respiration (if none, would need to call code) and then notify the health care provider immediately and be prepared to administer an antidote, such as an opioid-reversing agent. The nurse would take other measures as well, such as monitoring the patient's vital signs and administering oxygen if indicated. Assessing the infusion tubing would not help if a patient on PCA were difficult to arouse. Checking the infusion site for infiltration or infection would not help if a patient on PCA were difficult to arouse. Checking the infusion of maintenance fluid would not help if a patient on PCA were difficult to arouse.)

The nurse is concerned that a patient will not be able to turn independently in bed after having surgery. What must the nurse do to help this patient? A. Reinstruct the patient in proper turning techniques. B. Document that the patient refuses to turn independently. C. Communicate that the staff must turn the patient after surgery. D. Restrict turning unless absolutely necessary.

C. Communicate that the staff must turn the patient after surgery. (Rationale: The nurse must let the staff know to turn the patient after surgery. Reinstructing the patient will not improve the patient's ability to turn in bed. Documenting that the patient refuses to turn independently is not accurate. The patient is unable, but not necessarily unwilling, to turn without assistance. Restricting the patient from turning can lead to preventable postoperative complications. This should not be done.)

What is the primary way in which the nurse can lower a patient's risk for postsurgical complications? A. Adequately prepare the patient for discharge from the agency. B. Provide continuity of nursing care throughout the patient's stay at the agency. C. Identify deviations from normal that may interfere with the recovery process. D. Evaluate the patient's emotional reaction to the surgical process.

C. Identify deviations from normal that may interfere with the recovery process. (Rationale: Deviations from normal, such as vital signs that fall outside the expected range, may affect the success of the patient's recovery. Adequate preparation for discharge is appropriate, but it is not the primary way in which the nurse can lower a patient's postsurgical risk. Continuity of care is appropriate, but it is not the primary way in which the nurse can lower a patient's postsurgical risk. Evaluating the patient's emotional reaction to the surgical process does not minimize the patient's postsurgical risk.)

A patient scheduled for same-day surgery tells the nurse that he had a "few sips" of coffee while driving to the hospital. What would the nurse do first with this information? A. Document that the patient had coffee B. Notify the operating room C. Notify the surgeon D. Inform the recovery room nurse

C. Notify the surgeon (Rationale: The nurse would first notify the surgeon that the patient has not complied with NPO instructions. The procedure may need to be rescheduled. Although documentation is important, it would not be the first requirement in this situation. Notifying the operating room that the patient has not complied with NPO instructions may or may not be necessary. The patient has not had surgery yet; therefore the recovery room nurse does not need this information.)

What is the nurse's primary goal for appropriate, effective pain management when considering the patient's risk for injury? A. To minimize the potential for analgesic-induced dependency B. To evaluate the effect of pain on the patient's ability to provide self-care C. To maximize pain relief while maintaining the patient's ability to function D. To identify the patient's need for both physical and emotional pain relief

C. To maximize pain relief while maintaining the patient's ability to function (Rationale: Maintaining patient function is the nurse's primary goal because it directly affects the patient's risk for injury. Minimizing the potential for analgesic-induced dependency will not reduce the patient's risk for injury. Evaluating the effect of pain on the patient's ability to provide self-care will not reduce the patient's risk for injury. Identifying the patient's need for both physical and emotional pain relief will not reduce the patient's risk for injury.)

The telemetry unit nurse is reviewing laboratory results for a client who is scheduled for an operative procedure later in the day. The nurse notes on the laboratory report that the client has a serum potassium level of 6.5 mEq/L, indicative of hyperkalemia. The nurse informs the physician of this laboratory result because the nurse recognizes hyperkalemia increases the client's operative risk for which of the following? Cardiac problems Infection Bleeding and anemia Fluid imbalances

Cardiac problems (Hyperkalemia or hypokalemia increases the client's risk for cardiac problems. A decrease in the hematocrit and hemoglobin level may indicate the presence of anemia or bleeding. An elevated white blood cell count occurs in the presence of infection. Abnormal urine constituents may indicate infection or fluid imbalances.)

A client newly diagnosed with diabetes is not ready to learn diabetes control during the hospital stay. Which information is the priority for the nurse to teach the client and the client's family? Select all that apply. Pathophysiology of diabetes Causes and treatment of hypoglycemia Dietary control of blood glucose Insulin administration Physical activity and exercise

Causes and treatment of hypoglycemia Insulin administration (The priority information the nurse needs to teach the client and family about diabetes are the causes and treatment of hypoglycemia and proper insulin administration. This information is essential for the client's survival and must be understood by both the client and family to ensure client safety.The pathophysiology of diabetes and hyperglycemia is a topic for secondary teaching and is not a survival need or the priority during hospitalization. Dietary control and exercise regimen are important, but are not the priority during the acute care stay.)

A client with type 1 diabetes arrives in the emergency department breathing deeply and stating, "I can't catch my breath." The client's vital signs are: T 98.4°F (36.9°C), P 112 beats/min, R 38 breaths/min, BP 91/54 mm Hg, and O2 saturation 99% on room air. Which action will the nurse take first? Check the blood glucose. Administer oxygen. Offer reassurance. Attach a cardiac monitor.

Check the blood glucose. (The nurse would first obtain the client's glucose level. Breathing deeply and stating, "I can't catch my breath" is indicative of Kussmaul respirations which is a sign of diabetic ketoacidosis.Based on the oxygen saturation, oxygen administration is not indicated. The nurse provides support, but it is early in the course of assessment and intervention to offer reassurance without more information. Cardiac monitoring may be implemented, but the first action would be to obtain the glucose level.)

Which staff member will be best for the nurse manager to assign to update standard nursing care plans and policies for care of the client in the operating room (OR)? Surgical technologist with 10 years of experience in the OR at this hospital Certified registered nurse first assistant (CRNFA) who has worked for 5 years in the ORs of multiple hospitals Holding room RN who has worked in the hospital holding room for longer than 15 years Circulating RN who has been employed in the hospital OR for 7 years

Circulating RN who has been employed in the hospital OR for 7 years (The circulating RN is the best staff member for the nurse manager to assign. This nurse has the experience and background to write OR policy, has been employed in the hospital for 7 years, and is aware of hospital policy and procedures.A surgical technologist does not have the background to write policy for nurses. A CRNFA has worked in multiple hospitals but does not have a work history with this specific hospital to be aware of the unit policy. A holding room or preoperative or postoperative care nurse would not be the choice to write OR policy.)

During surgery, who is most responsible for monitoring for possible breaks in sterile technique? Circulating nurse Holding nurse Anesthesiologist Surgeon

Circulating nurse (All operating room team members are responsible, but the circulating nurse moves around the room and can see more of what is happening.The holding nurse is not in the operating room. The anesthesiologist is focused on providing sedation to the client. The surgeon is concentrating on the surgery and usually cannot monitor all staff.)

Who is the most likely person to administer blood products in an operating suite? Circulating nurse Holding area nurse Scrub nurse Specialty nurse

Circulating nurse (The circulating nurse is the most likely person to administer blood products to a client in the operating suite. Circulating nurses or "circulators" are registered nurses who coordinate, oversee, and are involved in the client's nursing care in the operating room.Holding area nurses manage the client's care before surgery; blood would not yet be needed at this point. Scrub nurses set up the sterile field, drape the client, and hand sterile supplies, sterile equipment, and instruments to the surgeon and the assistant. Specialty nurses may be in charge of a particular type of surgical specialty. They are responsible for nursing care specific to clients who need that type of surgery, such as assessing, maintaining, and recommending equipment, instruments, and supplies.)

A physician has ordered a nurse to administer conscious sedation to a client. Which of the following is possible after administering conscious sedation to a client? Client can respond verbally despite physical immobility. Client can tolerate long therapeutic surgical procedures. Client is relaxed, emotionally comfortable, and conscious. Client's consciousness level can be monitored by equipment.

Client is relaxed, emotionally comfortable, and conscious. (Conscious sedation refers to a state in which the client is sedated in a state of relaxation and emotional comfort, but is not unconscious. The client is free of pain, fear, and anxiety and can tolerate unpleasant diagnostic and short therapeutic surgical procedures, such as an endoscopy or bone marrow aspiration. The client can respond verbally and physically. However, no equipment can replace a nurse's careful observations for monitoring clients.)

The nurse has just taken change-of-shift report on a group of clients on the medical-surgical unit. Which client does the nurse assess first? Client taking repaglinide (Prandin) who has nausea and back pain Client taking glyburide (Diabeta) who is dizzy and sweaty Client taking metformin (Glucophage) who has abdominal cramps Client taking pioglitazone (Actos) who has bilateral ankle swelling

Client taking glyburide (Diabeta) who is dizzy and sweaty (The nurse needs to first assess the client taking glyburide (Diabeta) who is dizzy and sweaty and has symptoms consistent with hypoglycemia. Because hypoglycemia is the most serious adverse effect of antidiabetic medications, this client must be assessed as soon as possible.Nausea is a documented side effect of repaglinide. Checking the client's back pain requires assessment, which can be performed after the nurse assesses the client displaying signs and symptoms of hypoglycemia. Metformin may cause abdominal cramping and diarrhea, but the client taking it does not require immediate assessment. Ankle swelling is an expected side effect of pioglitazone.)

The nurse working on a medical surgical endocrine unit has just received change-of-shift report. Which client will the nurse see first? Client with type 1 diabetes whose insulin pump is beeping "occlusion" Newly diagnosed client with type 1 diabetes who is reporting thirst Client with type 2 diabetes who has a blood glucose of 150 mg/dL (8.3 mmol/L) Client with type 2 diabetes with a blood pressure of 150/90 mm Hg

Client with type 1 diabetes whose insulin pump is beeping "occlusion" (The client the nurse sees first is the client with type 1 diabetes whose insulin pump is beeping "occlusion." Because glucose levels will increase quickly in clients whose continuous insulin pumps malfunction, the nurse must assess this client and the insulin pump first to avoid hyperglycemia or diabetic ketoacidosis.Thirst is an expected symptom of hyperglycemia and, although important, is not a priority. The nurse could delegate fingerstick blood glucose to unlicensed assistive personnel while assessing the client whose insulin pump is beeping. Although a blood glucose reading of 150 mg/dL (8.3 mmol/L) is mildly elevated, this does not require immediate action. Mild hypertension does not require immediate action. The nurse can later assess if this is within the client's usual range or represents a change before taking action.)

A nurse is caring for a client who is scheduled to undergo a breast biopsy. Which of the following major tasks does the nurse perform immediately during the pre-operative period? Obtain a signature on the consent form. Review the surgical checklist. Conduct a nursing assessment. Reduce the dosage of toxic drugs.

Conduct a nursing assessment. (During the immediate pre-operative period, the nurse conducts a nursing assessment. Nurses obtain the signature of the client, nearest blood relative, or someone with durable power of attorney before the administration of any pre-operative sedatives. They also administer medications as ordered by the physician regardless of their toxicity. They assist the client with psychosocial preparation and complete the surgical checklist, which is reviewed by the operating room personnel.)

The nurse is providing teaching to a client who recently has been diagnosed with type 1 diabetes. The nurse reinforces the importance of monitoring for ketoacidosis. What are the signs and symptoms of ketoacidosis? Select all that apply. Confusion Hyperactivity Excessive thirst Fruity-scented breath Decreased urinary output

Confusion Excessive thirst Fruity-scented breath (Diabetic ketoacidosis signs and symptoms often develop quickly, sometimes within 24 hours. Diabetic ketoacidosis is a serious complication of diabetes that occurs when the body produces high levels of ketones (blood acids). Diabetic ketoacidosis develops when the body is unable to produce enough insulin. Without enough insulin, the body begins to break down fat as an alternative fuel. This process produces a buildup of ketones (toxic acids) in the bloodstream, eventually leading to diabetic ketoacidosis if untreated. Signs and symptoms include excessive thirst, frequent urination, nausea and vomiting, abdominal pain, weakness or fatigue, shortness of breath, fruity-scented breath, and confusion. Frequent urination, not decreased urination, is a symptom. Weakness or fatigue, not hyperactivity, is a symptom.)

When assessing a patient for adverse effects related to morphine sulfate (MS Contin), which clinical findings is the nurse MOST likely to find? (Select all that apply.) Weight gain Excessive bruising Constipation Inability to void Diarrhea

Constipation Inability to void (Morphine sulfate causes a decrease in GI motility (delayed gastric emptying and slowed peristalsis). This leads to constipation, not diarrhea. Morphine can also cause urinary retention (inability to void).)

Vicodin (acetaminophen/hydrocodone) is prescribed for a patient who has had surgery. The nurse informs the patient that which common adverse effects can occur with this medication? (Select all that apply.) Diarrhea Constipation Lightheadedness Nervousness Urinary retention Itching

Constipation Lightheadedness Urinary retention Itching (Constipation (not diarrhea), lightheadedness (not nervousness), urinary retention, and itching are some of the common adverse effects that the patient may experience while taking Vicodin.)

A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group? Constriction of the superficial vessels dilates the deep vessels. Constriction of the peripheral vessels increases the force of flow. Dilation of the superficial vessels causes constriction of collateral circulation. Dilation of the peripheral vessels causes reflex constriction of visceral vessels.

Constriction of the peripheral vessels increases the force of flow. (Constriction of the peripheral blood vessels and the resulting increase in blood pressure impairs circulation and limits the amount of oxygen being delivered to body cells, particularly in the extremities. Nicotine constricts all peripheral vessels, not just superficial ones. Its primary action is vasoconstriction; it will not dilate deep vessels. Nicotine constricts rather than dilates peripheral vessels.)

As the nurse obtains informed consent, the client asks, "Now what exactly are they going to do to me?" What is the nurse's response? Contact the anesthesiologist. Contact the surgeon. Explain the procedure. Have the client sign the form.

Contact the surgeon. (The nurse will contact the surgeon to convey the client's question. The nurse is not responsible for explaining or providing detailed information about the surgical procedure. Rather, the nurse's role is to clarify facts that have been presented by the health care provider and dispel myths that the client or family may have heard about the surgical experience.The anesthesiologist is responsible for the anesthesia, not the surgical details. Although the nurse is only witnessing the signature, it is the nurse's role to ensure that the facts are clarified before the consent form is signed.)

A patient with a diagnosis of pneumonia asks the nurse, "Why am I receiving codeine when I have no pain?" The nurse's response is based on knowledge that codeine also has what effect? Bronchodilation Increases sputum production Expectorant Cough suppressant

Cough suppressant (Codeine provides both analgesic and antitussive (cough suppressant) therapeutic effects.)

Which action does the nurse implement for a client with wound evisceration? Apply direct pressure to the wound. Cover the wound with a sterile, warm, moist dressing. Irrigate the wound with warm, sterile saline. Replace tissue protruding into the opening.

Cover the wound with a sterile, warm, moist dressing. (Covering the wound with a sterile, warm, moist dressing protects the organs until the surgeon can repair the wound. Evisceration occurs when a wound opens up and body organs are exposed.Applying direct pressure to a wound traumatizes the organs. Irrigating the wound is not necessary. Replacing protruding tissue could induce infection.)

Which electrolyte laboratory result does the nurse report immediately to the anesthesiologist? Creatinine, 1.9 mg/dL (168 mcmol/L) Fasting glucose, 80 mg/dL (4.4 mmol/L) Potassium, 3.9 mEq/L (3.9 mmol/L) Sodium, 140 mEq/L (140 mmol/L)

Creatinine, 1.9 mg/dL (168 mcmol/L) (The nurse will immediately report a creatinine of 1.9 mg/dL (168 mcmol/L) to the anesthesiologist. A creatinine of 1.9 mg/dL (168 mcmol/L) is outside the normal range and may indicate renal problems.A fasting glucose of 80 mg/dL (4.4 mmol/L), a potassium level of 3.9 mEq/L (3.9 mmol/L), and sodium level of 140 mEq/L (140 mmol/L) are normal laboratory values.)

When reviewing ordered pain medicine for a postoperative patient whose pain is not currently controlled, which nursing action has priority? A. Asking the family member if the patient seems in pain B. Reviewing the surgeon's preoperative pain medication order C. Examining the patient's medical record for analgesics used with previous surgeries D. Asking the postanesthesia care unit (PACU) nurse when the patient last received pain medication

D. Asking the postanesthesia care unit (PACU) nurse when the patient last received pain medication (Rationale: Asking the PACU nurse when the patient received his last dose of analgesic is the priority action because it establishes when the patient can safely be given more pain medication. The nurse would ask the patient for pain level. The nurse would not need to review the surgeon's preoperative pain medication order before administering the pain medication; looking at the postoperative order would be appropriate. The priority is on the current situation and orders.)

After the nurse provides a patient with preoperative medication, the patient needs to void. What would the nurse do? A. Walk the patient to the bathroom. B. Insert an indwelling urinary catheter. C. Insert an intermittent urinary catheter. D. Provide the patient with a bedpan.

D. Provide the patient with a bedpan. (Rationale: A bedpan both allows the patient to remain in bed and provides the patient with a way to void after receiving preoperative medication. After receiving preoperative medication, the patient must remain in bed. Although the patient must remain in bed, he or she does not need an indwelling urinary catheter. The patient does not need to have an intermittent urinary catheter to void, even though he or she must remain in bed after receiving preoperative medication.)

What might the nurse do to accommodate a patient's request to wear a wedding ring during surgery? A. Explain that the ring may be lost during surgery B. Suggest that the ring be placed in the top drawer of the bedside stand C. Recommend that family take the ring home D. Tape the ring to the patient's finger

D. Tape the ring to the patient's finger (Rationale: Taping the ring securely to the patient's finger keeps it from coming off during surgery and complies with the patient's wishes. The patient does not want to take the ring off, so explaining that the ring could be lost during surgery fails to address the patient's request. Valuables left in the room can be stolen. In addition, suggesting that the ring be placed in the top drawer of the bedside stand fails to address the patient's request. While recommending that the family take the ring home is often a good solution for valuables, this suggestion fails to address the patient's request.)

The nurse is performing an admission assessment on a 52-year-old client admitted with type 2 diabetes. -------------------------------- • Lungs clear • Glucose 179 mg/dL (9.9 mmol/L) • Regular insulin 8 units if blood glucose 250 to 275 mg/dL (13.9 to 15.3 mmol/L) • Right great toe mottled and cold to touch • Hemoglobin A1c 6.9% • Regular insulin 10 units if glucose 275 to 300 mg/dL (15.3 to 16.7 mmol/L) • Client states wears eyeglasses to read -------------------------------- After completing the above assessment, which complication of diabetes does the nurse report to the primary health care provider? Poor glucose control Visual changes Respiratory distress Decreased peripheral perfusion

Decreased peripheral perfusion (A cold, mottled right great toe may indicate arterial occlusion secondary to arterial occlusive disease or embolization. This must be reported to the primary health care provider to avoid potential gangrene and amputation.Although one glucose reading is elevated, the hemoglobin A1c indicates successful glucose control over the past 3 months. After the age of 40, reading glasses may be needed due to difficulty in accommodating to close objects. Lungs are clear and no evidence of distress is noted.)

In developing a plan of care for a client receiving an antihistamine antiemetic drug, which nursing diagnosis would be the highest priority? Deficient fluid volume related to nausea and vomiting Impaired physical mobility related to adverse effects of drugs Deficient knowledge regarding medication administration Risk for injury related to adverse effects of medication

Deficient fluid volume related to nausea and vomiting (Although all of the options are appropriate nursing diagnoses, fluid volume deficit is the highest priority because it has the highest associated mortality rate. Although a fall or injury could also prove fatal, this diagnosis is a risk; actual nursing diagnoses have priority over potential diagnoses.)

The nurse is caring for a patient who had abdominal surgery 3 days ago and will be discharged home later today. The nurse will know that teaching is effective if the patient does which of the following? Choose all that apply. Describes clinical findings associated with infection Performs the dressing change as prescribed Demonstrates freedom from surgical incision pain Completes the regimen of prescribed antibiotics

Describes clinical findings associated with infection Performs the dressing change as prescribed Completes the regimen of prescribed antibiotics (The nurse would know that patient teaching was effective if the patient verbalizes signs and symptoms of infection, can perform the ordered dressing change, and completes the regimen of ordered antibiotics. Nurses cannot teach a patient to be free of pain. Pain is subjective. The nurse can teach the patient strategies to assist with pain, but they may not remove the pain completely.)

An RN and an LPN/LVN are working together in caring for a client who needs all of these interventions after orthopedic surgery. Which action(s) would be best for the RN to accomplish? Reinforce the need to cough and deep-breathe every 2 to 4 hours. Develop the discharge teaching plan in conjunction with the client. Administer narcotic pain medications before assisting the client with ambulation. Listen for bowel sounds and monitor the abdomen for distention and pain.

Develop the discharge teaching plan in conjunction with the client. (The best and most appropriate action for the nurse to take is to develop the discharge teaching plan with the client. Education and preparation for discharge are within the scope of practice of the RN, but not within that of the LPN/LVN.Reinforcing the need to cough and deep-breathe and monitoring the client are within the scope of the LPN/LVN nurse. LPN/LVNs can also administer pain medications.)

The nurse completes the preoperative checklist on a client scheduled for general surgery. Which factor contributes the greatest risk for the planned procedure? Age 59 years General anesthesia complications experienced by the client's brother Diet-controlled diabetes mellitus Ten pounds (4.5 kg) over the client's ideal body weight

Diet-controlled diabetes mellitus (The client's greatest risk factor is diabetes mellitus. Diabetes contributes an increased risk for surgery or postsurgical complications.Older adults are at greater risk for surgical procedures, but this client is not classified as an older adult. Family medical history and problems with anesthetics may indicate possible reactions to anesthesia, but this is not the best answer. Obesity increases the risk for poor wound healing, but being 10 pounds (4.5 kg) overweight does not categorize this client as obese.)

