AH E1

The nurse explains to a client that because of alterations in liver function caused by cirrhosis, the client is predisposed to postoperative fluid shifts and wound infection related to a. elevated creatinine phosphokinase levels. b. elevated lactic dehydrogenase levels. c. low albumin levels. d. low blood urea nitrogen levels.

Ans C Low albumin levels predispose the client to fluid shifts, surgical wound infection, and ineffective coagulation.

A client who is extremely overweight has been advised to lose weight before surgery. To encourage the client, the nurse knows that the most appropriate statement is a. "It will decrease the operating room time by half if you lose weight." b. "Surgery requires more anesthesia if you are overweight." c. "With the weight loss, you decrease the chance of complications after surgery." d. "You'll feel better after surgery if you lose the weight before."

Ans C An obese client is more susceptible to postoperative pulmonary complications, immobility, wound infection, wound dehiscence, and wound evisceration.

A client with a long-standing diagnosis of type 1 diabetes has a history of poor glycemic control. The nurse recognizes the need to assess the client for signs and symptoms of peripheral neuropathy. Peripheral neuropathy constitutes a risk for what nursing diagnosis? A) Infection B) Acute pain C) Acute confusion D) Impaired urinary elimination

Answer A

A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. What action would 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 primary health care provider.

Answer A

A nurse assesses a client who has diabetes mellitus and notes that the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup (120 mL) of orange juice, the client's signs and symptoms have not changed. What action would the nurse take next? A) Administer another half-cup (120 mL) 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.

Answer A

A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement would 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 L a day." C) "Prevent hypoglycemia by eating a bedtime snack." D) "Limit your intake of protein to prevent ketoacidosis."

Answer A

A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement would 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."

Answer A

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 further 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."

Answer A

The nurse is caring for a newly admitted client who is diagnosed with hyperglycemic-hyperosmolar state (HHS). What is the nurse's priority action at this time? A) Assess the client's blood glucose level. B) Monitor the client's urinary output every hour. C) Establish intravenous access to provide fluids. D) Give regular insulin per agency policy

Answer A

The nurse assesses a client with diabetic ketoacidosis. Which assessment finding would 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

Answer A Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones. This condition develops when your body can't produce enough insulin. Without enough insulin, your body begins to break down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated. One of the symptoms of DKA is Kussmaul breathing, which is a deep and labored breathing pattern. This is a form of hyperventilation, which is any breathing pattern that reduces carbon dioxide in the blood due to increased rate or depth of respiration. Therefore, an increased rate and depth of respiration would be an assessment finding that a nurse could correlate with diabetic ketoacidosis.

The nurse is creating the plan of care for a client status post surgery for reduction of a femur fracture. What is the most important short-term goal for this client? A) Relief of pain B) Adequate respiratory function C) Resumption of activities of daily living (ADLs) D) Unimpaired wound healing

Answer A A Short-term goal is the goal that the nurse want to accomplish as soon as possible or in the near future. Relief of pain is the most important and basic goal for this client. The nurse would instruct the patient regarding correct methods to control and relieve the pain of after surgery of femur fracture. In the future, the patient will feel a pain-free, functional, and stable femur.

The nurse is preparing an elderly client for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the client? A) Hypothermia B) Pulmonary edema C) Cerebral ischemia D) Arthritis

Answer A Both inhalational and intravenous general anaesthetic agents affect the central nervous and cardio-respiratory systems in a dose-related manner.

An adult client has just been admitted to the PACU following abdominal surgery. As the client begins to awaken, he is uncharacteristically restless. The nurse checks his skin and it is cold, moist, and pale. The nurse concerned the client may be at risk for what? A) Hemorrhage and shock B) Aspiration C) Postoperative infection D) Hypertension and dysrhythmias

Answer A Hypotension, disorientation, restlessness, oliguria, and cold, pale skin are all symptoms of a hemorrhage. Airway disruption would be the result of aspiration. Pallor and chilly skin are less likely symptoms of hypertension or dysrhythmias. At this early time after surgery, no infection would be present.

A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which client most closely during the intraoperative period because of the increased risk for hypothermia? A) A 74-year-old woman with a low body mass index B) A 17-year-old boy with traumatic injuries C) A 45-year-old woman having an abdominal hysterectomy D) A 13-year-old girl undergoing craniofacial surgery

Answer A Hypothermia, or a dangerously low body temperature, is a risk during surgery, especially for older adults and those with low body mass index (BMI). Older adults are at a higher risk because their bodies have a harder time regulating temperature. Additionally, individuals with a low BMI have less body fat, which serves as insulation and helps maintain body temperature. Therefore, a 74-year-old woman with a low BMI would be at the highest risk for hypothermia during the intraoperative period and should be monitored most closely.

