Adult Health Exam One

A 75-year-old patient is being prepared for surgery. What assessment data needs to be included for this patient (select all that apply)? A) Fluid balance history B) Attitude about surgery C) Foods the patient dislikes D) Current mobility problems E) Current cognitive function F) Patient's opinion about the surgeon

A,D,E

If pharmacologic therapy is initiated, which lab value would indicate that the heparinization has been reached?

APTT 65 seconds, control 35 seconds.

Which decision is the most appropriate for the nurse to make regarding a low dose of morphine?

Administer it because it reduces pain and anxiety.

Which action should the nurse implement first?

Administer oxygen.

Which assessment is most important for the nurse to complete next?

Auscultate breath sounds.

What ethical principle is the most important for the nurse to consider when responding to the son?

Autonomy.

The nurse notifies the surgeon of the wound drainage. What lab data is important for the nurse to report to the surgeon? A) White blood cell count. B) Hemoglobin and hematocrit. C) Culture and sensitivity. D) Type and cross match.

B) Hemoglobin and hematocrit. The nurse is reporting the amount of surgical drainage to the surgeon due to a concern for excessive blood loss. The surgeon needs to know information related to blood volume, provided by the hemoglobin and hematocrit levels.

Before admitting a patient to the operating room, which forms or results must the nurse make sure are in the chart of all patients (select all that apply)? A) Electrocardiogram B) Signed consent form C) Functional status evaluation D) Renal and liver function tests E) A history and physical report

B,E

The nurse is doing a preoperative assessment on a male patient who has type 2 diabetes mellitus, weighs 146 kg, and is 5 feet 8 inches tall. Which patient assessment is a priority related to anesthesia? A) Has hemoglobin A1C of 8.5% B) Has several seasonal allergies C) Has body mass index of 48.8 kg/m2 D) Has history of postoperative vomiting

C

Which cardiac isoenzyme is the most sensitive indicator of myocardial damage?

CK-MB.

Which National Patient Safety Goal (NPSG) requirement is enacted immediately before surgery with a surgical time-out? A) Prevention of infection B) Improved staff communication C) Identify patients at risk for suicide. D) Patient, surgical procedure, and site are checked.

D

Which action should the nurse expect to take?

Decrease the heparin infusion.

Which adverse effect of nitro should the nurse prepare her for?

Dizziness.

Which route of administration should the nurse anticipate for heparin?

IV.

Which nursing diagnosis has the highest priority when planning care for Mr. Johnson?

Ineffective Airway Clearance.

What is the legal concern involved in this situation?

Malpractice.

Which nursing action should be implemented before administering the prescribed Unasyn?

Obtain a sputum culture.

Which medication that Mrs. Adams is taking places her at increased risk for the development of DVT?

Oral contraceptives.

What is the heparin antagonist?

Protamine sulfate

Which outcome statement is the best indicator that Mr. Johnson's pneumonia is resolves and he is ready to be discharged?

Sputum culture is negative.

Which action should the nurse initiate?

Stop the heparin infusion.

She should also be instructed to avoid which medication?

Tylenol.

After observing Mr. Johnson, what client teaching should the nurse initiate?

Wait at least 1min between each puff of the same medication.

A surgical patient's premedication regimen includes midazolam (Versed). What are the most likely desired effects of this medication? A) Monitored anesthesia care and amnesia B) Potentiates volatile agents to speed induction C) Analgesia and prevention of intraoperative vomiting D) Relaxation of skeletal muscles and facilitation of endotracheal intubation

A

The nurse would be alerted to the occurrence of malignant hyperthermia when the patient demonstrates what manifestation? A) Hypocapnia B) Muscle rigidity C) Decreased body temperature D) Confusion upon arousal from anesthesia

B

Unless contraindicated by the surgical procedure, which position is preferred for the unconscious patient immediately postoperative? A) Supine B) Lateral C) Semi-Fowler's D) High-Fowler's

B

What is the primary reason for accurately recording the patient's current medications during a preoperative assessment? A) Some medications may alter the patient's perceptions about surgery. B) Many anesthetics alter renal and hepatic function, causing toxicity of other drugs. C) Some medications may interact with anesthetics, altering the potency and effect of the drugs. D) Routine medications are withheld the day of surgery, requiring dosage and schedule adjustments after surgery.