When planning administration of antiemetic medications to a client, the nurse is aware that combination therapy is preferred because of which drug effect? It is easier to achieve the desired level of sedation. There are faster drug absorption and distribution. Different vomiting pathways are blocked. The risk of constipation is decreased.

Different vomiting pathways are blocked. (Combining antiemetic drugs from various categories allows the blocking of the vomiting center and chemoreceptor trigger zone (CTZ) through different pathways, thus enhancing the antiemetic effect.)

A client has undergone an 8-hour surgical procedure under general anesthesia. In assessing the client for complications related to positioning, the nurse is most concerned with which finding? Decreased sensation in the lower extremities Diminished peripheral pulses in the lower extremities Pale, cool extremities Reddened areas over bony prominences

Diminished peripheral pulses in the lower extremities (The nurse is most concerned with diminished peripheral pulses in the lower extremities. This could indicate diminished blood flow.Decreased sensation; pale, cool extremities; and reddened areas over bony prominences can be normal occurrences in clients who have undergone a long surgical procedure.)

A client, scheduled for open-heart surgery, tells the nurse he does not want to be "saved" if he dies during surgery. What should the nurse do next? Discuss with and document the wishes of the client and family Administer the ordered oral and intravenous preoperative medications Notify the physician after completion of the surgical procedure Verbally report the client's wishes to the operating room supervisor

Discuss with and document the wishes of the client and family (Advance directives allow the client to specify instructions for health care treatment if unable to communicate these wishes during or after surgery. It is important for the nurse to discuss and document exact do not resuscitate (DNR) wishes of the client and family before surgery.)

A patient is to receive acetylcysteine (Mucomyst) as part of the treatment for an acetaminophen (Tylenol) overdose. Which action by the nurse is appropriate when giving this medication? Giving the medication undiluted for full effect Avoiding the use of a straw when giving this medication Disguising the flavor with soda or flavored water Preparing to give this medication via a nebulizer

Disguising the flavor with soda or flavored water (Acetylcysteine has the flavor of rotten eggs and so is better tolerated if it is diluted and disguised by mixing with a drink such as cola or flavored water to help increase its palatability. The use of a straw helps to minimize contact with the mucous membranes of the mouth and is recommended. The nebulizer form of this medication is used for certain types of pneumonia, not for acetaminophen overdose.)

The nurse is teaching a group of teens about prevention of heart disease. Which point is most important for the nurse to emphasize? Reduce abdominal fat Avoid stress Do not smoke or chew tobacco Avoid alcoholic beverages

Do not smoke or chew tobacco (The most important point for the nurse to emphasize when teaching a group of teens about heart disease prevention is not to smoke or chew tobacco. Tobacco exposure, including secondhand smoke, reduces coronary blood flow, causing vasoconstriction, endothelial dysfunction, and thickening of the vessel walls. Smoking also increases carbon monoxide and decreases oxygen. Because it is highly addicting, beginning smoking in the teen years may lead to decades of exposure.Teens are not likely to experience metabolic syndrome from obesity but are very likely to use tobacco. Avoiding stress is a less modifiable risk factor, which is less likely to cause heart disease in teens. The risk of smoking outweighs the risk of alcohol use.)

A nurse is reviewing results of preoperative screening tests and notes the client's potassium level is dangerously low. What should the nurse do next? Nothing; potassium levels have no influence on surgical outcome. Include the information in the postoperative end of shift report. Document the data and notify the physician who will do the surgery. Ask the client and family members why the potassium is low.

Document the data and notify the physician who will do the surgery. (Either high or low levels of potassium put the surgical client at increased risk for cardiac problems during and after surgery. The nurse's role includes recording the data in the client's record and reporting abnormal findings.)

A diabetic client who is scheduled for vascular surgery is admitted on the day of surgery with several orders. Which order does the nurse accomplish first? Use electric clippers to cut hair at the surgical site. Start an infusion of lactated Ringer's solution at 75 mL/hr. Administer one-half of the client's usual lispro insulin dose. Draw blood for glucose, electrolyte, and complete blood count values.

Draw blood for glucose, electrolyte, and complete blood count values. (The blood sample needs to be drawn and sent to the laboratory first to confirm that results are within normal limits. If blood work is abnormal, the surgery may be rescheduled.Removal of hair can be accomplished in the operating room directly before the start of surgery. The IV infusion can be accomplished after the laboratory orders have been completed. The nurse should check blood glucose with the laboratory orders before administration of lispro.)

The nurse in the endocrine clinic is providing education for a client who has just been diagnosed with diabetes. Which factor is most important for the nurse to assess before providing instruction to the client about the disease and its management? Current lifestyle Educational and literacy level Sexual orientation Current energy level

Educational and literacy level (The most important factor for the nurse to determine before providing instruction to the newly diagnosed client with diabetes is the client's educational level and literacy level. A large amount of information must be synthesized. Written instructions are typically given. The client's ability to learn and read is essential to provide the client with instructions and information about diabetes.Although lifestyle would be taken into account, it is not the priority. Sexual orientation will have no bearing on the ability of the client to provide self-care. Although energy level will influence the ability to exercise, it is not essential.)

A female client is scheduled for liposuction surgery to reduce her weight. Based on urgency, how is this surgery classified? Urgent Elective Emergency Emergent

Elective (A liposuction procedure is classified as elective surgery, in which the procedure is preplanned and based on the client's choice. Other classifications are urgent (surgery is necessary for the client's health but not an emergency) and emergency (the surgery must be done immediately to preserve life, body part, or body function).)

Which of the following interventions is of major importance during preoperative education? Performing skills necessary for gastrointestinal preparation Encouraging the client to identify and verbalize fears Discussing the site and extent of the surgical incision Telling the client not to worry or be afraid of surgery

Encouraging the client to identify and verbalize fears (A surgical procedure causes anxiety and fear. The nurse should encourage the client to identify and verbalize fears; often simply talking about fears helps to diminish their magnitude.)

The focus of nursing care in the intraoperative phase is to: Prepare the patient for surgery. Maintain the sterile field. Ensure patient safety during the surgery. Obtain a signed informed consent.

Ensure patient safety during the surgery. (The intraoperative phase begins when the patient enters the operating suite and ends when the patient is admitted to the postanesthesia care unit. The nursing focus is to ensure patient safety during the surgical procedure by functioning as an advocate when clients cannot advocate for themselves and by monitoring the client and surgical environment throughout the procedure. Although the sterile field must be maintained in this phase, the focus of care is broader than the maintenance of sterility. Obtaining informed consent and preparing the patient for surgery are activities associated with the preoperative phase.)

A client who is preparing to undergo a vaginal hysterectomy is concerned about being exposed. How does the nurse ensure that this client's privacy will be maintained? Remind the client that she will be asleep. Ensure that drapes will minimize perianal exposure. Explain postoperative expectations. Restrict the number of technicians in the procedure.

Ensure that drapes will minimize perianal exposure. (Using drapes is the best action to take to ensure the client's privacy.Telling the client that she will be asleep or explaining the procedure will not alleviate the client's anxiety. The number of people involved in the procedure is not something the nurse can necessarily control.)

An unidentified client from the emergency department requires immediate surgery, but he is not conscious and no one is with him. What must the nurse, who is verifying the informed consent, do? Ensure written consultation of two noninvolved physicians. Read the surgeon's consult to determine whether the client's condition is life-threatening. Sign the operative permit. Withhold surgery until the next of kin is notified.

Ensure written consultation of two noninvolved physicians. (In a life-threatening situation in which every effort has been made to contact the person with medical power of attorney, consent is desired but not essential. In place of written or oral consent, written consultation by at least two physicians who are not associated with the case may be requested by the health care provider.It is not within the nurse's role to make a judgment about the client's life-threatening status based on the surgeon's consult. Signing documents on the client's behalf is not legal. Withholding surgery is not in this client's best interests.)

The nurse teaches a patient prescribed the fentanyl (Duragesic) transdermal delivery system to change the patch at what interval? When pain recurs Every 72 hours Once a week Every 24 hours

Every 72 hours (The fentanyl transdermal delivery system is designed to slowly release analgesic over a 72-hour time frame.)

The preoperative patient has called the nurse about his upcoming surgical procedure, which will be six weeks from now. He is concerned about receiving blood after surgery for fear of acquiring a bloodborne disease. Which of the following might the nurse do? Instruct the patient to notify the physician. Remind the patient that blood is tested prior to administration, making it safe and free of disease. Ask the patient if he has ever had any blood products. Explain to the patient the use of autologous blood donation. Instruct patient to refuse transfusion.

Explain to the patient the use of autologous blood donation. (Because of the fears of hepatitis B and human immunodeficiency virus infection associated with blood transfusion, donation of autologous blood (one's own blood) for surgery is becoming a common practice. If the patient wishes, provide the necessary information about blood donation if the patient is seen a number of weeks before surgery.)

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? Postural drainage Cupping the chest Nasotracheal suctioning Frequent changes of position

Frequent changes of position (Frequent changes of position minimize pooling of respiratory secretions and maximize chest expansion, which aids in the removal of secretions; this helps maintain the airway and is an independent nursing function. Postural drainage and cupping the chest are part of pulmonary therapy that requires a healthcare provider's prescription. Nasotracheal suctioning will remove secretions once they accumulate in the upper airway, but will not prevent their accumulation.)

The patient tells the nurse, "I'm so nervous. I want to be knocked out for the surgery so that I don't know what is going on." When the nurse communicates with the surgeon and anesthetist, she tells them that the patient desires which type of anesthesia? Conscious sedation General anesthesia Local anesthesia Regional anesthesia

General anesthesia (General anesthesia produces rapid unconsciousness and loss of sensation. During conscious sedation, the client feels sleepy but is easily aroused by touch or speech. Regional anesthesia interrupts nerve impulses to and from the affected area, but the patient remains alert. Local anesthesia produces loss of pain sensation at the desired site and is typically used for minor procedures. The client remains alert during local anesthesia.)

At 8:00 a.m., the registered nurse is admitting a client scheduled for sinus surgery to the outpatient surgery department. Which information given by the client is of most immediate concern to the nurse? An allergy to iodine and shellfish Being nauseated after a previous surgery Having a small glass of juice at 7:00 a.m. Expressing anxiety about the surgery

Having a small glass of juice at 7:00 a.m. (Clients need to be NPO for a sufficient length of time before surgery to prevent aspiration of fluid into the lungs. Intake of food or fluids may delay the start time of the surgery, so the nurse must notify the surgeon and anesthesiologist for possible rescheduling.The nurse would confirm that all allergies are charted, and that the client has the correct allergy band identification. Many clients experience nausea after surgery; the nurse would document this in the client's information as well. The nurse would talk with the client and explore the anxiety; this is a normal feeling before surgery.)

A client has been taking aspirin since his heart attack in 1997. The client is at risk for Infection Thrombophlebitis Hemorrhage Blood clots

Hemorrhage (Current medication use, especially use of medications that can affect coagulation status (warfarin, nonsteroidal anti-inflammatory drugs, aspirin) is important and should be reported to the surgeon.)

A 38-year-old man has come into the urgent care center with severe hip pain after falling from a ladder at work. He says he has taken several pain pills over the past few hours but cannot remember how many he has taken. He hands the nurse an empty bottle of acetaminophen (Tylenol). The nurse is aware that the most serious toxic effect of acute acetaminophen overdose is which condition? Tachycardia Central nervous system depression Hepatic necrosis Nephropathy

Hepatic necrosis (Hepatic necrosis is the most serious acute toxic effect of an acute overdose of acetaminophen. The other options are incorrect.)

A patient is recovering from abdominal surgery, which he had this morning. He is groggy but complaining of severe pain around his incision. What is the most important assessment data to consider before the nurse administers a dose of morphine sulfate to the patient? His pulse rate His respiratory rate The appearance of the incision The date of his last bowel movement

His respiratory rate (One of the most serious adverse effects of opioids is respiratory depression. The nurse must assess the patient's respiratory rate before administering an opioid. The other options are incorrect.)

A surgical client has signed do-not-resuscitate (DNR) orders before going to the operating room (OR). A complication requiring resuscitation occurs during surgery. What is the nurse's proper action? Call the legal department. Call the client's primary health care provider. Honor the DNR order. Resuscitate per OR procedure.

Honor the DNR order. (According to the Association of Perioperative Registered Nurses, suspending a DNR order during surgery violates a client's right to self-determination.Calling the legal department or the client's health care provider is not an appropriate response. Resuscitating this client after a DNR has been signed is inappropriate.)

A patient will be discharged with a 1-week supply of an opioid analgesic for pain management after abdominal surgery. The nurse will include which information in the teaching plan? How to prevent dehydration due to diarrhea The importance of taking the drug only when the pain becomes severe How to prevent constipation The importance of taking the drug on an empty stomach

How to prevent constipation (Gastrointestinal (GI) adverse effects, such as nausea, vomiting, and constipation, are the most common adverse effects associated with opioid analgesics. Physical dependence usually occurs in patients undergoing long-term treatment. Diarrhea is not an effect of opioid analgesics. Taking the dose with food may help minimize GI upset.)

Which statement accurately represents a recommended guideline when providing postoperative care for the following clients? Force fluids for an adult client who has a urine output of less that 30 mL per hour. If client is febrile within 12 hours of surgery, notify the physician immediately. If the dressing was clean but now has a large amount of fresh blood, remove the dressing and reapply it. If vital signs are progressively increasing or decreasing from baseline, notify the physician of possible internal bleeding.

If vital signs are progressively increasing or decreasing from baseline, notify the physician of possible internal bleeding. (A continued decrease in blood pressure or an increase in heart rate could indicate internal bleeding, and the physician should be notified. If an adult client has a urine output of less than 30 mL per hour, the physician should be notified, unless this is expected. If the client is febrile within 12 hours of surgery, the nurse should assist the client with coughing and deep-breathing exercises. When large amounts of fresh blood are present, the dressing should be reinforced with more bandages and the physician notified.)

Which of the following clients will see the greatest permanent changes in lifestyle following surgery? Right total knee replacement Left mastectomy Ileostomy Appendectomy

Ileostomy (Permanent changes in the client's activity level may occur as a result of surgery. The client with an ileostomy will encounter the greatest changes in lifestyle.)

The nurse anesthetist notices that a surgical client has an unexpected rise in the end-tidal carbon dioxide level, with a decrease in oxygen saturation and sinus tachycardia. What is the nurse anesthetist's initial action? Administer cardiopulmonary resuscitation. Continue as normal. Immediately stop all inhalation anesthetic agents and succinylcholine. Inform the surgeon.

Immediately stop all inhalation anesthetic agents and succinylcholine. (The nurse anesthetist's initial action is to stop all inhalation anesthetic agents and succinylcholine. This client is exhibiting early symptoms of malignant hyperthermia (MH). The most sensitive indication of MH is an unexpected rise in the end-tidal carbon dioxide level, along with a decrease in oxygen saturation. Another early indication is sinus tachycardia. Survival depends on early diagnosis and the actions of the entire surgical team. Time is crucial when MH is diagnosed, and MH requires immediate intervention.This client does not require resuscitation. Continuing as normal is inappropriate. Informing the surgeon is not the priority.)

In developing a plan of care for a patient receiving morphine sulfate (MS Contin), which nursing diagnosis has the highest priority? Constipation related to decreased GI motility Acute pain related to metastatic tumor cancer Impaired gas exchange related to respiratory depression Risk for injury related to CNS adverse effects

Impaired gas exchange related to respiratory depression (Using Maslow's hierarchy of needs and the ABCs of prioritization, impaired gas exchange is a priority over pain, constipation, and a risk for injury. If a patient cannot oxygenate sufficiently, all of the other problems will not matter because the patient will not live to worry about them.)

A client with diabetes who is receiving long-term corticosteroid therapy is admitted to the hospital with leg ulcers. What increased risk does the nurse consider when assessing this client? Weight loss Hypoglycemia Decreased blood pressure Inadequate wound healing

Inadequate wound healing (Because the antiinflammatory response is depressed as a result of increased cortisol levels, the wounds of clients receiving long-term corticosteroid therapy tend to heal slowly. A common finding associated with long-term corticosteroid use is weight gain, caused not only by fluid retention but also by alterations in fat, carbohydrate, and protein metabolism. Persistent hyperglycemia (steroid diabetes) occurs because of altered glucose metabolism. Hypertension, not hypotension, occurs as a result of sodium and fluid retention.)

A 2-year-old child is scheduled for a tonsillectomy. When determining the plan of care, the nurse should: Include the parents or caregivers in the plan of care. Explain to the child that she will have a sore throat after surgery. Tell the child that she can have her favorite foods for the first 24 hours after surgery. Prepare the child for discharge from the hospital as soon as she is alert.

Include the parents or caregivers in the plan of care. (It is developmentally normal for toddlers to experience anxiety with separation from parents or caregivers. Be sure to include these people in the plan of care. Developmentally, a 2-year-old lives in the "here and now" and wouldn't grasp an intangible concept, such as pain in the future. The toddler would take liquids and soft foods within the first 24 hours when her throat is sore during swallowing. She should not eat foods that are rough and crunchy because they may scratch her throat and cause bleeding. After a tonsillectomy, the child will need to be monitored for bleeding and stable vital signs; therefore, she will not be discharged as soon as she is alert.)

A patient is prescribed an opioid analgesic for chronic pain. Which information should the nurse discuss with the patient to minimize the GI adverse effects? Avoid eating foods high in lactobacilli. Increase fluid intake and fiber in the diet. Take diphenoxylate-atropine (Lomotil) with each dose. Take the medication on an empty stomach.

Increase fluid intake and fiber in the diet. (Opioid analgesics decrease GI intestinal motility (peristalsis), leading to constipation. Increasing fluid and fiber in the diet or use of stool softener or mild laxative can prevent constipation.)

Which characteristics place women at high risk for myocardial infarction (MI)? Select all that apply. Premenopausal Increasing age Family history Abdominal obesity Breast cancer

Increasing age Family history Abdominal obesity (Increasing age is a risk factor, especially after 70 years. Family history is a significant risk factor in both men and women. Also, a large waist size and/or abdominal obesity are risk factors for both metabolic syndrome and MI.Premenopausal women are not at higher risk for MI, and breast cancer is not a risk factor for MI.)

The preoperative nurse is preparing a patient for surgery. Identify the interventions the nurse will perform. Choose all that apply. Inform the family to wait in the surgical waiting room. Prepare the surgical suite for the operation. Remove the patient's dentures and contact lenses. Assist the patient to complete a living will.

Inform the family to wait in the surgical waiting room. Remove the patient's dentures and contact lenses. (Before being transported to the operating suite, the patient must remove all artificial body parts, such as dentures, artificial limbs, or contact lenses. Wigs, eyeglasses, makeup, and jewelry must also be removed. The nurse will also inform the patient's relatives where they may wait during the surgery. The surgical suite will be prepared by the surgical team. It is not necessary to have a living will prior to surgery. However, the nurse will ask the patient if there is one when obtaining the nursing history.)

The nurse is preparing to send a client to the operating room for an exploratory laparoscopy. The nurse recognizes that there is no informed consent for the procedure on the client's chart. The nurse informs the physician who is performing the procedure. The physician asks the nurse to obtain the informed consent signature from the client. What is the nurse's best action to the physician's request? Inform the physician that it is his or her responsibility to obtain the signature. Obtain the signature and ask another nurse to cosign the signature. Inform the physician that the nurse manager will need to obtain the signature. Call the house officer to obtain the signature.

Inform the physician that it is his or her responsibility to obtain the signature. (The responsibility for securing informed consent from the client lies with the person who will perform the procedure. The nurse's best action is to inform the physician that it is his or her responsibility to obtain the signature.)

A patient is admitted from a local skilled nursing facility to the outpatient surgery center for surgical débridement of a stage IV sacral pressure ulcer. The perioperative nurse discovers that the patient does not have a signed consent form for the surgery on the chart or in the surgery center. The patient says that she has not talked to the surgeon and that she has many questions regarding her surgery. When informed of this, the surgeon tells the nurse to have the patient sign the informed consent form, and he will review it prior to the surgery. What should the nurse do? Follow the surgeon's orders, and ask the patient to sign the surgical consent form. Inform the surgeon that she will have the patient sign after he discusses the surgery with the patient. Ensure that the signed surgical consent is witnessed by two nurses, because the surgeon is not available. Cancel the surgery and transfer the patient back to the long-term care facility.

Inform the surgeon that she will have the patient sign after he discusses the surgery with the patient. (Informed surgical consent requires that the surgeon present information about the surgery to the patient, that the patient understands the information and agrees to the surgery, and that the patient has not been coerced to give consent. As a patient advocate, the nurse should verify with the patient that the surgeon has explained the procedure and answered all her questions. The surgeon is responsible for giving the patient the necessary information and determining the patient's competence to make an informed decision about the surgery. If the patient has further questions, the nurse should notify the surgeon and delay sending the patient to surgery until an informed consent is obtained.)

After emergency surgery, the nurse teaches a client how to use an incentive spirometer. What client behavior indicates to the nurse that the spirometer is being used correctly? Inhales deeply through the mouthpiece, relaxes, and then exhales. Inhales deeply, seals the lips around the mouthpiece, and exhales. Uses the incentive spirometer for 10 consecutive breaths per hour. Coughs several times before inhaling deeply through the mouthpiece.