The perioperative nurse is providing care for a client who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The client is reluctant to ambulate, citing the need to recover in bed. For what complication is the client most at risk? A) Atelectasis B) Anemia C) Dehydration D) Peripheral edema

Answer A Perioperative nurse is providing care for a client Atelectasis. During atelectasis, the whole lung or a portion of the lung (lobe) collapses. These tiny air sacs (known as alveoli) collapse or accumulate alveolar fluid, which causes the symptoms of pneumonia. One of most common post-operative respiratory problems is atelectasis. There are two main causes of atelectasis, this same collapse of a lung: bronchial obstruction or lung pressure. Anesthesia, prolonged bed rest, shallow breathing, and underlying lung disease are all risk factors for atelectasis. It's possible to have atelectasis and other conditions, such as collapsing lung. An atelectasis is a condition in which the lungs fail to expand, resulting in an inability to distribute oxygen to vital organs and tissues.

The nurse is caring for a postoperative client with a history of congestive heart failure and peptic ulcer disease. The client is highly reluctant to ambulate and will not drink fluids except for hot tea with her meals. The client's vital signs are slightly elevated, and she has a nonproductive cough. The nurse auscultates crackles at the base of the lungs. What complication should the nurse first suspect? A) Pulmonary embolism B) Hypervolemia C) Hypostatic pulmonary congestion D) Malignant hyperthermia

Answer A Pulmonary embolism is a serious complication that can occur after surgery. This condition occurs when a blood clot forms in the lungs and blocks the flow of blood. This can cause the lungs to become damaged and can lead to death. The nurse should suspect this complication if the client has a history of congestive heart failure and peptic ulcer disease. The client's vital signs are slightly elevated and she has a nonproductive cough. The nurse auscultates crackles at the base of the lungs. Pulmonary embolism is a serious condition that can be life-threatening. It is important for the nurse to be aware of the signs and symptoms of this condition so that they can provide timely and appropriate treatment.

The perioperative nurse is preparing to discharge a female client home from day surgery performed under general anesthetic. What instruction should the nurse give the client prior to the client leaving the hospital? A) The client should not drive herself home. B) The client should take an OTC sleeping pill for 2 nights. C) The client should attempt to eat a large meal at home to aid wound healing. D) The client should remain in bed for the first 48 hours postoperative.

Answer A The client should not drive herself home because she has had a general anesthetic and will be feeling the effects of the medication. It is important for her to have someone else drive her home so that she can rest and not be in a position where she could fall asleep at the wheel. The effects of general anesthesia can impair a person's ability to drive. The anesthesia can cause drowsiness, confusion, and impaired judgment. These effects can last for a few hours to a few days after the anesthesia is administered. It is important for people to not drive until they are no longer feeling the effects of the anesthesia.

The nurse is performing the shift assessment of a postsurgical client. The nurse finds the client's mental status, level of consciousness, speech, and orientation are intact and at baseline, but the client appears unusually restless. What should the nurse do next? A) Assess the client's oxygen levels. B) Administer antianxiety medications. C) Page the client's physician. D) Initiate a social work referral.

Answer A This option is correct because Postoperative patients are susceptible to hypoxemia due to incomplete lung re-expansion and diaphragmatic activity caused by surgical operation.

A client presents to the clinic reporting symptoms that suggest diabetes. What criteria would support checking blood levels for the diagnosis of diabetes? A) Fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L) B) Random plasma glucose greater than 150 mg/dL (8.3 mmol/L) C) Fasting plasma glucose greater than 116 mg/dL (6.4 mmol/L) on two separate occasions D) Random plasma glucose greater than 126 mg/dL (7.0 mmol/L)

Answer A This option is correct because normal fasting blood glucose is 70-100mg/dl as it's is greater than 126 mg/dl

In the teaching plan for a client being discharged from the PACU after ambulatory surgery, the nurse should include the instruction to a. "Be sure that you have someone who can drive you home." b. "Change your dressing frequently." c. "Have someone wake you every 2 hours for the first 24 hours." d. "Measure urine output for 48 hours."

Answer A A responsible adult must accompany the same-day surgery client being discharged from the ambulatory surgery center. Taxi cabs are not an appropriate means of transportation after surgery. This instruction would apply to any client being discharged from the ambulatory surgery center; the other instructions would be specific after specific types of operations.