C

When reviewing the preoperative forms, the nurse notices that the informed consent form is not present or signed. What is the best action for the nurse to take? A) Have the patient sign the consent form. B) Have the family sign the form for the patient. C) Call the surgeon to obtain consent for surgery. D) Teach the patient about the surgery and get verbal permission.

C

The nurse observes that the word, "Yes" has been marked on Ms. Jackson's left hip, and the word, "No" has been written on her right hip. What action should the nurse implement? A) Use an antimicrobial agent to cleanse the operative site. B) Take a photograph of the markings to place in the chart. C) Confirm that the left hip is the site of the scheduled surgery. D) Reassure the client that the surgeon will not make a mistake.

C) Confirm that the left hip is the site of the scheduled surgery. The nurse should ensure that the markings on the hips are correct, to help reduce the potential for error during surgery. When the surgical site involves a distinction between left and right sides of the body, marking the site is a required component of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) universal protocol to prevent wrong site, wrong procedure, wrong person surgery.

Based on these findings, which action should the nurse implement?

Continue with discharge teaching.

A 78-year-old patient is having surgery. What risk areas will the nurse need to be especially aware of for this patient during surgery? A) Sterility B) Paralysis C) Urine output D) Skin integrity

D

A 70-year-old woman has been admitted prior to having surgery for a bilateral mastectomy and breast reconstruction. What should the nurse include in the patient's preoperative teaching (select all that apply)? A) Information about various options for reconstructive surgery B) Information about the risks and benefits of her particular surgery C) Information about risk factors for breast cancer and the role of screening D) Information about where in the hospital she will be taken postoperatively E) Information about performing postoperative deep-breathing and coughing exercises

D, E

After checking the sensor site to make sure the readings are accurate, which intervention should the nurse initiate next?

Elevate the head of the bed to a high-Fowler's position.

Which food should the nurse instruct Mrs. Adams to avoid?

Green leafy vegetables.

Which description best identifies the purpose of an adverse occurrence, or incident, report?

Hospital records that keeps track patterns of risk to guide corrective action.

Which nursing intervention should the nurse implement in order to reduce the risk for abnormal bleeding during heparin therapy?

Maintain heparin on a continuous infusion pump.

Which assessment finding supports Mr. Johnson's diagnosis of pneumonia?

Pulse rate of 115.

PH- 7.28 PCO2 - 55 HCO3 - 25 PO2 - 89 Based on these ABG results, which acid base imabalance is Mr. Johnson experiencing?

Respiratory Acidosis.

Which nursing diagnosis is priority with Mrs. Adams?

Risk for injury (bleeding) due to anticoagulant therapy.

The nurse should immediately intervene to prevent violation of which client right?

The right to know the qualifications of caregivers.

Which action should be implemented during the administration of low molecular weight heparin?

Use SC sites in the abdomen.

Which instruction should the nurse provide Mr. Johnson for an acute episode of asthma

Use the Ventolin inhaler for acute asthma attacks.

Which additional discharge instruction(s) should the nurse include in the teaching plan to promote optimal health for Mr. Johnson?

-Avoid crowds and people with infections -Store prescribed inhalers away from extreme heat or colds

Which nursing interventions will reduce pain related to decreased venous flow?