Inhales deeply through the mouthpiece, relaxes, and then exhales. (Inhaling deeply through the mouthpiece, relaxing, and then exhaling are correct techniques; deep inhalation promotes alveolar expansion, and exhalation promotes lung recoil. Inhaling deeply, sealing the lips around the mouthpiece, and exhaling are incorrect techniques; inhalation should occur through the mouthpiece. The breaths should not be taken in succession; they should be spaced by several normal breaths to avoid fatigue. Coughing is done after deep breathing.)

Which task would be best for the charge nurse to assign to the LPN/LVN working in the surgery admitting area? Provide preoperative teaching to a client who needs insertion of a tunneled central venous catheter. Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer. Obtain the medical history from a client who is scheduled for a total hip replacement. Assess the client who is being admitted for an elective laparoscopic cholecystectomy.

Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer. (Insertion of a catheter is the best task within the scope of skills approved for the LPN/LVN.Preoperative teaching and physical assessment of a preoperative client are under the scope of the RN. History information would be completed by the RN on the unit.)

The health care provider prescribes one tube of glucose gel for the client with type 1 diabetes. The nurse recognizes that this is for treatment of which diabetes complication? Diabetic acidosis Hyperinsulin secretion Insulin-induced hypoglycemia Idiosyncratic reactions to insulin

Insulin-induced hypoglycemia (Glucose gel delivers a measured amount of simple sugars to provide glucose to the blood for rapid action. Acidosis occurs when there is an increased serum glucose level; therefore glucose gel is not indicated. Diabetes mellitus involves a decreased insulin production. Glucose gel is not indicated in idiosyncratic reactions to insulin.)

What pain management does a client who has been admitted to the post-anesthesia care unit typically receive? Intramuscular nonopioid analgesics Intramuscular opioid analgesics Intravenous nonopioid analgesics Intravenous opioid analgesics

Intravenous opioid analgesics (Intravenous (IV) opioid analgesics are given in small doses to provide pain relief, but not to mask an anesthetic reaction.Intramuscular nonopioid analgesics and opioid analgesics are too long-acting. IV nonopioid analgesics usually are not given within the first 48 hours after surgery.)

A patient is scheduled for abdominal surgery tomorrow. While gathering preoperative data, the nurse learns that the patient takes the following medications daily: an anticoagulant, a multivitamin, and vitamin E 1,500 IU. The patient reports that he stopped taking the anticoagulant 4 days ago as instructed by the surgeon. He has continued to take the multivitamin and vitamin E. Based on the information given, the nurse telephones the surgeon because she: Needs an order to restart the anticoagulant. Is concerned about continued use of the multivitamin. Is concerned about the vitamin E dosage. Thinks the surgery should be delayed until further notice.

Is concerned about the vitamin E dosage. (Both prescribed and over-the-counter medications may increase surgical risk. Many herbs can cause potassium loss and increase the risk for cardiac arrhythmias. High doses of vitamin E may increase the risk for bleeding. This patient's use of 1,500 IU of vitamin E daily exceeds the recommended dosage, so the nurse should inform the surgeon of the vitamin E intake. Generally, the surgeon or anesthesiologist instructs patients to continue or discontinue taking their prescribed medicines. However, it is important to assess use of supplements and over-the-counter medicines. The surgeon would determine if the surgery should be delayed.)

A nurse is assisting a physician during a cesarean section for a client. The client is administered epidural anesthesia. Which of the following is an advantage of epidural anesthesia? It counteracts the effects of conscious sedation. It decreases the risk of gastrointestinal complications. It prevents clients from remembering the initial recovery period. It acts on the central nervous system to produce loss of sensation.

It decreases the risk of gastrointestinal complications. (Epidural anesthesia is a regional anesthesia administered to a client before surgery; it decreases the risk of gastrointestinal complications in clients. Reversal drugs are medications that counteract the effects of those used for conscious sedation. General anesthesia acts on the central nervous system to produce loss of sensation; it prevents clients from remembering their initial recovery period.)

A student is assessing a postoperative client who has developed pneumonia. The plan of care includes positioning the client in the Fowler's or semi-Fowler's position. What is the rationale for this position? It increases blood flow to the heart. The client will be more comfortable and have less pain. It facilitates nursing assessments of skin color and temperature. It promotes full aeration of the lungs.

It promotes full aeration of the lungs. (Pneumonia may occur in the postoperative client from aspiration, immobilization, depressed cough reflex, infection, increased secretions from anesthesia, or dehydration. Nursing interventions include positioning the client in the Fowler or semi-Fowler position to promote full aeration of the lungs.)

The nurse recognizes that metoclopramide (Reglan) is useful in treating postoperative nausea and vomiting because of what action? It inhibits chemoreceptor stimulation. It promotes motility in the small intestine. It improves the body's response to analgesia. It decreases peristalsis in the intestinal wall.

It promotes motility in the small intestine. (Metoclopramide works by increasing gastrointestinal (GI) motility in the small intestine, thus minimizing gastric distention and accompanying stimulation of the vomiting center.)

Which of the following surgical clients will return to activities in their everyday lives more quickly? Vaginal hysterectomy Laparoscopic cholecystectomy Right nephrectomy Open-heart surgery

Laparoscopic cholecystectomy (Clients who have surgery using a laparoscope are able to return to previous activity levels much sooner.)

Upon assessment, a client reports that he drinks five to six bottles of beer every evening after work. Based upon this information, the nurse is aware that the client may require which of the following? Larger doses of anesthetic agents and larger doses of postoperative analgesics Larger doses of anesthetic agents and lower doses of postoperative analgesics Lower doses of anesthetic agents and lower doses of postoperative analgesics Lower doses of anesthetic agents and larger doses of postoperative analgesics

Larger doses of anesthetic agents and larger doses of postoperative analgesics (Clients with a large habitual intake of alcohol require larger doses of anesthetic agents and postoperative analgesics, increasing the risk for drug-related complications.)

An operating room nurse is preparing for a surgical procedure on an infant. The nurse's perioperative care is based on what physiologic factor that puts infants at greater risk from surgery than adults? Increased vascular rigidity Diminished chest expansion Lower total blood volume Decreased peripheral circulation

Lower total blood volume (Infants are at a greater risk from surgery as a result of various physiologic factors. A major factor is that the infant has a lower total blood volume, making even a small loss of blood a serious consideration because of the risk for dehydration and the inability to respond to the need for increased oxygen during surgery.)

Which of the following nursing actions provides the greatest assistance in healing? Maintaining a restful environment Providing solid food in the first day Allowing family members to visit often Keeping the client recumbent

Maintaining a restful environment (The nurse should plan for adequate periods of rest and sleep, maintaining a quiet, restful environment.)

The nurse-anesthetist is monitoring his client during surgery. He notices a ventricular dysrhythmia and unstable blood pressure. He notifies the surgeon. The operative team suspects Myocardial infarction Malignant hyperthermia Mitral valve prolapse Major blood loss

Malignant hyperthermia (The symptoms of malignant hyperthermia are masseter muscle rigidity, ventricular dysrhythmia, tachypnea, cyanosis, skin mottling, and unstable blood pressure.)

The nurse is providing preoperative care for a client who will have an arthroscopy of the left knee. As part of the Joint Commission National Patient Safety Goals (NPSG), what will the nurse be required to do? Ensure that the correct procedure is noted in the client's history. Remind the surgeon that the client will have a left knee arthroscopy. Verify with the client that a left knee arthroscopy will be performed. Mark the left knee site with the client awake and the surgeon present.

Mark the left knee site with the client awake and the surgeon present. (The nurse will be required to mark the left knee site with the client awake and the surgeon present. The Joint Commission NSPG requires that the surgical site be marked by an independent licensed professional and should, when possible, involve the client. The surgeon is accountable and should be present.The EMR should identify the correct procedure, but is not a specific JCAHO requirement. The nurse will verify the procedure with the client when possible, but this is not a requirement. Communication with the surgeon is ideal, but is not specifically required.)

The nurse is caring for a patient with opioid addiction. The nurse anticipates that the patient will be prescribed which medication? Meperidine (Demerol) Naloxone (Narcan) Methadone (Dolophine) Morphine (MS Contin)

Methadone (Dolophine) (Methadone is a synthetic opioid analgesic with gentler withdrawal symptoms and is the drug of choice for detoxification treatment.)

After conducting a preoperative health assessment, the nurse documents that the client has physical assessments supporting the medical diagnosis of emphysema. Based on this finding, what postoperative interventions would be included on the plan of care? Perform sterile dressing changes each morning. Administer pain medications as needed. Conduct a head-to-toe assessment each shift. Monitor respirations and breath sounds.

Monitor respirations and breath sounds. (Respiratory disorders, including emphysema, increase the risk for respiratory depression from anesthesia as well as postoperative pneumonia and atelectasis.)

A nurse is taking care of a client during the immediate post-operative period. Which of the following duties performed during the immediate post-operative period is most important? Ensure the safe recovery of surgical clients. Monitor the client for complications. Prepare a room for the client's return. Assess the client's health constantly.

Monitor the client for complications. (The immediate post-operative period refers to the first 24 hours after surgery. During this time, the nurse monitors the client for complications as he or she recovers from anesthesia. Once the client is stable, the nurse prepares a room for the client's return and assesses the client to prevent or minimize potential complications. The nurse ensures the safe recovery of the client after the client has stabilized.)

In the postanesthesia care unit a client received intrathecal morphine intraoperatively to control pain. Considering the administration of this medication, what should the nurse include as part of the client's initial 24-hour postoperative care? Monitoring of respiratory rate hourly Assessing the client for tachycardia Administering naloxone every 3 to 4 hours Observing the client for signs of central nervous system (CNS) excitement

Monitoring of respiratory rate hourly (Intrathecal morphine can depress respiratory function depending on the level it reaches within the spinal column; hourly assessments during the first 12 to 24 hours will allow for early intervention with an antidote if respiratory depression needs to be corrected. Bradycardia, not tachycardia, and hypotension occur. Administering naloxone every 3 to 4 hours is too infrequent if the client's respirations are depressed. The recommended adult dosage usually is 0.4 to 2 mg every 2 to 3 minutes, if indicated. CNS depression occurs secondary to hypoxia.)

A patient needs to switch analgesic drugs secondary to an adverse reaction to the current treatment regimen. The patient is concerned that the new prescription will not provide optimal pain control. The nurse's response is based on knowledge that doses of analgesics are determined using an equianalgesic table with which drug prototype? Fentanyl Meperidine Morphine Codeine

Morphine (An equianalgesic table is a conversion chart for commonly used opioids. It identifies oral and parenteral dosages that provide comparable analgesia. The equianalgesic table identifies dosages of various narcotics that are equal to 10 mg of morphine. It is important to use when changing to a new opioid or different route. Morphine is the drug prototype for all opioid drugs.)

Which medication is used to treat a patient with severe adverse effects of a narcotic analgesic? Flumazenil (Romazicon) Methylprednisolone (Solu-Medrol) Acetylcysteine (Mucomyst) Naloxone (Narcan)

Naloxone (Narcan) (Naloxone is the narcotic antagonist that will reverse the effects, both adverse and therapeutic, of opioid narcotic analgesics.)

The nurse provides education about signs and symptoms of hypoglycemia to a client with newly diagnosed type 1 diabetes. The nurse concludes that the teaching was effective when the client acknowledges the need to drink orange juice when experiencing which symptoms? Nervous and weak Thirsty with a headache Flushed and short of breath Nausea and abdominal cramps

Nervous and weak (Nervousness and weakness are the most commonly reported symptoms of hypoglycemia and are related to increased sympathetic nervous system activity. Feeling flushed and short of breath are adaptations of hyperglycemia. Being thirsty, having a headache, being nauseated, or having abdominal cramps are symptoms of hyperglycemia.)

he healthy adult patient is given a narcotic prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the patient. Which of the following should the nurse do first? Immediately have the patient sign the consent form. Have the patient's family member sign the consent form. Ask the patient if he still wants to proceed with the procedure. Notify the physician of the oversight.

Notify the physician of the oversight. (Do not administer any medications that might alter judgment or perception before the patient signs the consent form because many drugs commonly administered as preoperative medications, such as narcotics or barbiturates, can alter cognitive abilities and invalidate informed consent.)

The nurse is performing a dressing change on a client who underwent abdominal surgery 6 days prior. The nurse notes a moderate amount of serosanguineous drainage on the old dressing. What will the nurse do? Apply extra gauze to the new dressing. Contact the surgeon to discuss the need for antibiotics. Notify the surgeon about possible wound dehiscence. Perform the dressing change according to unit protocol.

Notify the surgeon about possible wound dehiscence. (Serosanguineous discharge persisting past the 5th postoperative day may indicate wound dehiscence and would be reported to the surgeon.The nurse would not just reinforce the dressing, but would notify the surgeon. Serosanguineous discharge does not indicate infection. Persistent serosanguineous discharge is an abnormal finding and to be reported.)

A female client is scheduled for a hysterectomy. While discussing the preoperative preparations, the nurse determines that the client's understanding of the surgery is inadequate. What is the next nursing intervention? Describing the proposed surgery to the client Proceeding with the preoperative plan Notifying the surgeon that the client needs more information Explaining gently to the client that she should have asked more questions

Notifying the surgeon that the client needs more information (Legally the person performing the surgery is responsible for informing the client adequately; the nurse may clarify information, witness the client's signature, and co-sign the consent form. Describing the proposed surgery to the client is beyond the scope of nursing practice. The nurse could face criminal charges of assault and battery for proceeding when there is a lack of informed consent. Explaining gently that she should have asked more questions places blame on the client; it is the responsibility of the surgeon to impart the vital information required for consent.)

A patient has been treated for lung cancer for 3 years. Over the past few months, the patient has noticed that the opioid analgesic is not helping as much as it had previously and more medication is needed for the same pain relief. The nurse is aware that this patient is experiencing which of these? Opioid addiction Opioid tolerance Opioid toxicity Opioid abstinence syndrome

Opioid tolerance (Opioid tolerance is a common physiologic result of long-term opioid use. Patients with opioid tolerance require larger doses of the opioid agent to maintain the same level of analgesia. This situation does not describe toxicity (overdose), addiction, or abstinence syndrome (withdrawal).)

Which intervention does the nurse implement for an older adult client to minimize skin breakdown related to surgical positioning? Apply elastic stockings to lower extremities. Monitor for excessive blood loss. Pad bony prominences. Secure joints on a board in anatomic positions.

Pad bony prominences. (Padding bony prominences best minimizes skin breakdown.Elastic stockings assist in increased venous return. Monitoring for blood loss and securing joints do not protect the skin.)

The nurse plans pharmacologic management for a patient with pain. The nurse should administer the pain medication based on what dosage schedule? Pain relief is best obtained by administering analgesics around the clock. Administer the analgesic when the pain level reaches a "6" on a scale of 1 to 10. Opioid analgesics should not be used for more than 24 hours to prevent drug addiction. Analgesics should be administered as needed (prn) to minimize adverse effects.

Pain relief is best obtained by administering analgesics around the clock. (When pain is present for more than 12 hours a day, analgesic dosages are best administered around the clock rather than on an as-needed basis, but dosages should always be within the dosage guidelines for each drug used. The around-the-clock (or "scheduled") dosing maintains steady-state levels of the medication and prevents drug troughs and escalation of pain.)

Colostomy surgery is categorized as what type of surgery? Cosmetic Curative Diagnostic Palliative

Palliative (Colostomy surgery is categorized as palliative. Palliative surgery is performed to relieve symptoms of a disease process, but does not cure the disease.Cosmetic surgery is performed primarily to alter or enhance personal appearance. Curative surgery is performed to resolve a health problem by repairing or removing the cause. Diagnostic surgery is performed to determine the origin and cause of a disorder or the cell type for cancer.)

Identify the type of surgery a terminally ill patient will undergo if the purpose is removal of tissue to relieve pain. Procurement Ablative Palliative Diagnostic

Palliative (Palliative surgery alleviates discomfort or other disease symptoms without producing a cure. Procurement surgery occurs when an organ or tissue is harvested for transplantation into another. Ablative surgery involves removal of a body part. Diagnostic surgery confirms or negates a diagnosis.)

In the postoperative phase of abdominal surgery, the client complains of severe abdominal pain, and in the second postoperative day, the client's bowel sounds are absent. What does the nurse suspect? Normal response Abdominal infection Hernia development Paralytic ileus

Paralytic ileus (A potential complication after surgery is paralytic ileus, a condition in which there is decreased bowel functioning.)

When an elderly client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this most likely a result of Effects of anesthesia Normal return of reflexes Partial airway obstruction Type of surgery

Partial airway obstruction (Loud, irregular respirations may indicate obstruction of the airway, possibly from emesis, accumulated secretions, or client positioning that allows the tongue to fall to the back of the throat.)

A patient had a hiatal hernia repair earlier today and is now in the postanesthesia care unit (PACU). The family asks the nurse why the patient is in the PACU rather than back in his room on the postsurgical unit. The nurse should inform the family that: Patients who have had surgical complications are observed in the PACU until they are stable enough to return to the floor. Patients recover from the effects of anesthesia in the PACU and then return to the postsurgical unit for further care. The PACU is a holding area for patients awaiting a surgical unit bed or awaiting adequate staff to provide care on the postsurgical unit. The nurse will ask the surgeon explain to them why the patient is not on the postsurgical unit, as is the usual procedure.

Patients recover from the effects of anesthesia in the PACU and then return to the postsurgical unit for further care. (A client remains in the PACU until he has recovered from the effects of anesthesia. In the PACU, the client is assessed every 5 to 15 minutes in order to quickly identify surgical or anesthesia-related problems. Most surgical units routinely admit patients to the PACU for a period of observation. Admission to the PACU does not indicate surgical complications nor imply that a holding area is required. There is no reason the surgeon would need to explain this to the family, as the nurse could do it. It is not usual procedure for a patient to be transferred directly from surgery to the postsurgical unit.)

The nurse caring for four clients with diabetes has these activities to perform. Which activity is appropriate to delegate to unlicensed assistive personnel (UAP)? Perform a blood glucose check on a client who requires insulin. Verify the infusion rate on a continuous infusion insulin pump. Assess a client who reports tremors and irritability. Monitor a client who is reporting palpitations and anxiety.

Perform a blood glucose check on a client who requires insulin. (Performing bedside glucose monitoring is a task that may be delegated to UAPs because it does not require extensive clinical judgment to perform. There is no evidence the client is unstable at this time. The nurse will follow up with the results and insulin administration after assessing the less stable clients.Intravenous therapy and medication administration are not within the scope of practice for UAPs. The client with tremors and irritability is displaying symptoms of hypoglycemia requiring further assessment and intervention that are not within the scope of practice for UAPs. The client reporting palpitations and anxiety may have hypoglycemia, requiring further intervention. This client must be assessed by licensed nursing staff.)

A cleansing enema is ordered for a client who is scheduled to have colon surgery. What is the rationale for this procedure? Surgical clients routinely are given a cleansing enema. Cleansing enemas are given before surgery at the client's request. There will be less flatus and discomfort postoperatively. Peristalsis does not return for 24 to 48 hours after surgery.

Peristalsis does not return for 24 to 48 hours after surgery. (If the client is scheduled for gastrointestinal tract surgery, a cleansing enema is usually ordered. Peristalsis does not return for 24 to 48 hours after the bowel is handled, so preoperative cleansing helps decrease postoperative constipation.)

If sterile gauze falls to the ground and hits the front of the surgeon's gown on the way down, what does the nurse do to ensure proper infection control? Helps the surgeon change the gown Picks the gauze up with a pair of sterile gloves Picks the gauze up without touching the surgeon Sprays an antimicrobial on the surgeon's gown

Picks the gauze up without touching the surgeon (To ensure proper infection control, the nurse picks up the gauze without touching the surgeon. The surgeon is sterile, but the gauze is now nonsterile and must be removed and counted.A sterile gauze touching a sterile gown does not require a gown change. Sterile gloves are not needed to pick up the gauze. An antimicrobial spray is inappropriate in this situation.)

A nurse is teaching a preoperative client about postoperative breathing exercises. Which information should the nurse include? Select all that apply. Take short, frequent breaths Exhale with the mouth open wide Perform the exercises twice a day Place a hand on the abdomen while feeling it rise Hold the breath for several seconds at the height of inspiration

Place a hand on the abdomen while feeling it rise Hold the breath for several seconds at the height of inspiration (Abdominal breathing improves lung expansion because it makes the contraction of the diaphragm more efficient. Placing the hand on the abdomen to watch it rise provides feedback, ensuring that abdominal rather than intercostal breathing is accomplished. Holding the breath for several seconds at the height of inspiration allows several additional seconds for oxygen and carbon dioxide to exchange in the alveoli. Short breaths do not expand the lungs; deep, slow breaths should be encouraged. Exhalation with pursed lips, not with an open mouth, promotes exhalation of air from the lung and minimizes trapping of air in the alveoli. Breathing exercises should be performed at least every two hours.)

A client states he has a latex allergy. What action should the nurse take? Inform the client to tell the anesthesiologist Have the client take a Benadryl before surgery Send the client to the OR with epinephrine Place an allergy identification band

Place an allergy identification band (Assist client with allergies to medications, food, and latex before the surgical procedure, and clearly mark them on the client record and on the client identification band.)

After gastric surgery, a client arrives in the post-anesthesia care unit. Which nursing action is most appropriate for the RN to delegate to an experienced nursing assistant? Monitor respiratory rate and airway patency. Irrigate the nasogastric tube with saline. Position the client on the left side. Assess the client's pain level.

Position the client on the left side. (Positioning the client on the left side would most likely be delegated to an experienced, unlicensed care provider.Airway patency requires the care of a nurse in case of emergency management requirements. Irrigating the nasogastric tube with saline is a nursing skill and care by a nurse would be required. Pain assessment is also within the scope of a nurse.)

An intensive care client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. When the cardiac monitor shows ventricular ectopy, which assessment will the nurse make? Urine output 12-lead electrocardiogram (ECG) Potassium level Rate of IV fluids

Potassium level (After DKA therapy starts, serum potassium levels drop quickly. An ECG shows conduction changes and ectopy related to alterations in potassium. Hypokalemia is a common cause of death in the treatment of DKA. Detecting and treating the underlying cause of the ectopy is essential.Ectopy is not associated with changes in urine output even though hyperglycemia will cause osmotic diuresis. A 12-lead ECG can verify the ectopy, but the priority is to detect and fix the underlying cause, which is most likely hypokalemia. Increased fluids treat the symptoms of dehydration secondary to DKA, but do not treat the hypokalemia.)

A patient is admitted for hip surgery. The patient usually takes the following medications daily: an anticoagulant, a multivitamin, and vitamin E 1,500 IU. He stopped taking his anticoagulant 4 days ago as instructed by his surgeon, but has continued to take the multivitamin and vitamin E. An important collaborative problem or nursing diagnosis for this patient is which of the following? Potential complication: anemia Risk for infection related to inadequate anticoagulant dosage Risk for noncompliance related to inability to follow instructions Potential complication: increased bleeding

Potential complication: increased bleeding (The patient is at an increased risk for bleeding due to his intake of vitamin E. He may be at risk for anemia if he experiences a large blood loss in surgery; however, this problem is not appropriate before he experiences the blood loss. This patient does not have a higher-than-average risk for infection because he is not having surgery involving a "contaminated" system (e.g., the gastrointestinal system). There is no evidence to suggest that this is noncompliant simply he because he stopped taking his anticoagulant as ordered.)

The focus of nursing activities in the preoperative phase is to: Admit the patient to the surgical suite. Prepare the patient mentally and physically for surgery. Set up the sterile field in the operating room. Perform the primary surgical scrub to the surgical site.

Prepare the patient mentally and physically for surgery. (The nursing focus in the preoperative phase is to prepare the patient mentally and physically for surgery. The patient is in the intraoperative phase when admitted to the surgical suite. The sterile field and the surgical scrub would be performed in the surgery suite during the intraoperative phase.)

The nurse should teach a client about which antiemetic commonly used to prevent motion sickness? Prochlorperazine (Compazine) Droperidol (Inapsine) Metoclopramide (Reglan) Scopolamine (Transderm-Scōp)

Prochlorperazine (Compazine) (Scopolamine has potent effects on the vestibular nuclei, which are located in the area of the brain that controls balance. These effects make scopolamine one of the most commonly used drugs for the treatment and prevention of nausea and vomiting associated with motion sickness.)

When educating a client in the postoperative period, it is important to educate the client to consume a diet high in Protein Calcium Bicarbonate Potassium

Protein (After surgery, a diet with sufficient amounts of protein and vitamins A and C helps rebuild tissues and promotes wound healing.)

Five RNs from other units have been assigned to the post-anesthesia care unit for the day. A 16-year-old client with diabetes has also just arrived from the operating room (OR) after having laparoscopic abdominal surgery. The charge nurse assigns the RN with which kind of experience to care for this new client? RN who usually works on the inpatient pediatric unit RN who provides education to diabetic clients in a clinic RN who has 5 years of experience in the delivery room RN who ordinarily works as a scrub nurse in the OR

RN who has 5 years of experience in the delivery room (The RN with delivery room experience would have experience with abdominal surgery and with postoperative care of clients with diabetes, and would be aware of possible postoperative complications for this client.The RN who usually works on the pediatric unit would not be aware of potential complications and routine assessments for this client. The RN who provides education to diabetic clients in a clinic would be able to provide required care for the client's diabetes but not the postoperative aspect of care. The RN who works as a scrub nurse would not have the knowledge and understanding of routine postoperative care that is needed for this client.)

A client scheduled for major surgery will receive general anesthesia. Why is inhalation anesthesia often used to provide the desired actions? Rapid excretion and reversal of effects Safe administration in the client's own room Involves only the respiratory system and skin Slow onset of action and maintains reflexes

Rapid excretion and reversal of effects (General anesthesia involves the administration of drugs by inhalation and intravenous routes to produce central nervous system depression. Inhalation anesthesia is often used because it has the advantage of rapid excretion and reversal of effects.)

The nurse assesses a client's wound 24 hours postoperatively. Which finding causes the nurse the greatest concern and should be reported to the surgeon? Crusting along the incision line Redness and swelling around the incision Sanguineous drainage at the suture site Serosanguineous drainage on the dressing

Redness and swelling around the incision (The nurse's greatest concern is redness and swelling around the incision. This needs to be reported to the surgeon because these signs could indicate an infection.Crusting along the incision line, sanguineous drainage, and serosanguineous drainage are normal.)

A nurse in the postanesthesia care unit (PACU) is providing care to a client who had an abdominal cholecystectomy and observes serosanguineous drainage on the abdominal dressing. What is the next nursing action? Change the dressing. Reinforce the dressing. Replace the tape with Montgomery ties. Support the incision with an abdominal binder.

Reinforce the dressing. (The nurse should anticipate drainage and reinforce the surgical dressing as needed. Changing a dressing at this time is unnecessary and increases the risk for infection. Montgomery ties are used when frequent dressing changes are anticipated; they are not appropriate at this time. An abdominal binder rarely is prescribed, and it will interfere with assessment of the dressing at this time.)

What nursing action will assist in pain management for a client in the postoperative phase? Client teaching Relaxation techniques Dim lighting Provide food and medication

Relaxation techniques (Nursing interventions vital in helping clients cope with pain include administering medications, positioning, relaxation techniques, psychological support, distraction techniques, and appropriate referrals to other health professionals.)

The nurse is assessing a patient who has been admitted to the emergency department for a possible opioid overdose. Which assessment finding is characteristic of an opioid drug overdose? Dilated pupils Restlessness Respiration rate of 6 breaths/min Heart rate of 55 beats/min

Respiration rate of 6 breaths/min (The most serious adverse effect of opioid use is CNS depression, which may lead to respiratory depression. Pinpoint pupils, not dilated pupils, are seen. Restlessness and a heart rate of 55 beats/min are not indications of an opioid overdose.)

Which of the following are potential complications of anesthesia? Choose all that apply. Hypothermia Respiratory depression Cardiovascular compromise Aspiration

Respiratory depression Cardiovascular compromise Aspiration (Hypothermia is a potential complication of surgery. It is not induced by anesthesia.)

When assessing for the MOST serious adverse effect to an opioid analgesic, what does the nurse monitor for in this patient? Blood pressure Respiratory rate Mental status Heart rate

Respiratory rate (The most serious adverse effect of opioid analgesics is respiratory depression.)

Which assessment finding in a postoperative client after general anesthesia requires immediate intervention? Heart rate of 58 beats/min Pale, cool extremities Respiratory rate of 6 breaths/min Suppressed gag reflex

Respiratory rate of 6 breaths/min (The most immediate postoperative assessment is respiratory assessment, and a rate less than 10 breaths/min is too low.A heart rate of 58 beats/min, pale and cool extremities, and a suppressed gag reflex are all normal postoperative findings.)

A preoperative assessment finds a client to be 75 pounds overweight. The client is to have abdominal surgery. What nursing diagnosis would be appropriate based on the client's weight? Risk for Aspiration Risk for Imbalanced Body Temperature Risk for Infection Risk for Falls

Risk for Infection (Fatty tissue in obese clients has a poor blood supply and, therefore, has less resistance to infections. Postoperative complications of delayed wound healing, wound infection, and disruption of the wound are more common in obese clients.)

A client is being discharged following surgery for cancer care. The client will require extensive dressing changes two times per day. The client is on a fixed income and cannot afford to purchase dressing supplies. The nurse contacts the local Peregrine Society to assist in the provision of dressings. This contribution in care will assist in improving the client's Family relationships Return to daily activities Decision making Self-concept

Self-concept (In addition to providing the client with the necessary technical care, teaching, extensive rehabilitation, and emotional support, nursing interventions may also include referral to agencies and support groups that can benefit the client after surgery and discharge from the acute care facility.)

Which of the following is the most appropriate nursing goal for a 2-year-old who is to have a tonsillectomy? Separation anxiety will be minimal. The child will verbalize understanding of expected pain. The child will tolerate a normal diet 24 hours after surgery. The parent will indicate readiness to assume the child's care.

Separation anxiety will be minimal. (The only concrete information in this question is that the child is 2 years old. Therefore, the only problem the nurse can reasonably predict from this would be developmental in nature. It is developmentally normal for toddlers to experience anxiety with separation from parents or caregivers. Minimizing anxiety by involving the parents or caregivers would be the appropriate goal for separation anxiety. A 2-year-old child would not be expected to verbalize understanding of expected pain. The toddler would take liquids and soft foods within the first 24 hours when her throat is sore during swallowing. She should not eat foods that are rough and crunchy because they may scratch her throat and cause bleeding. Nurses should encourage parental involvement, but parents should not be expected to assume the child's care.)

The client is returned to the surgical unit from the postanesthesia care unit (PACU) after a having a splenectomy. In the immediate postoperative period, the nurse specifically should monitor for which potential complications? Select all that apply. Shock Infection Intestinal obstruction Abdominal distention Pulmonary complications

Shock Abdominal distention Pulmonary complications (Because of its great blood supply and general fragility, the spleen may hemorrhage, causing shock and abdominal distention. Pulmonary complications may occur because the spleen is close to the diaphragm, resulting in defensive shallow breathing and the effects of anesthesia. The immediate postoperative period is too soon for the client to exhibit signs of infection. An intestinal obstruction is not associated with a splenectomy.)

How does the nurse position a client with postoperative nausea and vomiting? Flat in bed, with the head in alignment with the body Prone, with the head of the bed flat Side-lying, with the head in a neutral position Supine in bed, with the neck flexed

Side-lying, with the head in a neutral position (The side-lying position with the client's head in a neutral position helps reduce postoperative nausea and vomiting.The flat-in-bed position with the head in alignment is not a neutral position. The prone position with the head of the bed flat is unnatural, as is the supine position with the neck flexed.)

A nurse has been asked to ensure informed consent for a surgical procedure. What might be a role of the nurse? Securing informed consent from the client Signing the consent form as a witness Ensuring the client does not refuse treatment Refusing to participate based on legal guidelines

Signing the consent form as a witness (The responsibility for securing informed consent from the client lies with the person who will perform the procedure, usually the physician. The nurse may sign as a witness, signifying that the client signed the consent form without coercion, and was alert and aware of the act.)

A client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further assessment in the post-anesthesia care unit? Pain at the surgical site Requirement for verbal stimuli to awaken Snoring sounds when inhaling Sore throat on swallowing

Snoring sounds when inhaling (Snoring sounds when inhaling may indicate respiratory depression.Postsurgical pain at the surgical site is normal. Requiring verbal stimuli to awaken and a sore throat on swallowing are normal post-sedation.)

A client newly diagnosed with type 2 diabetes is receiving glyburide and asks the nurse how this drug works. What mechanism of action does the nurse provide? Stimulates the pancreas to produce insulin Accelerates the liver's release of stored glycogen Increases glucose transport across the cell membrane Lowers blood glucose in the absence of pancreatic function

Stimulates the pancreas to produce insulin (Glyburide, an antidiabetic sulfonylurea, stimulates insulin production by the beta cells of the pancreas. Accelerating the liver's release of stored glycogen occurs when serum glucose drops below normal levels. Increasing glucose transport across the cell membrane occurs in the presence of insulin and potassium. Antidiabetic medications of the chemical class of biguanide improve sensitivity of peripheral tissue to insulin, which ultimately increases glucose transport into cells. Beta cells must have some function to enable this drug to be effective.)

A client with type 2 diabetes controlled with Metformin is recovering from surgery. The primary health care provider has placed the client on insulin in addition to the metformin. What is the nurse's best response about why the client needs to take insulin? "Your diabetes is getting worse, so you will need to take insulin." "You can't take your metformin while in the hospital." Stress, such as surgery, increases blood glucose levels. You'll need insulin to control your blood glucose temporarily." "You must take insulin from now on because the surgery will affect your diabetes."

Stress, such as surgery, increases blood glucose levels. You'll need insulin to control your blood glucose temporarily." (The nurse's best response is that due to the stress of surgery and NPO status, short-term insulin therapy may be needed perioperatively for clients with diabetes who use oral antidiabetic agents. For those receiving insulin, dosage adjustments may be required until the stress of surgery subsides.No evidence suggests that the client's diabetes has worsened. However, surgery is stressful and may increase insulin requirements. Metformin may be taken in the hospital, but not on days when the client is NPO for surgery. When the client returns to his or her previous health state, oral agents will be resumed.)

A client has an acute case of opioid depression and receives a dose of naloxone (Narcan). Which statement is true about this client? Supplemental pain reduction is needed. One dose is needed. This is an acute emergency. The client will be hostile.

Supplemental pain reduction is needed. (Supplemental pain reduction is needed. The client has breakthrough pain after the opioid antagonist is given, so other interventions to promote comfort are needed.Several doses of naloxone may be needed because the drug has a short half-life. Opioid depression is a manageable situation, not an acute emergency. The client with opioid depression usually is not fully conscious.)

Which of the following members of the operative team use sterile technique during the surgical procedure? Choose all that apply. Surgeon Anesthetist Scrub nurse Registered nurse first assistant

Surgeon Scrub nurse Registered nurse first assistant (The anesthetist is a member of the clean team and remains outside the sterile field. Members of the sterile team include the surgeon, the scrub nurse, and the registered first nurse assistant.)

When planning to administer metoclopramide (Reglan), the nurse is aware that this drug must be given in regards to which fluid or food consideration? Give with a full glass of water in the morning. Take with 8 oz of orange or apple juice. Take 30 minutes before meals and at bedtime. Give with food to decrease GI upset.

Take 30 minutes before meals and at bedtime. (Metoclopramide should be administered 30 minutes before meals and at bedtime. Administering the medication before meals allows time for onset to increase GI motility before food ingestion, thus decreasing stomach distention and resulting nausea and vomiting.)

A client who is taking an oral hypoglycemic daily for type 2 diabetes develops the flu and is concerned about the need for special care. What should the nurse advise the client? Select all that apply. Avoid solid food. Take the oral medication. Drink fluids throughout the day. Monitor capillary glucose levels. Do not take medication until tolerating food.

Take the oral medication. Drink fluids throughout the day. Monitor capillary glucose levels. (Physiologic stress increases gluconeogenesis, requiring continued pharmacologic therapy despite an inability to eat; fluids prevent dehydration; monitoring of glucose levels permits early intervention if necessary. Skipping the oral hypoglycemic agent may precipitate hyperglycemia. Food intake should be attempted to prevent acidosis. Delaying an oral hypoglycemic agent may precipitate hyperglycemia.)

An older client's adult child tells the nurse that the client does not want life support. What does the nurse do first? Call the legal department to draft the paperwork. Document this in the chart. Thank the person and do nothing else. Talk to the client.

Talk to the client. (The nurse would first talk to the client in order to determine the client's wishes and state of mind.The nurse should not call the legal department or document in the client's chart before speaking with the client. Doing nothing is not appropriate.)

A preoperative client smokes a pack of cigarettes a day. What is the nurse's teaching priority for the best physical outcomes? Instruct the client to quit smoking. Teach about the dangers of tobacco. Teach the importance of incentive spirometry. Tell the client that smoking increases postoperative complications.

Teach the importance of incentive spirometry. (The nurse would first teach the importance of incentive spirometry. Incentive spirometry is good for lung hygiene and it encourages deep breathing.The nurse can suggest quitting or advice about the dangers of tobacco, but it is not therapeutic to instruct it at this time. Telling the client that smoking causes increased complications is not helpful or therapeutic just prior to surgery.)

The charge nurse for a hospital operating room is making client assignments for the day. Which client is most appropriate to assign to the least-experienced circulating nurse? The 20-year-old client who has a ruptured appendix and is having an emergency appendectomy The 28-year-old client with a fractured femur who is having an open reduction and internal fixation The 45-year-old client with coronary artery disease who is having coronary artery bypass grafting The 52-year-old client with stage I breast cancer who is having a tunneled central venous catheter placed

The 52-year-old client with stage I breast cancer who is having a tunneled central venous catheter placed (The client with stage I breast cancer who is having a tunneled central venous catheter placed is the most stable client among all scheduled procedures. This assignment would be appropriate for the beginning nurse or one with less experience.The client who has a ruptured appendix is less stable and at high risk for infection/sepsis; a more experienced nurse is required. The client with a fractured femur is at high risk for clotting, infection, and aspiration owing to the surgery; a more experienced nurse would be better. The client with coronary artery disease is having high-risk surgery with risk for multiple complications and requires an experienced operating room nurse.)

Following a surgical procedure, which of the following are generally responsible for moving the patient to the recovery area? The surgeon The orderly The recovery nurses The anesthesiologist, circulating nurse, and surgeon

The anesthesiologist, circulating nurse, and surgeon (After the intraoperative phase of the surgical procedure has been completed, the circulating nurse, the anesthesia provider, and the surgeon safely transport the patient to the PACU, taking care to maintain the patient's airway during this critical time.)

In monitoring a patient for adverse effects related to morphine sulfate (MS Contin), the nurse assesses for stimulation of which area in the central nervous system (CNS)? Autonomic control over circulation Sympathetic baroreceptors The cough reflex center The chemoreceptor trigger zone

The chemoreceptor trigger zone (Morphine sulfate can irritate the gastrointestinal (GI) tract, causing stimulation of the chemoreceptor trigger zone in the brain, which in turn causes nausea and vomiting.)

The nursing instructor is discussing the role of the circulating nurse in the operative suite with the student nurses. Which of the following would the nursing instructor include as duties of the circulating nurse? Select all that apply. The circulating nurse is included in the responsibility of accounting for all sponges and instruments following the surgical procedure. The circulating nurse is responsible for preparing the surgical table for the procedure. The circulating nurse is responsible for assisting the surgeon with instruments during the procedure. The surgical nurse is responsible for maintaining the patient's rights during the surgical procedure.

The circulating nurse is included in the responsibility of accounting for all sponges and instruments following the surgical procedure. The surgical nurse is responsible for maintaining the patient's rights during the surgical procedure. (The circulating nurse ensures that the patient's rights are protected and coordinates patient care in the operating room. The circulating nurse and the scrub person are responsible for accounting for all sponges and instruments at the close of surgery.)

A nurse in an outpatient surgical center is teaching a client about what will be necessary for discharge to home. What information should the nurse include about transportation? The client is not allowed to drive a car home. If the client is not dizzy, driving a car is allowed. Only adults over the age of 25 may drive home. None; this is not necessary information.

The client is not allowed to drive a car home. (After outpatient surgery, clients may go home when they are no longer dizzy or drowsy, have stable vital signs, and have voided. Clients are not allowed to drive a car home.)

The preoperative phase encompasses which period of time? Entry to the operating suite until admission to postanesthesia care Entry into the operating suite until discharge from the hospital The decision to have surgery until admission to postanesthesia care The decision to have surgery until entry to the operating suite

The decision to have surgery until entry to the operating suite (The preoperative phase begins with the decision to have surgery and ends when the patient enters the operating room. The intraoperative phase begins when the patient enters the operating suite and ends when the patient is admitted to the postanesthesia care unit.)

Which of the following describes the Perioperative Nursing Data Set? Choose all that apply. A standardized tool for assessing high-risk surgical patients A standardized vocabulary encompassing all surgical patient outcomes The first specialized nursing language recognized by the ANA A standardized language designed to describe the care of perioperative patients

The first specialized nursing language recognized by the ANA A standardized language designed to describe the care of perioperative patients (The Perioperative Nursing Data Set (PNDS) is a standardized vocabulary specifically designed to describe the care of perioperative clients. It consists of 74 nursing diagnoses, 133 nursing interventions, and 28 nurse-sensitive patient outcomes appropriate for use in any surgical setting. It was the first specialty language recognized by the ANA.)

The patient has been transported to the operating suite and positioned on the operating table. Suddenly, the patient states, "I don't want to do this. Get me out of here now!" Which of the following actions should occur? The patient should be given the anesthesia. The surgeon should tell the patient to remain calm and the procedure will be over soon. The patient should be told it is too late to change his mind. The procedure should be stopped.

The procedure should be stopped. (The patient has the right to ask any questions and to withdraw consent at any point before the surgery begins.)

Which of the following personnel are legally responsible for obtaining the patient's informed consent for a surgical procedure? The surgeon The registered nurse The admissions clerk The licensed practical nurse Any licensed person

The surgeon (The surgeon is legally responsible for obtaining the patient's informed consent.)

A young woman has been in an automobile crash that resulted in an amputation of her left lower leg. She verbalizes grief and loss. What knowledge by the nurse is used to provide interventions to help the client cope? The client should be grateful to be alive. This is a normal, appropriate response. This is an abnormal, inappropriate response. Tissue healing will help the client adapt.