-elevate leg -apply warm compress

When Ms. Jackson arrives on the unit, the nurse notes that her IV is wide open. Review of Ms. Jackson's postoperative prescriptions indicates that 0.9% Normal Saline is to infuse at 75 ml/hour, alternating with Lactated Ringer's solution at 75 ml/hour. An infusion pump is not immediately available, so the nurse notes that the infusion tubing has a drop factor of 10 drops/ml and resets the IV. At what rate should the IV infuse? (drops per minute)

13 drops per minute. 75 ml/60 minutes × 10 gtts/1 ml = 12.5, which rounds up to 13 drops per minute.

An alert male patient needs a tracheostomy because he has been intubated for 7 days with an endotracheal tube and cannot be weaned from the ventilator. The patient does not want the tracheostomy, but his family insists that the surgery be performed. What is the best action for the nurse to take? A) Advocate for the patient's rights. B) Try to change the patient's mind. C) Call surgery to cancel the procedure. D) Tell the family they cannot interfere.

A

Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks to get up to go to the bathroom to urinate. What is the most appropriate action for the nurse to take? A) Offer the patient to use the urinal/bedpan after explaining the need to maintain safety. B)Assist the patient to the bathroom and stay next to the door to assist patient back to bed when done. C)Allow the patient to go to the bathroom since the onset of the medication will be more than 5 minutes. D)Ask the patient to hold the urine for a short period since a urinary catheter will be placed in the operating room.

A

The patient is having a mole removed that has changed appearance. What does the nurse teach the patient about the rationale for this surgical procedure? A) It is to prevent malignancy. B) It is to alleviate symptoms. C) It is to cure the malignancy. D) It is to provide cosmetic improvement.

A

What event in the surgical suite represents a violation of aseptic technique? A) A glove contacts the leg of the table that supports the sterile field. B) The cuff of the scrub nurse's sterile gown contacts the sterile field. C) The sterile field was established at 0650, and the current time is 0900. D) Bacteria are present in the nares and upper respiratory passages of the nurse.

A

The next week, Ms. Jackson arrives at the surgery center 3 hours before her scheduled surgery. Which question is most important for the nurse to ask Ms. Jackson during the admission interview? A) "Have you had anything to eat or drink since midnight?" B) "Are any of your family members or friends here with you?" C) "Do you understand you will be admitted to the hospital following surgery?" D) "Did you bring any valuables with you that need to be stored during surgery?"

A) "Have you had anything to eat or drink since midnight?" Ensuring that the client has remained NPO for the prescribed length of time before surgery is critical to prevent vomiting and aspiration during surgery.

After completing the admission interview, the nurse reviews Ms. Jackson's medical record and notes that the surgical consent form is filled out but is not signed by the client. What action should the nurse take? A) Ask Ms. Jackson if she has received sufficient information to sign the consent form. B) Call the operating room and notify the staff that the surgery needs to be cancelled. C) Notify the surgeon of the need to come to the client's room so the consent can be signed. D) Inform a family member of the need to serve as a witness to the client's signature.

A) Ask Ms. Jackson if she has received sufficient information to sign the consent form. The nurse may witness the client's signature if the nurse is able to determine that the client has been sufficiently informed of the necessary information.

The nurse continues the postoperative assessment. To assess for atelectasis, what action should the nurse take? A) Auscultate the client's breath sounds. B) Observe the appearance of the sputum. C) Determine the client's temperature. D) Measure the client's blood pressure.

A) Auscultate the client's breath sounds. Atelectasis is a condition in which the alveoli collapse. Dull or absent breath sounds, along with changes in breathing patterns, are expected findings when atelectasis occurs.

The nurse begins the preoperative assessment by taking Ms. Jackson's vital signs. 1. Which vital sign requires follow-up by the nurse? A) BP of 160/88. B) Pulse of 68. C) Respirations of 14. D) Temperature of 97.2° F.

A) BP of 160/88. This blood pressure is elevated and requires further action by the nurse.

The nurse determines that Ms. Jackson's bowel sounds are hypoactive. What action should the nurse implement in response to this finding? A) Document the assessment finding in the chart. B) Notify the surgeon of the assessment finding. C) Review the client's serum electrolyte values. D) Administer a laxative prescribed for PRN use.