This is a normal, appropriate response. (Many surgical clients have the same reaction to loss of a body part as they would to a death. A surgical client's grief is a normal, appropriate response. The nurse must be aware of the client's needs and provide interventions to meet those needs in coping with change.)

he nurse in the endocrine clinic is reviewing type 1 and type 2 diabetes with a group of nursing students. Which explanation by the students indicates their understanding of the types of diabetes? Most clients with type 1 diabetes are born with it. People with type 1 diabetes are often obese. Those with type 2 diabetes make insulin, but in inadequate amounts. People with type 2 diabetes do not develop typical diabetic complications.

Those with type 2 diabetes make insulin, but in inadequate amounts. (The explanation by the students that indicate understanding of the type of diabetes is "Those with type 2 diabetes make insulin, but in inadequate amounts." People with type 2 diabetes may also have resistance to existing insulin.Most clients with type 1 diabetes are not born with it. Although type 1 diabetes may occur early in life, it is considered an autoimmune disorder in which beta cells are destroyed in a genetically susceptible person. Risk for type 1 DM is determined by inheritance of genes coding for the HLA-DR and HLA-DQA and DQB tissue types (McCance et al., 2014). However, inheritance of these genes only increases the risk, and most people with these genes do not develop type 1 DM. Obesity is typically associated with type 2 diabetes. People with type 2 diabetes are at risk for typical diabetic complications, especially cardiovascular diseases.)

What is the rationale for the administration of IV cephalosporin antibiotic before surgery? To prevent the development of strep To prevent the development of pneumonia To allow for decreased level of white blood cells To allow the client high levels of medication

To allow the client high levels of medication (A cephalosporin antibiotic is administered just before the surgical procedure so that the level of medication circulating in the client's blood will be high during surgery.)

What is the rationale for having the client void before surgery? To assess for pregnancy in women To assess for urinary tract infection To prevent bladder distention To prevent electrolyte imbalance

To prevent bladder distention (Having the client void before surgery will assist in the prevention of bladder distention during or after the procedure.)

A nurse working in a PACU is responsible for conducting assessments on immediate postoperative clients. What is the purpose of these assessments? To determine the length of time to recover from anesthesia To use intraoperative data as a basis for comparison To focus on cardiovascular data and findings To prevent complications from anesthesia and surgery

To prevent complications from anesthesia and surgery (Immediate postoperative care in the PACU involves assessing the postoperative client with emphasis on preventing complications from the surgery.)

The nurse is preparing to teach a client that metabolic syndrome can increase the risk for myocardial infarction (MI). Which signs of metabolic syndrome should the nurse include in the discussion? Select all that apply. Truncal obesity Hypercholesterolemia Elevated homocysteine levels Glucose intolerance Client taking losartan (Cozaar)

Truncal obesity Hypercholesterolemia Glucose intolerance Client taking losartan (Cozaar) (Truncal obesity related to large waist size (excessive abdominal fat causing central obesity)—40 inches (102 cm) or greater for men, 35 inches (89 cm) or greater for women—is a sign of metabolic syndrome. Decreased high-density lipoprotein cholesterol (HDL-C) (usually with high low-density lipoprotein cholesterol)—HDL-C less than 45 mg/dL (1.17 mmol/L) for men or less than 55 mg/dL (1.42 mmol/L) for women—or taking an anticholesterol drug is a sign of metabolic syndrome. Increased fasting blood glucose (caused by diabetes, glucose intolerance, or insulin resistance) is included in the constellation of metabolic syndrome. Blood pressure greater than 130/85 mm Hg or taking antihypertensive medication indicates metabolic syndrome.Although elevated homocysteine levels may predispose to atherosclerosis, they are not part of metabolic syndrome.)

A young adult woman is scheduled for a bilateral breast reduction under general anesthesia. She is normally healthy and takes no daily medications. Identify the preoperative screening tests appropriate for this patient. Choose all that apply. Urinalysis EKG Creatinine clearance CBC

Urinalysis CBC (Preoperative screening tests are ordered to determine if the client has undetected underlying health concerns. Most institutions require a complete blood count (CBC) and urinalysis prior to all surgical procedures. Generally, an electrocardiograph (ECG) is ordered for clients over the age of 50 years or with known cardiac disease. A creatinine clearance is not a routine presurgical screening test.)

A nurse is preparing to administer preoperative medication to a client scheduled for incision and drainage of a wound abscess. Which action is essential before the nurse administers the medication? Verify the consent. Have the client void. Check the vital signs. Remove the client's dentures.

Verify the consent. (Consent must be acquired when the client is fully oriented and in a clear mental state. Although important, having the client void, checking the vital signs, and removing the client's dentures can be implemented before surgery even if the client has received medication.)

A patient returns from surgery with a nasogastric tube and intermittent gastric suction to provide abdominal decompression. Which of the following are correct nursing activities for managing the equipment and drainage? Choose all that apply. Wear nonsterile procedure gloves when emptying the drainage container. When irrigating the nasogastric tube, use sterile water. Wear sterile gloves when irrigating the nasogastric tube. Apply water-soluble lubricant if the patient's lips are dry.

Wear nonsterile procedure gloves when emptying the drainage container. Apply water-soluble lubricant if the patient's lips are dry. (Nonsterile procedure gloves are to protect the nurse and other patients against microorganisms that might be present in body fluids; wearing them is in observance of standard precautions. For patients with an NG tube, frequent oral care, including water-soluble lubricant for dry lips, is important. Sterile gloves are not needed for irrigating the NG tube because the nasal passages, esophagus, and stomach are not sterile. Sterile normal saline and a sterile syringe are used for irrigation, however. Sterile water is not used.)

The nurse has a prescription to give a series of medications on an "on call" basis. The nurse realizes that these medications will be given: In the postanesthesia recovery unit. At the time specified in the order. On the patient's arrival in the surgery suite. When the OR staff notify the nurse to do so.

When the OR staff notify the nurse to do so. (The anesthesia team may order medications to be given "on call" if the surgery time is likely to vary. The nurse will give "on call" medications when he is notified to do so by the OR staff.)

A client recently admitted with new-onset type 2 diabetes will be discharged with a meter for self-monitoring of blood glucose (SMBG) levels. When is the best time for the nurse to explain to the client the proper use of the glucose monitor? Day of discharge On admission When the client states readiness While performing the test in the hospital

While performing the test in the hospital (Teaching the client about the operation of the machine while performing the test in the hospital is the best time for the nurse to introduce the client to SMBG. The teaching can be reinforced each time testing is performed on the client and again before discharge.Instructing the client on the day of admission or the day of discharge would not allow time for redemonstration and correction of the skill if needed. Other time-consuming activities are done on those days and could distract the client and make the client feel overwhelmed. Also, waiting for the client to state readiness may postpone the instructions too long.)

The nurse is preparing to administer an intravenous injection of morphine to a patient. The nurse assesses a respiratory rate of 10 breaths/min. Which action should the nurse perform? Withhold the medication and notify the health care provider. Administer a smaller dose and document in the patient's record. Administer the next prescribed dose intramuscularly. Check the pulse oximeter reading and reevaluate respiratory rate in 1 hour.

Withhold the medication and notify the health care provider. (Respiratory depression is an adverse effect of opioid analgesia. Therefore, because the patient's respiratory rate is below normal, the nurse should withhold the morphine and notify the health care provider.)

A student nurse is caring for clients on the postoperative unit. The student asks the registered nurse why malnutrition can lead to poor surgical outcomes. What responses by the nurse are best? (Select all that apply.) a. "A malnourished client will have fragile skin." b. "Malnourished clients always have other problems." c. "Many drugs are bound to protein in the body." d. "Protein stores are needed for wound healing." e. "Weakness and fatigue are common in malnutrition."

a. "A malnourished client will have fragile skin." c. "Many drugs are bound to protein in the body." d. "Protein stores are needed for wound healing." e. "Weakness and fatigue are common in malnutrition." (Malnutrition can lead to poorer surgical outcomes for several reasons, including fragile skin that might break down, altered pharmacokinetics, poorer wound healing, and weakness or fatigue that can interfere with recovery. Malnutrition can exist without other comorbidities.)

A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta blocker to the client. The student asks why this was needed. What response by the nurse is best? a. "A rapid heart rate requires more effort by the heart." b. "Anesthesia has bad effects if the client is tachycardic." c. "The client may have an undiagnosed heart condition." d. "When the heart rate goes up, the blood pressure does too."

a. "A rapid heart rate requires more effort by the heart." (Tachycardia increases the workload of the heart and requires more oxygen delivery to the myocardial tissues. This added strain is not needed on top of the physical and emotional stress of surgery. The other statements are not accurate.)

A postoperative client is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the client? (Select all that apply.) a. "Check all over-the-counter medications for acetaminophen." b. "Do not take more pills each day than you are prescribed." c. "Eat a diet that is high in fiber and drink lots of water." d. "If this gives you diarrhea, loperamide (Imodium) can help." e. "You shouldn't drive while you are taking this medication."

a. "Check all over-the-counter medications for acetaminophen." b. "Do not take more pills each day than you are prescribed." c. "Eat a diet that is high in fiber and drink lots of water." e. "You shouldn't drive while you are taking this medication." (Percocet is a common opioid analgesic that contains acetaminophen. The client should be taught to check all over-the-counter medications for acetaminophen and to not take more than the prescribed amount of Percocet, as the maximum daily dose of acetaminophen is 3000 mg. Percocet, like all opioid analgesics, can cause constipation, and the client can minimize this by eating a high-fiber diet and drinking plenty of water. Since Percocet can cause drowsiness, the client taking it should not drive or operate machinery. The medication is more likely to cause constipation than diarrhea.)

A nurse teaches a client with diabetes mellitus about foot care. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Do not walk around barefoot." b. "Soak your feet in a tub each evening." c. "Trim toenails straight across with a nail clipper." d. "Treat any blisters or sores with Epsom salts." e. "Wash your feet every other day."

a. "Do not walk around barefoot." c. "Trim toenails straight across with a nail clipper." (Clients who have diabetes mellitus are at high risk for wounds on the feet secondary to peripheral neuropathy and poor arterial circulation. The client should be instructed to not walk around barefoot or wear sandals with open toes. These actions place the client at higher risk for skin breakdown of the feet. The client should be instructed to trim toenails straight across with a nail clipper. Feet should be washed daily with lukewarm water and soap, but feet should not be soaked in the tub. The client should contact the provider immediately if blisters or sores appear and should not use home remedies to treat these wounds.)

After teaching a client who is recovering from pancreas transplantation, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional education? a. "If I develop an infection, I should stop taking my corticosteroid." b. "If I have pain over the transplant site, I will call the surgeon immediately." c. "I should avoid people who are ill or who have an infection." d. "I should take my cyclosporine exactly the way I was taught."

a. "If I develop an infection, I should stop taking my corticosteroid." (Immunosuppressive agents should not be stopped without the consultation of the transplantation physician, even if an infection is present. Stopping immunosuppressive therapy endangers the transplanted organ. The other statements are correct. Pain over the graft site may indicate rejection. Anti-rejection drugs cause immunosuppression, and the client should avoid crowds and people who are ill. Changing the routine of anti-rejection medications may cause them to not work optimally.)

A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement should the nurse include in this client's plan of care to delay the onset of microvascular and macrovascular complications? a. "Maintain tight glycemic control and prevent hyperglycemia." b. "Restrict your fluid intake to no more than 2 liters a day." c. "Prevent hypoglycemia by eating a bedtime snack." d. "Limit your intake of protein to prevent ketoacidosis."

a. "Maintain tight glycemic control and prevent hyperglycemia." (Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications. Maintaining tight glycemic control will help delay the onset of complications. Restricting fluid intake is not part of the treatment plan for clients with diabetes. Preventing hypoglycemia and ketosis, although important, are not as important as maintaining daily glycemic control.)

After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "The lower abdomen is the best location because it is closest to the pancreas." b. "I can reach my thigh the best, so I will use the different areas of my thighs." c. "By rotating the sites in one area, my chance of having a reaction is decreased." d. "Changing injection sites from the thigh to the arm will change absorption rates."

a. "The lower abdomen is the best location because it is closest to the pancreas." (The abdominal site has the fastest rate of absorption because of blood vessels in the area, not because of its proximity to the pancreas. The other statements are accurate assessments of insulin administration.)

A nurse cares for a client with diabetes mellitus who is visually impaired. The client asks, "Can I ask my niece to prefill my syringes and then store them for later use when I need them?" How should the nurse respond? a. "Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up." b. "Yes. Syringes can be filled with insulin and stored for a month in a location that is protected from light." c. "Insulin reacts with plastic, so prefilled syringes are okay, but you will need to use glass syringes." d. "No. Insulin syringes cannot be prefilled and stored for any length of time outside of the container."

a. "Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up." (Insulin is relatively stable when stored in a cool, dry place away from light. When refrigerated, prefilled plastic syringes are stable for up to 3 weeks. They should be stored in the refrigerator in the vertical position with the needle pointing up to prevent suspended insulin particles from clogging the needle.)

A nurse cares for a client who has a family history of diabetes mellitus. The client states, "My father has type 1 diabetes mellitus. Will I develop this disease as well?" How should the nurse respond? a. "Your risk of diabetes is higher than the general population, but it may not occur." b. "No genetic risk is associated with the development of type 1 diabetes mellitus." c. "The risk for becoming a diabetic is 50% because of how it is inherited." d. "Female children do not inherit diabetes mellitus, but male children will."

a. "Your risk of diabetes is higher than the general population, but it may not occur." (Risk for type 1 diabetes is determined by inheritance of genes coding for HLA-DR and HLA-DQ tissue types. Clients who have one parent with type 1 diabetes are at increased risk for its development. Diabetes (type 1) seems to require interaction between inherited risk and environmental factors, so not everyone with these genes develops diabetes. The other statements are not accurate.)

A nurse assesses clients at a health fair. Which clients should the nurse counsel to be tested for diabetes? (Select all that apply.) a. 56-year-old African-American male b. Female with a 30-pound weight gain during pregnancy c. Male with a history of pancreatic trauma d. 48-year-old woman with a sedentary lifestyle e. Male with a body mass index greater than 25 kg/m² f. 28-year-old female who gave birth to a baby weighing 9.2 pounds

a. 56-year-old African-American male d. 48-year-old woman with a sedentary lifestyle e. Male with a body mass index greater than 25 kg/m² f. 28-year-old female who gave birth to a baby weighing 9.2 pounds (Risk factors for type 2 diabetes include certain ethnic/racial groups (African Americans, American Indians, Hispanics), obesity and physical inactivity, and giving birth to large babies. Pancreatic trauma and a 30-pound gestational weight gain are not risk factors.)

The circulating nurse reviews the day's schedule and notes clients who are at higher risk of anesthetic overdose and other anesthesia-related complications. Which clients does this include? (Select all that apply.) a. A 75-year-old client scheduled for an elective procedure b. Client who drinks a 6-pack of beer each day c. Client with a serum creatinine of 3.8 mg/dL d. Client who is taking birth control pills e. Young male client with a RYR1 gene mutation

a. A 75-year-old client scheduled for an elective procedure b. Client who drinks a 6-pack of beer each day c. Client with a serum creatinine of 3.8 mg/dL e. Young male client with a RYR1 gene mutation (People at higher risk for anesthetic overdose or other anesthesia-related complications include people with a slowed metabolism (older adults generally have slower metabolism than younger adults), those with kidney or liver impairments, and those with mutations of the RYR1 gene. Drinking a 6-pack of beer per day possibly indicates some liver disease; a creatinine of 3.8 is high, indicating renal disease; and the genetic mutation increases the chance of malignant hyperthermia. Taking birth control pills is not a risk factor.)

A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first? a. Administer 1 mg of intramuscular glucagon. b. Encourage the client to drink orange juice. c. Insert a new intravenous access line. d. Administer 25 mL dextrose 50% (D50) IV push.

a. Administer 1 mg of intramuscular glucagon. (The client's blood glucose level is dangerously low. The nurse needs to administer glucagon IM immediately to increase the client's blood glucose level. The nurse should insert a new IV after administering the glucagon and can use the new IV site for future doses of D50 if the client's blood glucose level does not rise. Once the client is awake, orange juice may be administered orally along with a form of protein such as a peanut butter.)

A client in the operating room has developed malignant hyperthermia. The client's potassium is 6.5 mEq/L. What action by the nurse takes priority? a. Administer 10 units of regular insulin. b. Administer nifedipine (Procardia). c. Assess urine for myoglobin or blood. d. Monitor the client for dysrhythmias.

a. Administer 10 units of regular insulin. (For hyperkalemia in a client with malignant hyperthermia, the nurse administers 10 units of regular insulin in 50 mL of 50% dextrose. This will force potassium back into the cells rapidly. Nifedipine is a calcium channel blocker used to treat hypertension and dysrhythmias, and should not be used in a client with malignant hyperthermia. Assessing the urine for blood or myoglobin is important, but does not take priority. Monitoring the client for dysrhythmias is also important due to the potassium imbalance, but again does not take priority over treating the potassium imbalance.)

A nurse assesses a client who has diabetes mellitus and notes the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup of orange juice, the client's clinical manifestations have not changed. Which action should the nurse take next? a. Administer another half-cup of orange juice. b. Administer a half-ampule of dextrose 50% intravenously. c. Administer 10 units of regular insulin subcutaneously. d. Administer 1 mg of glucagon intramuscularly.

a. Administer another half-cup of orange juice. (This client is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, the nurse should administer oral glucose in the form of orange juice. If the symptoms do not resolve immediately, the treatment should be repeated. The client does not need intravenous dextrose, insulin, or glucagon.)

A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority? a. Airway b. Bleeding c. Breathing d. Cardiac rhythm

a. Airway (Assessing the airway always takes priority, followed by breathing and circulation. Bleeding is part of the circulation assessment, as is cardiac rhythm.)

A nurse is admitting an older client for surgery to the inpatient surgical unit. The client relates a prior history of acute confusion after a previous operation. What interventions does the nurse include on the client's plan of care to minimize the potential for this occurring? (Select all that apply.) a. Allow family and friends to visit as the client desires. b. Ask the client about coping techniques frequently used. c. Instruct the nursing assistant to ensure the client is bathed. d. Place the client in a room secluded at the end of the hall. e. Provide the client with uninterrupted periods of sleep.

a. Allow family and friends to visit as the client desires. b. Ask the client about coping techniques frequently used. c. Instruct the nursing assistant to ensure the client is bathed. e. Provide the client with uninterrupted periods of sleep. (Older clients may have difficulty adjusting to the stress of the hospital environment and illness or surgery. Techniques that are helpful include allowing liberal visitation, assisting the client to use successful coping techniques, and keeping the client bathed and groomed. Sleep deprivation can contribute to confusion, so the nurse ensures the client receives adequate sleep. Secluding the client at the end of the hall may lead to sensory deprivation and loneliness.)

A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort? (Select all that apply.) a. Allow the client to assume a position of comfort. b. Allow the client's family to remain at the bedside. c. Give the client a warm, non-caffeinated drink. d. Provide warm blankets or cool washcloths as desired. e. Pull the curtains around the bed to provide privacy.

a. Allow the client to assume a position of comfort. b. Allow the client's family to remain at the bedside. d. Provide warm blankets or cool washcloths as desired. e. Pull the curtains around the bed to provide privacy. (There are many nonpharmacologic comfort measures the nurse can employ, such as allowing the client to remain in the position that is most comfortable, letting the family stay with the client, providing warmth or cooling measures as requested by the client, and providing privacy. The client in the preoperative holding area is NPO, so drinks should not be provided.)

A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client? a. Allow the client to keep hearing aids in until anesthesia begins. b. Pad the table as appropriate for the surgical procedure. c. Position the client for maximum visualization of the site. d. Stay with the client, providing emotional comfort and support.

a. Allow the client to keep hearing aids in until anesthesia begins. (Many older clients have sensory loss. To help prevent disorientation, facilities often allow older clients to keep their eyeglasses on and hearing aids in until the start of anesthesia. The other actions are appropriate for all operative clients.)

A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort interventions can the nurse provide? (Select all that apply.) a. Apply stimulation to the contralateral leg. b. Assess the client's willingness to try meditation. c. Elevate the client's operative leg and apply ice. d. Reduce the noise level in the client's environment. e. Turn the TV on loudly to distract the client.

a. Apply stimulation to the contralateral leg. b. Assess the client's willingness to try meditation. c. Elevate the client's operative leg and apply ice. d. Reduce the noise level in the client's environment. (There are many nonpharmacologic comfort measures for pain, including applying stimulation to the opposite leg, providing opportunities for meditation, elevation of the leg, applying ice, and reducing noxious stimuli in the environment. Participating in diversional activities is another approach, but simply turning the TV on loudly does not provide a good diversion.)

A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming procedure. What action by the nurse is best? a. Ask the client to describe current feelings. b. Determine if the client wants a chaplain. c. Reassure the client this surgery is common. d. Tell the client there is no need to be anxious.

a. Ask the client to describe current feelings. (The nurse needs to conduct further assessment of the client's anxiety. Asking open-ended questions about current feelings is an appropriate way to begin. The client may want a chaplain, but the nurse needs to do more for the client. Reassurance can be good, but false hope is not, and simply reassuring the client may not be helpful. Telling the client not to be anxious belittles the client's feelings.)

A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%. What action by the nurse is most appropriate? a. Assess other indicators of oxygenation. b. Call the Rapid Response Team. c. Notify the anesthesia provider. d. Prepare to intubate the client.

a. Assess other indicators of oxygenation. (If a postoperative client's oxygen saturation (SaO2) drops below 95% (or the client's baseline), the nurse should notify the anesthesia provider. If the SaO2 drops by 10% or more, the nurse should call the Rapid Response Team. Since this is approximately a 3% drop, the nurse should further assess the client. Intubation (if the client is not intubated already) is not warranted.)

A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best? a. Assess the client for anxiety. b. Break the information into smaller bits. c. Give the client written information. d. Review the information again.

a. Assess the client for anxiety. (Anxiety can interfere with learning and cooperation. The nurse should assess the client for anxiety. The other actions are appropriate too, and can be included in the teaching plan, but effective teaching cannot occur if the client is highly anxious.)

A client is having surgery. The circulating nurse notes the client's oxygen saturation is 90% and the heart rate is 110 beats/min. What action by the nurse is best? a. Assess the client's end-tidal carbon dioxide level. b. Document the findings in the client's chart. c. Inform the anesthesia provider of these values. d. Prepare to administer dantrolene sodium (Dantrium).

a. Assess the client's end-tidal carbon dioxide level. (Malignant hyperthermia is a rare but serious reaction to anesthesia. The triad of early signs include decreased oxygen saturation, tachycardia, and elevated end-tidal carbon dioxide (CO2) level. The nurse should quickly check the end-tidal CO2 and then report findings to the anesthesia provider and surgeon. Documentation is vital, but not the most important action at this stage. Dantrolene sodium is the drug of choice if the client does have malignant hyperthermia.)

A client is having shoulder surgery with regional anesthesia. What actions by the nurse are most important to enhance client safety related to this anesthesia? (Select all that apply.) a. Assessing distal circulation to the operative arm after positioning b. Keeping the client warm during the operative procedure c. Padding the client's shoulder and arm on the operating table d. Preparing to suction the client's airway if the client vomits e. Speaking in a low, quiet voice as anesthesia is administered

a. Assessing distal circulation to the operative arm after positioning c. Padding the client's shoulder and arm on the operating table (After regional anesthesia is administered, the client loses all sensation distally. The nurse ensures client safety by assessing distal circulation and padding the shoulder and arm appropriately. Although awake, the client will not be able to report potential injury. Keeping the client warm is not related to this anesthesia, nor is suctioning or speaking quietly.)

The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best? a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. b. Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy. c. Hold educational meetings with the nursing and surgical staff on infection prevention. d. Monitor staff on both units for consistent adherence to established hand hygiene practices.

a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. (The SCIP project contains core measures that are mandatory for all surgical clients and focuses on preventing infection, serious cardiac events, and venous thromboembolism. The managers should start by reviewing charts to see if the guidelines of this project were implemented. The other actions may be necessary too, but first the managers need to assess the situation.)

An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment? a. Change in behavior b. Daily white blood cell count c. Presence of fever and chills d. Tolerance of increasing activity

a. Change in behavior (Older people have an age-related decrease in immune system functioning and may not show classic signs of infection such as increased white blood cell count, fever and chills, or obvious localized signs of infection. A change in behavior often signals an infection or onset of other illness in the older client.)

Maintaining a safe environment is a major responsibility of which surgical team member? a. Circulating nurse b. Scrub nurse c. Surgeon d. Certified registered nurse anesthetist

a. Circulating nurse (The circulating nurse observes the surgical procedure, coordinates the needs of the surgical team, and assists the team in maintaining a safe and comfortable environment. The scrub nurse is within the sterile field and passes instruments and other equipment needed to the surgeon during the surgical procedure. The surgeon performs the surgical procedure. The certified registered nurse anesthetist is a registered nurse who has been trained to deliver anesthesia.)

A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best? a. Consult the surgeon about a postoperative dietitian referral. b. Document the findings thoroughly in the client's chart. c. Encourage the client to eat more after recovering from surgery. d. Refer the client to Meals on Wheels after discharge.

a. Consult the surgeon about a postoperative dietitian referral. (This client has signs of malnutrition, which can impact recovery from surgery. The nurse should consult the surgeon about prescribing a consultation with a dietitian in the postoperative period. The nurse should document the findings but needs to do more. Encouraging the client to eat more may be helpful, but the client needs a professional nutritional assessment so that the appropriate diet and supplements can be ordered. The client may or may not need Meals on Wheels after discharge.)

What actions by the circulating nurse are important to promote client comfort? (Select all that apply.) a. Correct positioning b. Introducing one's self c. Providing warmth d. Remaining present e. Removing hearing aids

a. Correct positioning b. Introducing one's self c. Providing warmth d. Remaining present (The circulating nurse can do many things to promote client comfort, including positioning the client correctly and comfortably, introducing herself or himself to the client, keeping the client warm, and remaining present with the client. Removing hearing aids does not promote comfort and, if the client is still awake when they are removed, may contribute to disorientation and anxiety.)

A student nurse asks why older adults are at higher risk for complications after surgery. What reasons does the registered nurse give? (Select all that apply.) a. Decreased cardiac output b. Decreased oxygenation c. Frequent nocturia d. Mobility alterations e. Inability to adapt to changes

a. Decreased cardiac output b. Decreased oxygenation c. Frequent nocturia d. Mobility alterations (Older adults have many age-related physiologic changes that put them at higher risk of falling and other complications after surgery. Some of these include decreased cardiac output, decreased oxygenation of tissues, nocturia, and mobility alterations. They also have a decreased ability to adapt to new surroundings, but that is not the same as being unable to adapt.)

A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations should the nurse monitor the client? (Select all that apply.) a. Deep and fast respirations b. Decreased urine output c. Tachycardia d. Dependent pulmonary crackles e. Orthostatic hypotension

a. Deep and fast respirations c. Tachycardia e. Orthostatic hypotension (DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension. Usually clients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur.)

A preoperative nurse assesses a client who has type 1 diabetes mellitus prior to a surgical procedure. The client's blood glucose level is 160 mg/dL. Which action should the nurse take? a. Document the finding in the client's chart. b. Administer a bolus of regular insulin IV. c. Call the surgeon to cancel the procedure. d. Draw blood gases to assess the metabolic state.

a. Document the finding in the client's chart. (Clients who have type 1 diabetes and are having surgery have been found to have fewer complications, lower rates of infection, and better wound healing if blood glucose levels are maintained at between 140 and 180 mg/dL throughout the perioperative period. The nurse should document the finding and proceed with other operative care. The need for a bolus of insulin, canceling the procedure, or drawing arterial blood gases is not required.)

A nurse prepares to administer insulin to a client at 1800. The client's medication administration record contains the following information: -------------------------------- • Insulin glargine: 12 units daily at 1800 • Regular insulin: 6 units QID at 0600, 1200, 1800, 2400 -------------------------------- Based on the client's medication administration record, which action should the nurse take? a. Draw up and inject the insulin glargine first, and then draw up and inject the regular insulin. b. Draw up and inject the insulin glargine first, wait 20 minutes, and then draw up and inject the regular insulin. c. First draw up the dose of regular insulin, then draw up the dose of insulin glargine in the same syringe, mix, and inject the two insulins together. d. First draw up the dose of insulin glargine, then draw up the dose of regular insulin in the same syringe, mix, and inject the two insulins together.

a. Draw up and inject the insulin glargine first, and then draw up and inject the regular insulin. (Insulin glargine must not be diluted or mixed with any other insulin or solution. Mixing results in an unpredictable alteration in the onset of action and time to peak action. The correct instruction is to draw up and inject first the glargine and then the regular insulin right afterward.)

A student nurse observing in the operating room notes that the functions of the Certified Registered Nurse First Assistant (CRNFA) include which activities? (Select all that apply.) a. Dressing the surgical wound b. Grafting new or synthetic skin c. Reattaching severed nerves d. Suctioning the surgical site e. Suturing the surgical wound

a. Dressing the surgical wound d. Suctioning the surgical site e. Suturing the surgical wound (The CRNFA can perform tasks under the direction of the surgeon such as suturing and dressing surgical wounds, cutting away tissue, suctioning the wound to improve visibility, and holding retractors. Reattaching severed nerves and performing grafts would be the responsibility of the surgeon.)

The nursing student observing in the perioperative area notes the unique functions of the circulating nurse, which include which roles? (Select all that apply.) a. Ensuring the client's safety b. Accounting for all sharps c. Documenting all care given d. Maintaining the sterile field e. Monitoring traffic in the room

a. Ensuring the client's safety e. Monitoring traffic in the room (The circulating nurse has several functions, including maintaining client safety and privacy, monitoring traffic in and out of the operating room, assessing fluid losses, reporting findings to the surgeon and anesthesia provider, anticipating needs of the team, and communicating to the family. The circulating nurse and scrub person work together to ensure accurate counts of sharps, sponges, and instruments. The circulating nurse also documents care, but in the perioperative area, the preoperative or holding room nurse would also document care received there. Maintaining the sterile field is a joint responsibility among all members of the surgical team.)

A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate? a. Explain the rationale for giving the medicine now. b. Leave the room and come back in 15 minutes. c. Provide holistic client care and come back later. d. Tell the client you must start the medication now.

a. Explain the rationale for giving the medicine now. (The preoperative antibiotic must be given within 60 minutes of the surgical start time to ensure the proper amount is in the tissues when the incision is made. The nurse should explain the rationale to the client for this timing. The other options do not take this timing into consideration and do not give the client the information needed to be cooperative.)

A client is scheduled for a below-the-knee amputation. The circulating nurse ensures the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate? a. Facilitate marking the site with the client and surgeon. b. Have the client mark the operative site. c. Mark the operative site with a waterproof marker. d. Tell the surgeon it is time to mark the surgical site.

a. Facilitate marking the site with the client and surgeon. (The Joint Commission now recommends that both the client and the surgeon mark the operative site together in order to prevent wrong-site surgery. The nurse should facilitate this process.)

A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which IV-push medication and dose does the nurse prepare to administer? a. Flumazenil (Romazicon) 0.2 to 1 mg b. Flumazenil (Romazicon) 2 to 10 mg c. Naloxone (Narcan) 0.4 to 2 mg d. Naloxone (Narcan) 4 to 20 mg

a. Flumazenil (Romazicon) 0.2 to 1 mg (Flumazenil is a benzodiazepine antagonist and would be the correct drug to use in this situation. The correct dose is 0.2 to 1 mg. Naloxone is an opioid antagonist.)

An emergency department nurse assesses a client with ketoacidosis. Which clinical manifestation should the nurse correlate with this condition? a. Increased rate and depth of respiration b. Extremity tremors followed by seizure activity c. Oral temperature of 102° F (38.9° C) d. Severe orthostatic hypotension

a. Increased rate and depth of respiration (Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation. Tremors, elevated temperature, and orthostatic hypotension are not associated with ketoacidosis.)

A nurse is caring for several clients prior to surgery. Which medications taken by the clients require the nurse to consult with the physician about their administration? (Select all that apply.) a. Metformin (Glucophage) b. Omega-3 fatty acids (Sea Omega 30) c. Phenytoin (Dilantin) d. Pilocarpine hydrochloride (Isopto Carpine) e. Warfarin (Coumadin)

a. Metformin (Glucophage) c. Phenytoin (Dilantin) d. Pilocarpine hydrochloride (Isopto Carpine) e. Warfarin (Coumadin) (Although the client will be on NPO status before surgery, the nurse should check with the provider about allowing the client to take medications prescribed for diabetes, hypertension, cardiac disease, seizure disorders, depression, glaucoma, anticoagulation, or depression. Metformin is used to treat diabetes; phenytoin is for seizures; pilocarpine is for glaucoma, and warfarin is an anticoagulant. The omega-3 fatty acids can be held the day of surgery.)

A patient who has severe nausea and vomiting following a case of food poisoning comes to the urgent care center. When reviewing his medication history, the nurse notes that he has an allergy to procaine. The nurse would question an order for which antiemetic drug if ordered for this patient? a. Metoclopramide (Reglan) b. Promethazine (Phenergan) c. Phosphorated carbohydrate solution (Emetrol) d. Palonosetron (Aloxi)

a. Metoclopramide (Reglan) (The use of metoclopramide (Reglan) is contraindicated in patients with a hypersensitivity to procaine or procainamide. There are no known interactions with the drugs listed in the other options.)

A patient is receiving a tube feeding through a gastrostomy. The nurse expects that which type of drug will be used to promote gastric emptying for this patient? a. Prokinetic drugs, such as metoclopramide (Reglan) b. Serotonin blockers, such as ondansetron (Zofran) c. Anticholinergic drugs, such as scopolamine (Transderm-Scop) d. Neuroleptic drugs, such as chlorpromazine (Thorazine)

a. Prokinetic drugs, such as metoclopramide (Reglan) (Prokinetic drugs promote the movement of substances through the gastrointestinal tract and increase gastrointestinal motility.)

The nurse is conducting a smoking-cessation program. Which statement regarding drugs used in cigarette-smoking-cessation programs is true? a. Rapid chewing of the nicotine gum releases an immediate dose of nicotine. b. Quick relief from withdrawal symptoms is most easily achieved by using a transdermal patch. c. Compliance with treatment is higher with use of the gum rather than the transdermal patch. d. The nicotine gum can be used only up to six times per day.

a. Rapid chewing of the nicotine gum releases an immediate dose of nicotine. (Quick or acute relief from withdrawal symptoms is most easily achieved with the use of the gum because rapid chewing of the gum produces an immediate dose of nicotine. However, treatment compliance is higher with the use of the transdermal patch system. Nicotine gum can be used whenever the patient has a strong urge to smoke.)

A nurse collaborates with the interdisciplinary team to develop a plan of care for a client who is newly diagnosed with diabetes mellitus. Which team members should the nurse include in this interdisciplinary team meeting? (Select all that apply.) a. Registered dietitian b. Clinical pharmacist c. Occupational therapist d. Health care provider e. Speech-language pathologist

a. Registered dietitian b. Clinical pharmacist d. Health care provider (When planning care for a client newly diagnosed with diabetes mellitus, the nurse should collaborate with a registered dietitian, clinical pharmacist, and health care provider. The focus of treatment for a newly diagnosed client would be nutrition, medication therapy, and education. The nurse could also consult with a diabetic educator. There is no need for occupational therapy or speech therapy at this time.)

A nurse provides diabetic education at a public health fair. Which disorders should the nurse include as complications of diabetes mellitus? (Select all that apply.) a. Stroke b. Kidney failure c. Blindness d. Respiratory failure e. Cirrhosis

a. Stroke b. Kidney failure c. Blindness (Complications of diabetes mellitus are caused by macrovascular and microvascular changes. Macrovascular complications include coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Microvascular complications include nephropathy, retinopathy, and neuropathy. Respiratory failure and cirrhosis are not complications of diabetes mellitus.)

A patient is taking gabapentin (Neurontin), and the nurse notes that there is no history of seizures on his medical record. What is the best possible rationale for this medication order? a. The medication is used for the treatment of neuropathic pain. b. The medication is helpful for the treatment of multiple sclerosis. c. The medication is used to reduce the symptoms of Parkinson's disease. d. The medical record is missing the correct information about the patient's history of seizures.

a. The medication is used for the treatment of neuropathic pain. (Gabapentin (Neurontin) is commonly used to treat neuropathic pain. The other options are incorrect.)

A nurse cares for a client with diabetes mellitus who asks, "Why do I need to administer more than one injection of insulin each day?" How should the nurse respond? a. "You need to start with multiple injections until you become more proficient at self-injection." b. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns." c. "A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates." d. "A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock."

b. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns." (Even when a single injection of insulin contains a combined dose of different-acting insulin types, the timing of the actions and the timing of food intake may not match well enough to prevent wide variations in blood glucose levels. One dose of insulin would not be appropriate even if the client decreased carbohydrate intake. Additional injections are not required to allow the client practice with injections, nor will one dose increase the client's risk of insulin shock.)

A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement should the nurse include in this client's teaching? a. "Change positions slowly when you get out of bed." b. "Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)." c. "If you miss a dose of this drug, you can double the next dose." d. "Discontinue the medication if you develop a urinary infection."

b. "Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)." (NSAIDs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a sulfonylurea. The other statements are not applicable to glipizide.)

A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate? a. "After you wash the surgical site, shave that area with your own razor." b. "Be sure to wash the area where you will have surgery very thoroughly." c. "Use a washcloth to wash the surgical site; do not take a full shower or bath." d. "Wash the surgical site first, then shampoo and wash the rest of your body."

b. "Be sure to wash the area where you will have surgery very thoroughly." (The entire proposed surgical site needs to be washed thoroughly and completely with the antimicrobial soap. Shaving, if absolutely necessary, should be done in the operative suite immediately before the operation begins, using sterile equipment. The client needs a full shower or bath (shower preferred). The client should wash the surgical site last; dirty water from shampooing will run over the cleansed site if the site is washed first.)

A nurse teaches a client about self-monitoring of blood glucose levels. Which statement should the nurse include in this client's teaching to prevent bloodborne infections? a. "Wash your hands after completing each test." b. "Do not share your monitoring equipment." c. "Blot excess blood from the strip with a cotton ball." d. "Use gloves when monitoring your blood glucose."

b. "Do not share your monitoring equipment." (Small particles of blood can adhere to the monitoring device, and infection can be transported from one user to another. Hepatitis B in particular can survive in a dried state for about a week. The client should be taught to avoid sharing any equipment, including the lancet holder. The client should be taught to wash his or her hands before testing. The client would not need to blot excess blood away from the strip or wear gloves.)

A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best? a. "All preoperative clients get this medication." b. "It helps prevent ulcers from the stress of the surgery." c. "Since you don't have ulcers, I will have to ask." d. "The physician prescribed this medication for you."

b. "It helps prevent ulcers from the stress of the surgery." (Ulcer prophylaxis is common for clients undergoing long procedures or for whom high stress is likely. The nurse is not being truthful by saying all clients get this medication. If the nurse does not know the information, it is appropriate to find out, but this is a common medication for which the nurse should know the rationale prior to administering it. Simply stating that the physician prescribed the medication does not give the client any useful information.)

A nurse reviews the medication list of a client with a 20-year history of diabetes mellitus. The client holds up the bottle of prescribed duloxetine (Cymbalta) and states, "My cousin has depression and is taking this drug. Do you think I'm depressed?" How should the nurse respond? a. "Many people with long-term diabetes become depressed after a while." b. "It's for peripheral neuropathy. Do you have burning pain in your feet or hands?" c. "This antidepressant also has anti-inflammatory properties for diabetic pain." d. "No. Many medications can be used for several different disorders."

b. "It's for peripheral neuropathy. Do you have burning pain in your feet or hands?" (Damage along nerves causes peripheral neuropathy and leads to burning pain along the nerves. Many drugs, including duloxetine (Cymbalta), can be used to treat peripheral neuropathy. The nurse should assess the client for this condition and then should provide an explanation of why this drug is being used. This medication, although it is used for depression, is not being used for that reason in this case. Duloxetine does not have anti-inflammatory properties. Telling the client that many medications are used for different disorders does not provide the client with enough information to be useful.)

A nurse teaches a client with diabetes mellitus about sick day management. Which statement should the nurse include in this client's teaching? a. "When ill, avoid eating or drinking to reduce vomiting and diarrhea." b. "Monitor your blood glucose levels at least every 4 hours while sick." c. "If vomiting, do not use insulin or take your oral antidiabetic agent." d. "Try to continue your prescribed exercise regimen even if you are sick."

b. "Monitor your blood glucose levels at least every 4 hours while sick." (When ill, the client should monitor his or her blood glucose at least every 4 hours. The client should continue taking the medication regimen while ill. The client should continue to eat and drink as tolerated but should not exercise while sick.)

A nurse cares for a client who is diagnosed with acute rejection 2 months after receiving a simultaneous pancreas-kidney transplant. The client states, "I was doing so well with my new organs, and the thought of having to go back to living on hemodialysis and taking insulin is so depressing." How should the nurse respond? a. "Following the drug regimen more closely would have prevented this." b. "One acute rejection episode does not mean that you will lose the new organs." c. "Dialysis is a viable treatment option for you and may save your life." d. "Since you are on the national registry, you can receive a second transplantation."

b. "One acute rejection episode does not mean that you will lose the new organs." (An episode of acute rejection does not automatically mean that the client will lose the transplant. Pharmacologic manipulation of host immune responses at this time can limit damage to the organ and allow the graft to be maintained. The other statements either belittle the client or downplay his or her concerns. The client may not be a candidate for additional organ transplantation.)

After teaching a client with type 2 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I need to have an annual appointment even if my glucose levels are in good control." b. "Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick." c. "I can still develop complications even though I do not have to take insulin at this time." d. "If I have surgery or get very ill, I may have to receive insulin injections for a short time."

b. "Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick." (Clients with diabetes need to be seen at least annually to monitor for long-term complications, including visual changes, microalbuminuria, and lipid analysis. The client may develop complications and may need insulin in the future.)

A 38-year-old male patient stopped smoking 6 months ago. He tells the nurse that he still feels strong cigarette cravings and wonders if he is ever going to feel "normal" again. Which statement by the nurse is correct? a. "It's possible that these cravings will never stop." b. "These cravings may persist for several months." c. "The cravings tell us that you are still using nicotine." d. "The cravings show that you are about to experience nicotine withdrawal."

b. "These cravings may persist for several months." (Cigarette cravings may persist for months after nicotine withdrawal. The other statements are false.)