A) Document the assessment finding in the chart. Hypoactive bowel sounds are an expected finding following general anesthesia, so the nurse should document this finding in the chart and continue to monitor the client.

Following surgery, Ms. Jackson is admitted to the Post Anesthesia Care Unit. The operative report indicates that Ms. Jackson had a left hip replacement under general anesthesia. The initial nursing assessment reveals that Ms. Jackson is not responding to verbal stimuli. Her vital signs are T 97.6° F, P 88, R 14, and BP 130/70. What action should the nurse implement first? A) Position the client on her side. B) Observe the surgical dressing. C) Place the call bell within reach. D) Remove the oral airway.

A) Position the client on her side. During the immediate postanesthesia period, the unconscious client should be positioned on the side to maintain an open airway and promote drainage of secretions.

While discussing postoperative pain management strategies with Ms. Jackson, the nurse observes that Ms. Jackson begins to cry. What action should the nurse take? A) Quietly sit with the client. B) Offer reassurance about the surgery. C) Calmly continue the preoperative instructions. D) Leave the room until the client has composed herself.

A) Quietly sit with the client. Offering one's presence is a caring and therapeutic response.

Ms. Jackson is currently receiving Lactated Ringer's solution IV at a rate of 75 ml/hour. In transfusing the 250 ml unit of packed red blood cells, what action should the nurse implement? A) Stop the IV solution and transfuse the packed cells at 125 mL/hour via tubing connected to a bag of saline solution. B) Infuse the Lactated Ringer's solution through the IV tubing concurrently with the blood at a combined rate of 75 mL/hour. C) Flush the IV tubing with a 5 mL bolus of normal saline before and after the transfusion, and transfuse the blood within 1 hour. D) Replace the Lactated Ringer's solution with the unit of packed red blood cells and administer through the tubing at 75 mL/hour.

A) Stop the IV solution and transfuse the packed cells at 125 ml/hour via tubing connected to a bag of saline solution. Packed red blood cells are only compatible with normal saline. The blood should be connected to a bag of saline solution using special Y-tubing and administered within 1½ to 2 hours, if possible, but no longer than 4 hours (250 ml transfused at 125 ml/hour = 2 hours).

Which information should the nurse include in the teaching plan?

An HDL of less than 50 mg/dL for women indicates increased risk.

Which action should the nurse implement to ensure accurate oxygen saturation readings via a pulse oximeter?

Assess adequacy of circulation prior to applying the sensor.

The new nursing student is confused about where the patient's family (who are wearing street clothes) can be with the patient in the surgical suite. Which explanation should the perioperative nurse give to the student nurse? A) The family is not allowed to talk to the nurse at the nursing station. B) The family can be with the patient in the preoperative holding area. C) The family cannot be with the patient until the postanesthesia care unit. D) The family is only allowed in the conference room for preoperative teaching.

B

The nurse is admitting a patient to the same-day surgery unit. The patient tells the nurse that he was so nervous he had to take kava last evening to help him sleep. Which nursing action would be most appropriate? A) Tell the patient that using kava to help sleep is often helpful. B) Inform the anesthesiologist of the patient's recent use of kava. C) Tell the patient that the kava should continue to help him relax before surgery. D) Inform the patient about the dangers of taking herbal medicines without consulting his health care provider.

B

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? A) Assess the patient's pain. B) Assess the patient's vital signs. C) Check the rate of the IV infusion. D) Check the physician's postoperative orders.