A nurse is teaching a client with diabetes mellitus who asks, "Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL?" How should the nurse respond? a. "Glucose is the only fuel used by the body to produce the energy that it needs." b. "Your brain needs a constant supply of glucose because it cannot store it." c. "Without a minimum level of glucose, your body does not make red blood cells." d. "Glucose in the blood prevents the formation of lactic acid and prevents acidosis."

b. "Your brain needs a constant supply of glucose because it cannot store it." (Because the brain cannot synthesize or store significant amounts of glucose, a continuous supply from the body's circulation is needed to meet the fuel demands of the central nervous system. The nurse would want to educate the client to prevent hypoglycemia. The body can use other sources of fuel, including fat and protein, and glucose is not involved in the production of red blood cells. Glucose in the blood will encourage glucose metabolism but is not directly responsible for lactic acid formation.)

A nurse cares for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 0700. At which time should the nurse assess the client for potential problems related to the NPH insulin? a. 0800 b. 1600 c. 2000 d. 2300

b. 1600 (Neutral protamine Hagedorn (NPH) is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4 to 12 hours, and duration of action of 22 hours. Checking the client at 0800 would be too soon. Checking the client at 2000 and 2300 would be too late. The nurse should check the client at 1600.)

A patient is on a chemotherapy regimen in an outpatient clinic and is receiving a chemotherapy drug that is known to be highly emetogenic. The nurse will implement which interventions regarding the pharmacologic management of nausea and vomiting? (Select all that apply.) a. Giving antinausea drugs at the beginning of the chemotherapy infusion b. Administering antinausea drugs 30 to 60 minutes before chemotherapy is started c. For best therapeutic effects, medicating for nausea once the symptoms begin d. Observing carefully for the adverse effects of restlessness and anxiety e. Instructing the patient that the antinausea drugs may cause extreme drowsiness f. Instructing the patient to rise slowly from a sitting or lying position because of possible orthostatic hypotension

b. Administering antinausea drugs 30 to 60 minutes before chemotherapy is started e. Instructing the patient that the antinausea drugs may cause extreme drowsiness f. Instructing the patient to rise slowly from a sitting or lying position because of possible orthostatic hypotension (Antiemetics should be given before any chemotherapy drug is administered, often 30 to 60 minutes before treatment, but not immediately before chemotherapy is administered. Do not wait until the nausea begins. Most antiemetics cause drowsiness, not restlessness and anxiety. Orthostatic hypotension is a possible adverse effect that may lead to injury.)

A nurse is caring for a postoperative client who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort? a. Assess the client's pain on a 0-to-10 scale. b. Assist the client into a position of comfort. c. Have the client sit up in a recliner. d. Tell the client when pain medication is due.

b. Assist the client into a position of comfort. (Several nonpharmacologic comfort measures can help postoperative clients with their pain, including distraction, music, massage, guided imagery, and positioning. The nurse should help this client into a position of comfort considering the surgical procedure and position of any tubes or drains. Assessing the client's pain is important but does not improve comfort. The client may be more uncomfortable in a recliner. Letting the client know when pain medication can be given next is important but does not improve comfort.)

A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important? a. Allow the client to rest. b. Auscultate lung sounds. c. Document the episode. d. Encourage the client to eat dry toast.

b. Auscultate lung sounds. (Vomiting after surgery has several complications, including aspiration. The nurse should listen to the client's lung sounds. The client should be allowed to rest after an assessment. Documenting is important, but the nurse needs to be able to document fully, including an assessment. The client should not eat until nausea has subsided.)

A client is in stage 2 of general anesthesia. What action by the nurse is most important? a. Keeping the room quiet and calm b. Being prepared to suction the airway c. Positioning the client correctly d. Warming the client with blankets

b. Being prepared to suction the airway (During stage 2 of general anesthesia (excitement, delirium), the client can vomit and aspirate. The nurse must be ready to react to this potential occurrence by being prepared to suction the client's airway. Keeping the room quiet and calm does help the client enter the anesthetic state, but is not the priority. Positioning the client usually occurs during stage 3 (operative anesthesia). Keeping the client warm is important throughout to prevent hypothermia.)

A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.) a. Allow small sips of plain water. b. Check that consent is on the chart. c. Ensure the client has an armband on. d. Have the client help mark the surgical site. e. Allow the client to use the toilet before giving sedation.

b. Check that consent is on the chart. c. Ensure the client has an armband on. d. Have the client help mark the surgical site. e. Allow the client to use the toilet before giving sedation. (Providing for client safety is a priority function of the preoperative nurse. Checking for appropriately completed consent, verifying the client's identity, having the client assist in marking the surgical site if applicable, and allowing the client to use the toilet prior to sedating him or her are just some examples of important safety measures. The preoperative client should be NPO, so water should not be provided.)

The circulating nurse and preoperative nurse are reviewing the chart of a client scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority? a. Allergies noted and allergy band on b. Consent for MIS procedure only c. No prior anesthesia exposure d. NPO status for the last 8 hours

b. Consent for MIS procedure only (All MIS procedures have the potential for becoming open procedures depending on findings and complications. The client's consent should include this possibility. The nurse should report this finding to the surgeon prior to surgery taking place. Having allergies noted and an allergy band applied is standard procedure. Not having any prior surgical or anesthesia exposure is not the priority. Maintaining NPO status as prescribed is standard procedure.)

A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best? a. Call the provider to request more analgesia. b. Demonstrate how to splint the incision. c. Have the client take shallower breaths. d. Tell the client a little pain is expected.

b. Demonstrate how to splint the incision. (Splinting an incision provides extra support during coughing and activity and helps decrease pain. If the client is otherwise comfortable, no more analgesia is required. Shallow breathing can lead to atelectasis and pneumonia. The client should know some pain is normal and expected after surgery, but that answer alone does not provide any interventions to help the client.)

A patient on chemotherapy is using ondansetron (Zofran) for treatment of nausea. The nurse will instruct the patient to watch for which adverse effect of this drug? a. Dizziness b. Diarrhea c. Dry mouth d. Blurred vision

b. Diarrhea (Diarrhea is an adverse effect of the serotonin blockers. The other adverse effects listed may occur with anticholinergic drugs.)

A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.) a. Administering antibiotics for 72 hours b. Disposing of dressings properly c. Leaving draining wounds open to air d. Performing proper hand hygiene e. Removing and replacing wet dressings

b. Disposing of dressings properly d. Performing proper hand hygiene e. Removing and replacing wet dressings (Interventions necessary to prevent surgical wound infection include proper disposal of soiled dressings, performing proper hand hygiene, and removing wet dressings as they can be a source of infection. Prophylactic antibiotics are given to clients at risk for infection, but are discontinued after 24 hours if no infection is apparent. Draining wounds should always be covered.)

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best? a. Answer the questions and document that teaching was done. b. Do not have the client sign the consent and call the surgeon. c. Have the client sign the consent, then call the surgeon. d. Remind the client of what teaching the surgeon has done.

b. Do not have the client sign the consent and call the surgeon. (In order to give informed consent, the client needs sufficient information. Questions about potential complications should be answered by the surgeon. The nurse should notify the surgeon to come back and answer the client's questions before the client signs the consent form. The other actions are not appropriate.)

A client is having robotic surgery. The circulating nurse observes the instruments being inserted, then the surgeon appears to "break scrub" when going to the console and sitting down. What action by the nurse is best? a. Call a "time-out" to discuss sterile procedure and scrub technique. b. Document the time the robotic portion of the procedure begins. c. Inform the surgeon that the scrub preparation has been compromised. d. Report the surgeon's actions to the charge nurse and unit manager.

b. Document the time the robotic portion of the procedure begins. (During a robotic operative procedure, the surgeon inserts the articulating arms into the client, then "breaks scrub" to sit at the viewing console to perform the operation. The nurse should document the time the robotic portion of the procedure began. There is no need for the other interventions.)

A client waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the client's anxiety. b. Give the client a back rub. c. Remind the client to turn. d. Teach about postoperative care.

b. Give the client a back rub. (A back rub reduces anxiety and can be delegated to the UAP. Once teaching has been done, the UAP can remind the client to turn, but this is not related to relieving anxiety. Assessing anxiety and teaching are not within the scope of practice for the UAP.)

A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen: -------------------------------- • Fasting blood glucose: 75 mg/dL • Postprandial blood glucose: 200 mg/dL • Hemoglobin A1c level: 5.5% -------------------------------- How should the nurse interpret these laboratory findings? a. Increased risk for developing ketoacidosis b. Good control of blood glucose c. Increased risk for developing hyperglycemia d. Signs of insulin resistance

b. Good control of blood glucose (The client is maintaining blood glucose levels within the defined ranges for goals in an intensified regimen. Because the client's glycemic control is good, he or she is not at higher risk for ketoacidosis or hyperglycemia and is not showing signs of insulin resistance.)

A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.) a. Blood glucose: 120 mg/dL b. Hemoglobin: 7.8 mg/dL c. pH: 7.68 d. Potassium: 2.9 mEq/L e. Sodium: 142 mEq/L

b. Hemoglobin: 7.8 mg/dL c. pH: 7.68 d. Potassium: 2.9 mEq/L (Fluid and electrolyte balance are assessed carefully in the postoperative client because many imbalances can occur. The low hemoglobin may be from blood loss in surgery. The higher pH level indicates alkalosis, possibly from losses through the NG tube. The potassium is very low. The blood glucose is within normal limits for a postsurgical client who has been fasting. The sodium level is normal.)

A nurse reviews the chart and new prescriptions for a client with diabetic ketoacidosis: -------------------------------- Vital Signs and Assessment: • Blood pressure: 90/62 mm Hg • Respiratory rate: 28 breaths/min • Urine output: 20 mL/hr via catheter Laboratory Results: • Serum potassium: 2.6 mEq/L Medications: • Potassium chloride 40 mEq IV bolus STAT • Increase IV fluid to 100 mL/hr -------------------------------- Which action should the nurse take? a. Administer the potassium and then consult with the provider about the fluid order. b. Increase the intravenous rate and then consult with the provider about the potassium prescription. c. Administer the potassium first before increasing the infusion flow rate. d. Increase the intravenous flow rate before administering the potassium.

b. Increase the intravenous rate and then consult with the provider about the potassium prescription. (The client is acutely ill and is severely dehydrated and hypokalemic. The client requires more IV fluids and potassium. However, potassium should not be infused unless the urine output is at least 30 mL/hr. The nurse should first increase the IV rate and then consult with the provider about the potassium.)

A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing? (Select all that apply.) a. Hemorrhage b. Infection c. Serious cardiac events d. Stroke e. Thromboembolism

b. Infection c. Serious cardiac events e. Thromboembolism (The SCIP project includes core measures to prevent infection, serious cardiac events, and thromboembolic events such as deep vein thrombosis.)

A patient scheduled for surgery takes several medications. Which medication indicates that the patient's surgical risk is increased? a. Tylenol b. Insulin c. Thyroid medication d. Vitamin C

b. Insulin (Insulin is taken for an elevated glucose level. This person has diabetes, which increases the surgical risk. Tylenol does not increase the risk. Aspirin, steroids, and herbal medications increase surgical risk. Thyroid medication does not increase surgical risk. Vitamin C is needed for normal growth and development. It is also required for the growth and repair of tissues in all parts of the body.)

A nursing instructor is teaching students about different surgical procedures and their classifications. Which examples does the instructor include? (Select all that apply.) a. Hemicolectomy: diagnostic b. Liver biopsy: diagnostic c. Mastectomy: restorative d. Spinal cord decompression: palliative e. Total shoulder replacement: restorative

b. Liver biopsy: diagnostic e. Total shoulder replacement: restorative (A diagnostic procedure is used to determine cell type of cancer and to determine the cause of a problem. An example is a liver biopsy. A restorative procedure aims to improve functional ability. An example would be a total shoulder replacement or a spinal cord decompression (not palliative). A curative procedure either removes or repairs the causative problem. An example would be a mastectomy (not restorative) or a hemicolectomy (not diagnostic). A palliative procedure relieves symptoms but will not cure the disease. An example is an ileostomy. A cosmetic procedure is done to improve appearance. An example is rhinoplasty (a "nose job").)

A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered at high risk? (Select all that apply.) a. Client with a humerus fracture b. Morbidly obese client c. Client who underwent a prolonged surgical procedure d. Client with severe heart failure e. Wheelchair-bound client

b. Morbidly obese client c. Client who underwent a prolonged surgical procedure d. Client with severe heart failure e. Wheelchair-bound client (All surgical clients should be assessed for VTE risk. Those considered at higher risk include those who are obese; are over 40; have cancer; have decreased mobility, immobility, or a spinal cord injury; have a history of any thrombotic event, varicose veins, or edema; take oral contraceptives or smoke; have decreased cardiac output; have a hip fracture; or are having total hip or knee surgery. Prolonged surgical time increases risk due to mobility and positioning needs.)

The nurse is teaching a patient about regional anesthesia. Which statement is accurate about this type of anesthesia? a. Patients will be awake but disoriented during the surgery. b. Patients are awake with loss of sensation in an area of the body. c. Patients will be asleep but may feel some pressure during the surgery. d. Patients are asleep and won't be able to remember the surgery.

b. Patients are awake with loss of sensation in an area of the body. (Regional anesthesia allows for the patient to remain awake. The patient will not feel any sensations during the surgery. The patient will not be disoriented. Many patients may be asked to follow instructions during the surgery. The patient will remain awake and he or she should not feel any pressure. The patient should have full memory of the surgical experience.)

A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first? a. Assess the client's blood pressure. b. Perform hand hygiene and apply gloves. c. Reinforce the dressing with a clean one. d. Remove the dressing to assess the wound.

b. Perform hand hygiene and apply gloves. (Prior to assessing or treating the drainage from the wound, the nurse performs hand hygiene and dons gloves to protect both the client and nurse from infection.)

A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.) a. All phases require the client to be in the hospital. b. Phase I care may last for several days in some clients. c. Phase I requires intensive care unit monitoring. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III.

b. Phase I care may last for several days in some clients. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III. (There are three phases of postoperative care. Phase I is the most intense, with clients coming right from surgery until they are completely awake and hemodynamically stable. This may take hours or days and can occur in the intensive care unit or the postoperative care unit. Phase II ends when the client is at a presurgical level of consciousness and baseline oxygen saturation, and vital signs are stable. Phase III involves the extended care environment and may continue at home or in an extended care facility if needed.)

A client has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important? a. Assist with administering muscle relaxants to the client. b. Place the client on a cardiac monitor and pulse oximeter. c. Prepare to administer intravenous antiemetics to the client. d. Prevent the client from experiencing postoperative shivering.

b. Place the client on a cardiac monitor and pulse oximeter. (Intravenous anesthetic agents have the potential to cause respiratory and circulatory depression. The nurse should ensure the client is on a cardiac monitor and pulse oximeter. Muscle relaxants are not indicated for this client at this time. Intravenous anesthetics have a lower rate of postoperative nausea and vomiting than other types. Shivering can occur in any client, but is more common after inhalation agents.)

A patient is having a conversation with a surgeon. Which perioperative phase should the nurse anticipate will begin once the patient has agreed to have surgery? a. Postoperative b. Preoperative c. Intraoperative d. Interoperative

b. Preoperative (The preoperative phase begins when the patient agrees to have surgery. The postoperative phase begins when the patient is transferred from the operating room to the PACU. The intraoperative phase begins when the patient is transferred to the operating room. Interoperative is not a surgical phase.)

A nurse assesses a client with diabetes mellitus. Which clinical manifestation should alert the nurse to decreased kidney function in this client? a. Urine specific gravity of 1.033 b. Presence of protein in the urine c. Elevated capillary blood glucose level d. Presence of ketone bodies in the urine

b. Presence of protein in the urine (Renal dysfunction often occurs in the client with diabetes. Proteinuria is a result of renal dysfunction. Specific gravity is elevated with dehydration. Elevated capillary blood glucose levels and ketones in the urine are consistent with diabetes mellitus but are not specific to renal function.)

A nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the client's diet should the nurse decrease? a. Carbohydrates b. Proteins c. Fats d. Total calories

b. Proteins (Restriction of dietary protein to 0.8 g/kg of body weight per day is recommended for clients with microalbuminuria to delay progression to renal failure. The client's diet does not need to be decreased in carbohydrates, fats, or total calories.)

A client has been given hydroxyzine (Atarax) in the preoperative holding area. What action by the nurse is most important for this client? a. Document giving the drug. b. Raise the siderails on the bed. c. Record the client's vital signs. d. Teach relaxation techniques.

b. Raise the siderails on the bed. (All actions are appropriate for a preoperative client. However, for client safety, the nurse should raise the siderails on the bed because hydroxyzine can make the client sleepy.)

A nurse cares for a client who is prescribed pioglitazone (Actos). After 6 months of therapy, the client reports that his urine has become darker since starting the medication. Which action should the nurse take? a. Assess for pain or burning with urination. b. Review the client's liver function study results. c. Instruct the client to increase water intake. d. Test a sample of urine for occult blood.

b. Review the client's liver function study results. (Thiazolidinediones (including pioglitazone) can affect liver function; liver function should be assessed at the start of therapy and at regular intervals while the client continues to take these drugs. Dark urine is one indicator of liver impairment because bilirubin is increased in the blood and is excreted in the urine. The nurse should check the client's most recent liver function studies. The nurse does not need to assess for pain or burning with urination and does not need to check the urine for occult blood. The client does not need to be told to increase water intake.)

A patient is taking chemotherapy with a drug that has a high potential for causing nausea and vomiting. The nurse is preparing to administer an antiemetic drug. Which class of antiemetic drugs is most commonly used to prevent nausea and vomiting for patients receiving chemotherapy? a. Prokinetic drugs, such as metoclopramide (Reglan) b. Serotonin blockers, such as ondansetron (Zofran) c. Anticholinergic drugs, such as scopolamine d. Neuroleptic drugs, such as promethazine (Phenergan)

b. Serotonin blockers, such as ondansetron (Zofran) (Serotonin blockers are used to prevent chemotherapy-induced and postoperative nausea and vomiting. The other options are incorrect.)

A patient is scheduled for surgery. Which should the nurse include in the preoperative teaching? a. Side effects of postoperative pain medication b. The importance of stopping smoking before the surgery c. The different types of wound drainage d. Advice to call the doctor if having severe pain while in the hospital

b. The importance of stopping smoking before the surgery (A patient should stop smoking once he or she has made the decision to have surgery. Smoking can increase the risk for respiratory complications. At this time the nurse may not know what will be ordered for postoperative pain management. The patient should be given information to help him or her understand signs of infection. Giving information on all the types of drainage is unnecessary. The patient would not be responsible for calling the doctor for inpatient pain management.)

A patient who has been newly diagnosed with vertigo will be taking an antihistamine antiemetic drug. The nurse will include which information when teaching the patient about this drug? a. The patient may skip doses if the patient is feeling well. b. The patient will need to avoid driving because of possible drowsiness. c. The patient may experience occasional problems with taste. d. It is safe to take the medication with a glass of wine in the evening to help settle the stomach.

b. The patient will need to avoid driving because of possible drowsiness. (Drowsiness may occur because of central nervous system (CNS) depression, and patients should avoid driving or working with heavy machinery because of possible sedation. These drugs must not be taken with alcohol or other CNS depressants because of possible additive depressant effects. The medication should be taken as instructed and not skipped unless instructed to do so.)

A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met? a. Drainage from the surgical site is 30 mL less than yesterday. b. There is no redness, warmth, or drainage at the insertion site. c. The client reports adequate pain control with medications. d. Urine is clear yellow and urine output is greater than 40 mL/hr.

b. There is no redness, warmth, or drainage at the insertion site. (The priority client problem related to a surgical drain is the potential for infection. An insertion site that is free of redness, warmth, and drainage indicates that goals for this client problem are being met. The other assessments are normal, but not related to the drain.)

The nurse is teaching a patient about being discharged after an elective surgery. The procedure is being performed at an ambulatory surgical center. What information should the nurse include about transportation? a. You will be able to drive home. b. You will need someone to drive you home. c. You can drive home if someone is in the car with you. d. If you are lightheaded or dizzy, you will not be able to drive home.

b. You will need someone to drive you home. (Patients undergoing surgery in an ambulatory center will need someone to drive them home because of the effects of anesthesia, pain medication, and the surgery itself. Patients are instructed not to drive home. A patient cannot drive home with or without feeling lightheaded or dizzy. Patients should not drive even if someone is in the car with them. Driving is not allowed because of the medications given during the surgical procedure.)

A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values should the nurse identify as potential ketoacidosis in this client? a. pH 7.38, HCO₃⁻ 22 mEq/L, PCO₂ 38 mm Hg, PO₂ 98 mm Hg b. pH 7.28, HCO₃⁻ 18 mEq/L, PCO₂ 28 mm Hg, PO₂ 98 mm Hg c. pH 7.48, HCO₃⁻ 28 mEq/L, PCO₂ 38 mm Hg, PO₂ 98 mm Hg d. pH 7.32, HCO₃⁻ 22 mEq/L, PCO₂ 58 mm Hg, PO₂ 88 mm Hg

b. pH 7.28, HCO₃⁻ 18 mEq/L, PCO₂ 28 mm Hg, PO₂ 98 mm Hg (When the lungs can no longer offset acidosis, the pH decreases to below normal. A client who has diabetic ketoacidosis would present with arterial blood gas values that show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels.)