B

The perioperative nurse would recognize the need to monitor the patient for hallucinations and agitation when which anesthetic agent is administered? A) Nitrous oxide B) Ketamine (Ketalar) C) Thiopental (Pentothal) D) Halothane (Fluothane)

B

This will be the patient's first surgical experience and the patient states, "I am nervous about this." The vital signs show BP 158/88, HR 96, RR 24. In the assessment, the nurse finds that the lungs are clear, bowel tones are evident, peripheral pulses are strong, and the patient is fidgeting nervously. The patient took alprazolam (Xanax) at bedtime last night and takes acetaminophen (Tylenol) for tension headaches. Related to this assessment information, what should the nurse do before the patient goes to surgery? A) Review the surgery with the patient. B) Notify the anesthesia care provider (ACP). C) Administer another dose of alprazolam (Xanax). D) Tell the patient that everything will be okay with the surgery.

B

The nurse observes that the Hemovac drain is full of sanguineous drainage. What action should the nurse implement first? A) Compress the drain and re-establish suction. B) Empty the drain and measure the amount of drainage. C) Page the surgeon to report the finding. D) Document the appearance of the drainage.

B) Empty the drain and measure the amount. The nurse should first empty the drain and measure the drainage, then compress the drain to re-establish suction. Documentation of the findings and notification of the surgeon can then be done.

Based on the lab data provided by the nurse, the healthcare provider prescribes the transfusion of two units of packed red blood cells as soon as possible. Once the first unit of packed red blood cells is ready, the nurse obtains the blood from the blood bank. When the nurse enters Ms. Jackson's room to begin the transfusion, the UAP is giving Ms. Jackson a partial bath. What action should the nurse take? A) Place the unit of blood in the medication refrigerator until the client's personal care is completed. B) Hang the transfusion of packed cells while the UAP continues to complete the client's personal care. C) Lock the unit of blood in the computerized medication cart and assist the UAP in completing the personal care. D) Return the blood to blood bank and send the UAP to obtain the blood when the personal care is completed.

B) Hang the transfusion of packed cells while the UAP continues to complete the client's personal care. Transfusion of the blood is a higher priority than personal care. If necessary, the remainder of the care can be delayed.

While assessing Ms. Jackson, the nurse observes that the surgical dressing is in place on the left hip, with no visible drainage. How should the nurse document this finding? A) No problems with dressing on left hip. B) Left hip dressing clean, dry, and intact. C) Dressing present over hip incision. D) Incision well-approximated with no drainage.

B) Left hip dressing clean, dry, and intact. This documentation is concise but thorough, providing a clear picture of the assessed data.

The 2 units of packed RBCs are transfused without complication. The drainage begins to decrease, and Ms. Jackson's hemoglobin and hematocrit remain stable. The nurse is assisting Ms. Jackson to the bedside commode on the second postoperative day. Ms. Jackson states, "I have never had to depend on anyone before. I like to take care of myself. I feel so helpless." In response to these remarks, the nurse plans care for Ms. Jackson based on the identification of which nursing diagnosis? A) Disturbed body image. B) Situational low self-esteem. C) Anticipatory grieving. D) Impaired physical mobility.

B) Situational low self-esteem. The client's remarks regarding feelings of helplessness relate to her sense of how she perceives herself and her present ability to care for herself.

While cleansing the incision, the nurse observes that the staples are intact, but a 2 cm gap has opened at the bottom of the incision. How should the nurse document this finding? A) Bottom edges of incision approximated. B) Small area of dehiscence at bottom of incision. C) Evisceration of incision noted at bottom edge. D) Wound healing via secondary intention.

B) Small area of dehiscence at bottom of incision. An unintentional opening in a surgical wound prior to healing is referred to as dehiscence.

The nurse then reviews Ms. Jackson's preoperative lab test results, drawn earlier in the week. 3. Which serum lab value requires follow-up by the nurse? A) Sodium of 135 mEq/L. B) WBC of 14,000/mm3. C) Creatinine of 0.8 mg/dl. D) Hemoglobin of 14 g/dl.

B) WBC of 14,000/mm3. The normal WBC count is 5,000 to 10,000/mm3. An increase may indicate the onset of an infection, which may be a contraindication to surgery. The nurse should notify the surgeon of this abnormal lab value.