After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I should increase my intake of vegetables with higher amounts of dietary fiber." b. "My intake of saturated fats should be no more than 10% of my total calorie intake." c. "I should decrease my intake of protein and eliminate carbohydrates from my diet." d. "My intake of water is not restricted by my treatment plan or medication regimen."

c. "I should decrease my intake of protein and eliminate carbohydrates from my diet." (The client should not completely eliminate carbohydrates from the diet, and should reduce protein if microalbuminuria is present. The client should increase dietary intake of complex carbohydrates, including vegetables, and decrease intake of fat. Water does not need to be restricted unless kidney failure is present.)

At 4:45 p.m., a nurse assesses a client with diabetes mellitus who is recovering from an abdominal hysterectomy 2 days ago. The nurse notes that the client is confused and diaphoretic. The nurse reviews the assessment data provided in the chart below: -------------------------------- Capillary Blood Glucose Testing (AC/HS): • At 0630: 95 • At 1130: 70 • At 1630: 47 Dietary Intake: • Breakfast: 10% eaten - client states she is not hungry • Lunch: 5% eaten - client is nauseous; vomits once -------------------------------- After reviewing the client's assessment data, which action is appropriate at this time? a. Assess the client's oxygen saturation level and administer oxygen. b. Reorient the client and apply a cool washcloth to the client's forehead. c. Administer dextrose 50% intravenously and reassess the client. d. Provide a glass of orange juice and encourage the client to eat dinner.

c. Administer dextrose 50% intravenously and reassess the client. (The client's symptoms are related to hypoglycemia. Since the client has not been tolerating food, the nurse should administer dextrose intravenously. The client's oxygen level could be checked, but based on the information provided, this is not the priority. The client will not be reoriented until the glucose level rises.)

The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first? a. Client with a blood pressure of 100/50 mm Hg b. Client with a pulse of 118 beats/min c. Client with a respiratory rate of 6 breaths/min d. Client with a temperature of 96° F (35.6° C)

c. Client with a respiratory rate of 6 breaths/min (The respiratory rate is the most critical vital sign for any client who has undergone general anesthesia or moderate sedation, or has received opioid analgesia. This respiratory rate is too low and indicates respiratory depression. The nurse should assess this client first. A blood pressure of 100/50 mm Hg is slightly low and may be within that client's baseline. A pulse of 118 beats/min is slightly fast, which could be due to several causes, including pain and anxiety. A temperature of 96° F is slightly low and the client needs to be warmed. But none of these other vital signs take priority over the respiratory rate.)

A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the client's breath has a "fruity" odor. Which action should the nurse take? a. Encourage the client to use an incentive spirometer. b. Increase the client's intravenous fluid flow rate. c. Consult the provider to test for ketoacidosis. d. Perform meticulous pulmonary hygiene care.

c. Consult the provider to test for ketoacidosis. (The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the client to ketoacidosis and metabolic acidosis. One manifestation of ketoacidosis is a "fruity" odor to the breath. Documentation should occur after all assessments have been completed. Using an incentive spirometer, increasing IV fluids, and performing pulmonary hygiene will not address this client's problem.)

A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. Which action should the nurse take first? a. Document the finding in the client's chart. b. Assess tactile sensation in the client's hands. c. Examine the client's feet for signs of injury. d. Notify the health care provider.

c. Examine the client's feet for signs of injury. (Diabetic neuropathy is common when the disease is of long duration. The client is at great risk for injury in any area with decreased sensation because he or she is less able to feel injurious events. Feet are common locations for neuropathy and injury, so the nurse should inspect them for any signs of injury. After assessment, the nurse should document findings in the client's chart. Testing sensory perception in the hands may or may not be needed. The health care provider can be notified after assessment and documentation have been completed.)

The circulating nurse is plugging in a piece of equipment and notes that the cord is frayed. What action by the nurse is best? a. Call maintenance for repair. b. Check the machine before using. c. Get another piece of equipment. d. Notify the charge nurse.

c. Get another piece of equipment. (The circulating nurse is responsible for client safety. If an electrical cord is frayed, the risk of fire or sparking increases. The nurse should obtain a replacement. The nurse should also tag the original equipment for repair as per agency policy. Checking the equipment is not important as the nurse should not even attempt to use it. Calling maintenance or requesting maintenance per facility protocol is important, but first ensure client safety by having a properly working piece of equipment for the procedure about to take place. The charge nurse probably does need to know of the need for equipment repair, but ensuring client safety is the priority.)

A nurse assesses a client who is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted? a. Serum potassium level has increased. b. Blood osmolarity has decreased. c. Glasgow Coma Scale score is unchanged. d. Urine remains negative for ketone bodies.

c. Glasgow Coma Scale score is unchanged. (A slow but steady improvement in central nervous system functioning is the best indicator of therapy effectiveness for HHS. Lack of improvement in the level of consciousness may indicate inadequate rates of fluid replacement. The Glasgow Coma Scale assesses the client's state of consciousness against criteria of a scale including best eye, verbal, and motor responses. An increase in serum potassium, decreased blood osmolality, and urine negative for ketone bodies do not indicate adequacy of treatment.)

The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate? a. Ask the surgeon to change the sterile gown. b. Do nothing; this is acceptable sterile procedure. c. Inform the surgeon that the sterile field has been broken. d. Obtain a new pair of sterile gloves for the surgeon to put on.

c. Inform the surgeon that the sterile field has been broken. (The surgical gown is considered sterile from the chest to the level of the surgical field. By placing the hands down by the hips, the surgeon has broken sterile field. The circulating nurse informs the surgeon of this breach. Changing only the gloves or only the gown does not "restore" the sterile sections of the gown. Doing nothing is unacceptable.)

A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the client's bed. The client's blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the nurse is best? a. Call the Rapid Response Team. b. Increase the IV fluid rate. c. Lower the head of the bed. d. Nothing; this is expected.

c. Lower the head of the bed. (A client who had epidural or spinal anesthesia may become hypotensive when the head of the bed is raised. If this occurs, the nurse should lower the head of the bed to its original position. The Rapid Response Team is not needed, nor is an increase in IV rate.)

A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority for this client? a. Hydroxyzine (Atarax) b. Lorazepam (Ativan) c. Metoclopramide (Reglan) d. Morphine sulfate

c. Metoclopramide (Reglan) (Reglan increases gastric emptying, an important issue for this client who was eating just prior to the operation. The other drugs are appropriate for any surgical client.)

A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care? a. Married young adult who is the primary caregiver for children b. Middle-aged client who is post knee replacement, needs physical therapy c. Older adult who lives at home despite some memory loss d. Young client who lives alone, has family and friends nearby

c. Older adult who lives at home despite some memory loss (The older adult has the most potentially complex discharge needs. With memory loss, the client may not be able to follow the prescribed home regimen. The client's physical abilities may be limited by chronic illness. This client has several safety needs that should be assessed. The other clients all have evidence of a support system and no known potential for serious safety issues.)

A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team? a. Creatinine: 1.2 mg/dL b. Hemoglobin: 14.8 mg/dL c. Potassium: 2.9 mEq/L d. Sodium: 134 mEq/L

c. Potassium: 2.9 mEq/L (A potassium of 2.9 mEq/L is critically low and can affect cardiac and respiratory status. The nurse should communicate this laboratory value immediately. The creatinine is at the high end of normal, the hemoglobin is normal, and the sodium is only slightly low (normal low being 136 mEq/L), so these values do not need to be reported immediately.)

A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN? a. Cleaning around the drain per agency protocol b. Placing a new sterile gauze under the drain c. Securing the drain's safety pin to the sheets d. Using sterile technique to empty the drain

c. Securing the drain's safety pin to the sheets (The safety pin that prevents the drain from slipping back into the client's body should be pinned to the client's gown, not the bedding. Pinning it to the sheets will cause it to pull out when the client turns. The other actions are appropriate.)

A nurse teaches a client who is prescribed an insulin pump. Which statement should the nurse include in this client's discharge education? a. "Test your urine daily for ketones." b. "Use only buffered insulin in your pump." c. "Store the insulin in the freezer until you need it." d. "Change the needle every 3 days."

d. "Change the needle every 3 days." (Having the same needle remain in place through the skin for longer than 3 days drastically increases the risk for infection in or through the delivery system. Having an insulin pump does not require the client to test for ketones in the urine. Insulin should not be frozen. Insulin is not buffered.)

After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations? a. "At my age, I should continue seeing the ophthalmologist as I usually do." b. "I will see the eye doctor when I have a vision problem and yearly after age 40." c. "My vision will change quickly. I should see the ophthalmologist twice a year." d. "Diabetes can cause blindness, so I should see the ophthalmologist yearly."

d. "Diabetes can cause blindness, so I should see the ophthalmologist yearly." (Diabetic retinopathy is a leading cause of blindness in North America. All clients with diabetes, regardless of age, should be examined by an ophthalmologist (rather than an optometrist or optician) at diagnosis and at least yearly thereafter.)

After teaching a client who has diabetes mellitus and proliferative retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I have so many complications; exercising is not recommended." b. "I will exercise more frequently because I have so many complications." c. "I used to run for exercise; I will start training for a marathon." d. "I should look into swimming or water aerobics to get my exercise."

d. "I should look into swimming or water aerobics to get my exercise." (Exercise is not contraindicated for this client, although modifications based on existing pathology are necessary to prevent further injury. Swimming or water aerobics will give the client exercise without the worry of having the correct shoes or developing a foot injury. The client should not exercise too vigorously.)

After teaching a client with type 2 diabetes mellitus who is prescribed nateglinide (Starlix), the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the prescribed therapy? a. "I'll take this medicine during each of my meals." b. "I must take this medicine in the morning when I wake." c. "I will take this medicine before I go to bed." d. "I will take this medicine immediately before I eat."

d. "I will take this medicine immediately before I eat." (Nateglinide is an insulin secretagogue that is designed to increase meal-related insulin secretion. It should be taken immediately before each meal. The medication should not be taken without eating as it will decrease the client's blood glucose levels. The medication should be taken before meals instead of during meals.)

A nurse cares for a client who has type 1 diabetes mellitus. The client asks, "Is it okay for me to have an occasional glass of wine?" How should the nurse respond? a. "Drinking any wine or alcohol will increase your insulin requirements." b. "Because of poor kidney function, people with diabetes should avoid alcohol." c. "You should not drink alcohol because it will make you hungry and overeat." d. "One glass of wine is okay with a meal and is counted as two fat exchanges."

d. "One glass of wine is okay with a meal and is counted as two fat exchanges." (Under normal circumstances, blood glucose levels will not be affected by moderate use of alcohol when diabetes is well controlled. Because alcohol can induce hypoglycemia, it should be ingested with or shortly after a meal. One alcoholic beverage is substituted for two fat exchanges when caloric intake is calculated. Kidney function is not impacted by alcohol intake. Alcohol is not associated with increased hunger or overeating.)

An older adult has been transferred to the postoperative inpatient unit after surgery. The family is concerned that the client is not waking up quickly and states "She needs to get back to her old self!" What response by the nurse is best? a. "Everyone comes out of surgery differently." b. "Let's just give her some more time, okay?" c. "She may have had a stroke during surgery." d. "Sometimes older people take longer to wake up."

d. "Sometimes older people take longer to wake up." (Due to age-related changes, it may take longer for an older adult to metabolize anesthetic agents and pain medications, making it appear that they are taking too long to wake up and return to their normal baseline cognitive status. The nurse should educate the family on this possibility. While everyone does react differently, this does not give the family any objective information. Saying "Let's just give her more time, okay?" sounds patronizing and again does not provide information. While an intraoperative stroke is a possibility, the nurse should concentrate on the more common occurrence of older clients taking longer to fully arouse and awake.)

When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, "I will never be able to stick myself with a needle." How should the nurse respond? a. "I can give your injections to you while you are here in the hospital." b. "Everyone gets used to giving themselves injections. It really does not hurt." c. "Your disease will not be managed properly if you refuse to administer the shots." d. "Tell me what it is about the injections that are concerning you."

d. "Tell me what it is about the injections that are concerning you." (Devote as much teaching time as possible to insulin injection and blood glucose monitoring. Clients with newly diagnosed diabetes are often fearful of giving themselves injections. If the client is worried about giving the injections, it is best to try to find out what specifically is causing the concern, so it can be addressed. Giving the injections for the client does not promote self-care ability. Telling the client that others give themselves injections may cause the client to feel bad. Stating that you don't know another way to manage the disease is dismissive of the client's concerns.)

Ten hours after surgery, a postoperative client reports that the antiembolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best? a. "Let me call the surgeon to see if you really need them." b. "No, you have to use those for 24 hours after surgery." c. "OK, we can remove them since you are stable now." d. "To prevent blood clots you need them a few more hours."

d. "To prevent blood clots you need them a few more hours." (According to the Surgical Care Improvement Project (SCIP), any prophylactic measures to prevent thromboembolic events during surgery are continued for 24 hours afterward. The nurse should explain this to the client. Calling the surgeon is not warranted. Simply telling the client he or she has to wear the hose and compression devices does not educate the client. The nurse should not remove the devices.)

A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement should the nurse include in this client's teaching to prevent injury? a. "Examine your feet using a mirror every day." b. "Rotate your insulin injection sites every week." c. "Check your blood glucose level before each meal." d. "Use a bath thermometer to test the water temperature."

d. "Use a bath thermometer to test the water temperature." (Clients with diminished sensory perception can easily experience a burn injury when bathwater is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and checking blood glucose levels will not prevent injury.)

A nurse teaches a client with type 1 diabetes mellitus. Which statement should the nurse include in this client's teaching to decrease the client's insulin needs? a. "Limit your fluid intake to 2 liters a day." b. "Animal organ meat is high in insulin." c. "Limit your carbohydrate intake to 80 grams a day." d. "Walk at a moderate pace for 1 mile daily."

d. "Walk at a moderate pace for 1 mile daily." (Moderate exercise such as walking helps regulate blood glucose levels on a daily basis and results in lowered insulin requirements for clients with type 1 diabetes mellitus. Restricting fluids and eating organ meats will not reduce insulin needs. People with diabetes need at least 130 grams of carbohydrates each day.)

A nurse is preparing a client for discharge after surgery. The client needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important? a. "Be sure you keep all your postoperative appointments." b. "Call your surgeon if you have any questions at home." c. "Eat a diet high in protein, iron, zinc, and vitamin C." d. "Wash your hands before touching the drain or dressing."

d. "Wash your hands before touching the drain or dressing." (All options are appropriate for the client being discharged after surgery. However, for this client who is changing a dressing and managing a drain, infection control is the priority. The nurse should instruct the client to wash hands often, including before and after touching the dressing or drain.)

A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk? a. A 29-year-old Caucasian b. A 32-year-old African-American c. A 44-year-old Asian d. A 48-year-old American Indian

d. A 48-year-old American Indian (Diabetes is a particular problem among African Americans, Hispanics, and American Indians. The incidence of diabetes increases in all races and ethnic groups with age. Being both an American Indian and middle-aged places this client at highest risk.)

A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take? a. Administration of oxygen via face mask b. Intravenous administration of 10% glucose c. Implementation of seizure precautions d. Administration of intravenous insulin

d. Administration of intravenous insulin (The rapid, deep respiratory efforts of Kussmaul respirations are the body's attempt to reduce the acids produced by using fat rather than glucose for fuel. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. The client who is in ketoacidosis may not experience any respiratory impairment and therefore does not need additional oxygen. Giving the client glucose would be contraindicated. The client does not require seizure precautions.)

The nurse is reviewing new postoperative orders and notes that the order reads, "Give hydroxyzine (Vistaril) 50 mg IV PRN nausea or vomiting." The patient is complaining of slight nausea. Which action by the nurse is correct at this time? a. Hold the dose until the patient complains of severe nausea. b. Give the dose orally instead of intravenously. c. Give the patient the IV dose of hydroxyzine as ordered. d. Call the prescriber to question the route that is ordered.

d. Call the prescriber to question the route that is ordered. (The nurse needs to question the route. Hydroxyzine (Vistaril) is an antihistamine-class antiemetic that is only to be given either by oral or intramuscular routes. It may be easy to make the mistake of giving hydroxyzine intravenously because many other antiemetics are given by that route. It is important to note that intravenous, intra-arterial, or subcutaneous administration of hydroxyzine may result in significant tissue damage, thrombosis, and gangrene. The nurse cannot change the route of an ordered medication without a prescriber's order. Antiemetic drugs are best given before the patient's nausea become severe.)

A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin injection. Which action should the nurse take? a. Apply ice to the site to reduce inflammation. b. Consult the provider for a new administration route. c. Assess the client for other signs of cellulitis. d. Instruct the client to rotate sites for insulin injection.

d. Instruct the client to rotate sites for insulin injection. (The client's tissue has been damaged from continuous use of the same site. The client should be educated to rotate sites. The damaged tissue is not caused by cellulitis or any type infection, and applying ice may cause more damage to the tissue. Insulin can only be administered subcutaneously and intravenously. It would not be appropriate or practical to change the administration route.)

A nurse reviews the medication list of a client recovering from a computed tomography (CT) scan with IV contrast to rule out small bowel obstruction. Which medication should alert the nurse to contact the provider and withhold the prescribed dose? a. Pioglitazone (Actos) b. Glimepiride (Amaryl) c. Glipizide (Glucotrol) d. Metformin (Glucophage)

d. Metformin (Glucophage) (Glucophage should not be administered when the kidneys are attempting to excrete IV contrast from the body. This combination would place the client at high risk for kidney failure. The nurse should hold the metformin dose and contact the provider. The other medications are safe to administer after receiving IV contrast.)

A client has arrived in the postoperative unit. What action by the circulating nurse takes priority? a. Assessing fluid and blood output b. Checking the surgical dressings c. Ensuring the client is warm d. Participating in hand-off report

d. Participating in hand-off report (Hand-offs are a critical time in client care, and poor communication during this time can lead to serious errors. The postoperative nurse and circulating nurse participate in hand-off report as the priority. Assessing fluid losses and dressings can be done together as part of the report. Ensuring the client is warm is a lower priority.)

A client on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations of 24 breaths/min. The client denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection. What should the nurse assess next? a. Cognitive status b. Family stress c. Nutrition status d. Psychosocial status

d. Psychosocial status (After ensuring the client's physiologic status is stable, these manifestations should lead the nurse to assess the client's psychosocial status. Anxiety especially can be demonstrated with elevations in vital signs. Cognitive and nutrition status are not related. Family stress is a component of psychosocial status.)

A circulating nurse wishes to provide emotional support to a client who was just transferred to the operating room. What action by the nurse would be best? a. Administer anxiolytics. b. Give the client warm blankets. c. Introduce the surgical staff. d. Remain with the client.

d. Remain with the client. (The nurse can provide emotional support by remaining with the client until anesthesia has been provided. An extremely anxious client may need anxiolytics, but not all clients require this for emotional support. Physical comfort and introductions can also help decrease anxiety.)

A nurse reviews laboratory results for a client with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL. Which laboratory result should the nurse correlate with the client's polyuria? a. Serum sodium: 163 mEq/L b. Serum creatinine: 1.6 mg/dL c. Presence of urine ketone bodies d. Serum osmolarity: 375 mOsm/kg

d. Serum osmolarity: 375 mOsm/kg (Hyperglycemia causes hyperosmolarity of extracellular fluid. This leads to polyuria from an osmotic diuresis. The client's serum osmolarity is high. The client's sodium would be expected to be high owing to dehydration. Serum creatinine and urine ketone bodies are not related to the polyuria.)

A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately? a. Serum chloride level of 98 mmol/L b. Serum calcium level of 8.8 mg/dL c. Serum sodium level of 132 mmol/L d. Serum potassium level of 2.5 mmol/L

d. Serum potassium level of 2.5 mmol/L (Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium. The chloride level is normal. The calcium and sodium levels are slightly low, but this would not be related to hyperglycemia and insulin administration.)

A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team? a. Allergy to bee and wasp stings b. History of lactose intolerance c. No previous experience with surgery d. Use of multiple herbs and supplements

d. Use of multiple herbs and supplements (Some herbs and supplements can interact with medications, so this information needs to be reported as the priority. An allergy to bee and wasp stings should not affect the client during surgery. Lactose intolerance should also not affect the client during surgery but will need to be noted before a postoperative diet is ordered. Lack of experience with surgery may increase anxiety and may require higher teaching needs, but is not the priority over client safety.)

The recovery nurse is caring for a surgical patient in the PACU. The patient's blood pressure is dropping and their heart rate is increasing. The nurse suspects the patient is: overmedicated. experiencing normal adaptation to the postoperative period. allergic to the anesthesia. developing shock.

developing shock. (Decreasing blood pressure and an increased pulse rate in the postoperative patient are significant because they may signify hemorrhage or shock.)

A patient receiving narcotic analgesics for chronic pain can minimize the GI side effects by: eating foods high in lactobacilli. taking Lomotil with each dose. taking the medication on an empty stomach. increasing fluid and fiber in the diet.

increasing fluid and fiber in the diet. (Narcotic analgesics decrease intestinal motility, leading to constipation. Increasing fluid and fiber in the diet can prevent constipation.)

A client is being prepared for gastrointestinal surgery and undergoes a bowel preparation. This preoperative procedure is done to decrease expected blood loss during surgery. eliminate any risk of infection. ensure that the bowel is sterile. reduce the number of intestinal bacteria.

reduce the number of intestinal bacteria. (Bowel or intestinal preparations are performed to empty the bowel to minimize the leaking of bowel contents, prevent injury to the colon, and reduce the number of intestinal bacteria.Decreasing expected blood loss and sterilizing the bowel are not the goals of a bowel preparation. While the bowel prep may reduce the number of intestinal bacteria, it will not completely eliminate the risk of infection.)