Which intraoperative nursing responsibilities should be performed by the scrub nurse (select all that apply)? A) Documenting intraoperative care B) Keeping track of irrigation solutions for monitoring of blood loss C) Passing instruments and supplies to the surgeon by anticipating his or her needs D) Coordinating the flow and activities of members of the surgical team in the surgical suite E) Performing the count of sponges, needles, and instruments used during the surgical procedure

B,C,E

What instructions does the nurse give before an echocardiogram?

Be sure to come to the exam table immediately after exercise.

As the nurse is preparing a patient for outpatient surgery, the patient wants to give his hearing aid to his wife so it will not be lost during surgery. Which action by the nurse should be taken in this situation? A) Give the hearing aid to the wife as he wishes. B) Tape the hearing aid to his ear to prevent loss. C) Encourage the patient to wear it for the surgery. D) Tell the surgery nurse that he has his hearing aid out.

C

Which preoperative patient has the greatest risk of bleeding as a result of his or her medication? A) A woman who takes metoprolol (Lopressor) for the treatment of hypertension B) A man whose type 1 diabetes is controlled with insulin injections four times daily C) A man who is taking clopidogrel (Plavix) after the placement of a coronary artery stent D) A man who recently started taking finasteride (Proscar) for the treatment of benign prostatic hyperplasia

C

While performing preoperative teaching, the patient asks when she needs to stop drinking water before the surgery. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, the nurse tells the patient that A) she must be NPO after breakfast. B) she needs to be NPO after midnight. C) she can drink clear liquids up to 2 hours before surgery. D) she can drink clear liquids up until she is moved to the OR.

C

When the nurse begins teaching about the benefits of early mobilization following surgery, Ms. Jackson states, "Oh, I know if I stay in bed very long I will get bedsores." How should the nurse respond? A) "Getting a bedsore is very serious. Sometimes people die from infected bedsores." B) "The nurses will make sure you do not stay in bed long enough to get bedsores." C) "Bedsores are one of many problems that can occur from prolonged bedrest." D) "Those are now called pressure ulcers because they are caused by pressure."

C) "Bedsores are one of many problems that can occur from prolonged bedrest." This response acknowledges the client's previous learning and promotes further learning related to other complications of immobility such as thrombus formation, constipation, and atelectasis.

After Ms. Jackson stops crying, she states, "My father was in so much pain before he died. Talking about pain brings back so many memories." How should the nurse respond? A) "We do not need to talk about pain control today if it makes you sad." B) "Perhaps you need to see a counselor to help you resolve your grief." C) "It sounds as if you went through a difficult time when your father died." D) "You need to focus on your own needs now and not on past memories."

C) "It sounds as if you went through a difficult time when your father died." This open-ended acknowledgment of the client's distress is therapeutic and allows the opportunity for further discussion by the client if desired.

After Ms. Jackson ambulates with the physical therapist, the nurse prepares to change the surgical dressing. While obtaining supplies, the nurse reviews the sterile procedure to be followed. At what step in the procedure should the nurse don sterile gloves? A) Prior to removing the dressing on the client's hip. B) Before opening the new sterile dressing package. C) Before cleansing the client's hip incision. D) After cleansing the client's hip incision.

C) Before cleansing the client's hip incision. When using surgical asepsis for wound care, the sterile gloves should be donned prior to cleaning the wound and applying the new sterile dressing.

The nurse talks with Ms. Jackson about what to expect the day of surgery and during the immediate postoperative period. The nurse provides instructions regarding cough and deep breathing exercises. Ms. Jackson performs a return demonstration by breathing in through her mouth deeply and exhaling through pursed lips forcefully and rapidly. 4. What action should the nurse implement? A) Advise the client to avoid pursing her lips when exhaling. B) Remind the client to cough after taking two to three breaths. C) Demonstrate the deep breathing and coughing technique again. D) Document successful completion of the return demonstration.

C) Demonstrate the deep breathing and coughing technique again. Ms. Jackson has demonstrated incorrect technique. When performing deep breathing exercises, the client should inhale through the nose and exhale slowly through the mouth without pursing the lips. The nurse should demonstrate the entire procedure again for best learning by the client.

During the postoperative assessment, the nurse observes Ms. Jackson's surgical site. The left hip dressing has a moderate amount of sanguineous drainage. What action should the nurse implement? (select all that apply) A) Apply pressure to the site. B) Elevate the leg on a pillow. C) Observe the linens under the hip. D) Use sterile technique to replace the dressing. E) Mark the amount of drainage on the dressing.

C) Observe the linens under the hip. Gravity pulls drainage down, so the nurse should inspect the area below the surgical site for additional drainage. The nurse may also mark the amount of drainage on the dressing for later comparison. E) Mark the amount of drainage on the dressing. Marking the amount of drainage on the dressing will allow for later comparison.

Once the OR team has assembled in the room, the circulating nurse calls for a time out. What action should the nurse take during the time out? A) Ensure that sufficient surgical supplies are available. B) Check that all surgical personnel are properly attired. C) Review the scheduled procedure, site, and client. D) Confirm that informed consent has been obtained.

C) Review the scheduled procedure, site, and client. A time out, the designated method for final verification before surgery begins, is a component of the JCAHO universal protocol to prevent wrong site, wrong procedure, wrong person surgery.

Ms. Jackson is transferred to a stretcher and taken to the operating room (OR). The nurse assists Ms. Jackson off the stretcher and onto the OR table. After general anesthesia is induced, the nurse positions Ms. Jackson for surgery. Which nursing diagnosis has the highest priority at this time? A) Ineffective protection. B) Ineffective tissue perfusion. C) Risk for perioperative-positioning injury. D) Risk for imbalanced body temperature.

C) Risk for perioperative-positioning injury. During surgery the client may remain in one position for a prolonged period of time. The nurse must ensure that the client is protected from injury secondary to inappropriate positioning.

A 52-year-old female patient has come to the ambulatory surgery center for surgery. When reviewing the assessment record, what test should the nurse seek an order for before this patient has surgery? Smoker for past 25 years, last cigarette yesterday Has hypertension CBC within normal limits Chest X-ray clear UA within normal limits No other lab work drawn Takes hydrochlorothiazide 50 mg every morning A) Blood glucose B) Pregnancy test C) Serum albumin D) Serum potassium

D

A 71-year-old male patient who is currently undergoing coronary artery bypass graft (CABG) surgery has just experienced intraoperative vomiting. The nurse should consequently anticipate the use of which drug? A) Midazolam (Versed) B) Fentanyl (Sublimaze) C) Meperidine (Demerol) D) Ondansetron (Zofran)

D

A patient having an open reduction internal fixation (ORIF) of a left lower leg fracture will receive regional anesthesia during the procedure. As the patient is prepared in the operating room, what should the nurse implement to maintain patient safety during surgery that is directly related to the type of anesthesia being used? A) Apply grounding pad to unaffected leg. B) Assess peripheral pulses and skin color. C) Verify the last oral intake before surgery. D) Ensure a smooth surface under the patient.

D

In which surgical area will the patient's skin be prepped for surgery, and what clothing will the person doing the prepping be wearing? A) Surgical suite wearing a lab coat B) Preoperative holding area wearing street clothes C) Postanesthesia care unit (PACU) wearing scrubs D) Operating room wearing surgical attire and masks

D

It is 6:00 AM. The anesthesiologist prescribes preoperative medications for a patient who is scheduled for surgery at 7:30 AM: cefazolin (Ancef) IV to be infused 30 minutes before surgery; midazolam (Versed) before surgery and scopolamine patch (Transderm Scop) behind the ear. Which medication should the nurse administer first? A) Cefazolin (Ancef) B) Fentanyl (Sulimaze) C) Midazolam (Versed) D) Scopolamine (Transderm Scop)

D

The patient is going to have a colonoscopy. Which type of anesthesia should the nurse expect to be used? A) Local anesthesia B) Moderate sedation C) General anesthesia D) Monitored anesthesia care (MAC)

D

The nurse discusses postoperative pain management with Ms. Jackson and explains the use of a patient-controlled analgesia (PCA) pump. Ms. Jackson expresses fear that she might accidentally overdose herself, since she will be sleepy after surgery. How should the nurse respond? A) "You will only use the PCA pump for the first 24 hours after surgery." B) "The surgeon will prescribe the dose of medication that is correct for you." C) "I will tell the surgeon that you prefer that the nurses administer your pain medicine." D) "The pump has a control device that prevents you from taking too much medicine."

D) "The pump has a control device that prevents you from taking too much medicine." This response provides the client with the information needed to understand that she cannot overdose herself while she is sedated after surgery.

While the nurse begins to assess the client, another nurse finds an infusion pump and prepares a prescribed "now" dose of an intravenous antibiotic. The prescription is for 2 grams of cefazolin (Ancef), which arrives from the pharmacy diluted in 100 ml of normal saline and is to be administered over 30 minutes. At what rate should the infusion pump be set? (mL/hr)

D) 200 ml/hour. CORRECT 100 ml/30 minutes = X ml/60 minutes. 30X = 100 × 60 = 200 ml/hour.

The nurse reviews the medications taken by Ms. Jackson. Ms. Jackson states she has been taking two medications, hydrochlorothiazide (Hydrodiuril), a diuretic, and warfarin (Coumadin), an anticoagulant, every day for over a year. 2. What nursing action is most important? A) Observe the appearance of the client's oral mucosa. B) Assess the client for any signs of excessive bruising. C) Review common side effects of each of the medications. D) Explain the need to hold the warfarin prior to surgery.

D) Explain the need to hold the warfarin prior to surgery. Anticoagulants increase the risk for bleeding during surgery and the postoperative period, so the nurse must explain the need to hold the warfarin prior to surgery and instruct the client to contact the surgeon to determine how long before surgery the medication should be stopped.

The nurse teaches Ms. Jackson safe transfer techniques and consults with the physical therapist to begin ambulation activities as soon as possible. What is the rationale for the inclusion of these actions in Ms. Jackson's plan of care? A) Frequent activity will distract the client from her concerns. B) Maintaining a safe environment reduces client depression. C) The client should depend on the therapist rather than the nurse. D) Increased mobility will promote an improved sense of control.

D) Increased mobility will promote an improved sense of control. Increasing mobility should result in increased independence and an improved sense of control, which will reduce the client's feelings of helplessness.

Which expected outcomes indicate that discharge teaching was effective?

-she will choose a diet low in fat. -she will choose walking as initial form of exercise.

Which information in Kyra's history increases her risk for CAD? -smoking -bowling league -family history of hyperlipidemia -frequent hypoglycemia -frequent air travel

-smoking -hyperlipidemia

Which ongoing lab test should Kyra expect to be monitored during use of antihyperlipidemics?

Liver enzymes. They cause increased liver enzymes.

Which physical assessment would the nurse perform to assist in the diagnoses of suspected DVT?

Measure calf circumference bilaterally.

Which assessment is most important for the nurse to perform while Mr. Johnson is receiving Ventolin?

Monitor pulse and blood pressure.

Which instruction should the nurse give Kyra on the use of sublingual use of nitroglycerin?

Place a tablet under the tongue for 5 minutes, up to 3 tablets.

Which ECG change is indicative of myocardial injury?

ST segment elevation.

Which term should be used to accurately report that Mrs. Adams may have developed a clot in her vein that is causing pain and swelling in her leg?

Thrombophlebitis.