A client has the nursing diagnosis Fear related to the unknown regarding upcoming surgery. The nurse would know that goals for this diagnosis have been met when the client says "I feel a little better now because a. a nurse will be with me during the entire experience." b. I can tolerate anything for 2-3 hours." c. I know I won't have any complications." d. this operation is really routine and done all the time."

Answer A Clients are commonly fearful and anxious before surgery. There are many interventions the nurse can provide to alleviate fear; one of the most powerful is telling a client that a nurse will be with him/her the entire time.

The recovery room nurse places the client in the lateral Sims position on admission to the post-anesthesia care unit (PACU) because this position a. allows the tongue to fall forward. b. discourages thrombophlebitis. c. helps stabilize blood pressure. d. prevents abdominal distention.

Answer A The lateral Sims position allows the tongue to fall forward to prevent it from falling backward and interfering with respiration. This position also allows mucus and vomitus to drain out, preventing aspiration.

Before administering the preoperative medication, the nurse should a. ensure that the permit has been properly signed. b. have the unlicensed assistive personnel call for transportation. c. make sure there is nothing else left to do. d. take and record a set of vital signs.

Answer A The purposes of various preoperative medications are to allay anxiety, reduce side effects of anesthetic agents, and create amnesia. Before administering any of them, make sure the permit has been correctly signed because once premedicated, the client can no longer sign the consent form.

Important actions the nurse takes to avoid "wrong site surgery" include (Select all that apply) a. asking the surgeon to initial the marked site and operate through the initials. b. calling a time-out to verify right client, right surgical site before starting the operation. c. having the client mark the surgical site with permanent marker. d. involving multiple surgeons in the case to check each other.

Answer A, B, C Preventing "wrong site surgery" is vital and is an important safety consideration. Several things can help prevent it, including options a, b, and c. A root factor analysis identified several contributing factors to this problem, one of which was the involvement of multiple surgeons in a case

A client has left to go to the operating room. Important supportive interventions the nurse can provide the family include (Select all that apply) a. asking them for a way to contact them if they leave the area. b. giving families a way to contact the nurses' station. c. letting the physician meet with them in person instead of the nurse. d. showing them where the family waiting room is.

Answer A, B, D Another option would be to provide families with pagers so they can leave the immediate area and still know that you can contact them. The physician should meet with the family, especially after the operation to give them a report, but caring for the family remains a nursing priority.

A nurse on the surgical floor has several clients who had surgery during the day. Which of the following actions can this nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) a. Encouraging the use of the incentive spirometer b. Outlining drainage present on dressings c. Providing comfort measures d. Recording output from drains e. Taking vital signs

Answer A, C, D, E Once the client has been taught the use of the incentive spirometer and the nurse has completed a respiratory assessment, the UAP can encourage the client to use the device and reinforce correct technique. The UAP can provide nonpharmacologic comfort measures such as back rubs or positioning and can assist with surveillance for pain relief. The nurse should ensure that drains are secured and appropriately labeled; then the UAP can empty and record the drainage. The nurse should instruct the UAP on frequency of drain emptying and on the frequency of vital signs, which is also within the scope of a UAP's practice. However, the registered nurse should assess all drainage on dressings and outline the amount to establish a baseline. New or increased drainage is immediately reportable by the UAP to the RN.

A client with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the client's initial phase of treatment? A) Monitoring the client for dysrhythmias B) Maintaining and monitoring the client's fluid balance C) Assessing the client's level of consciousness D) Assessing the client for signs and symptoms of venous thromboembolism

Answer B

A nurse is caring for a client with type 1 diabetes who is being discharged home tomorrow. What is the best way to assess the client's ability to prepare and self-administer insulin? A) Ask the client to describe the process in detail. B) Observe the client drawing up and administering the insulin. C) Provide a health education session reviewing the main points of insulin delivery. D) Review the client's first hemoglobin A1C result after discharge.

Answer B

A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement would 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."

Answer B

An elderly client with diabetes comes to the clinic with her daughter. The nurse reviews foot care with the client and her daughter. Why would the nurse feel that foot care is so important to this client? A) An elderly client with foot ulcers experiences severe foot pain due to the diabetic polyneuropathy. B) Avoiding foot ulcers may mean the difference between institutionalization and continued independent living. C) Hypoglycemia is linked with a risk for falls; this risk is elevated in older adults with diabetes. D) Oral antihyperglycemics have the possible adverse effect of decreased circulation to the lower extremities

Answer B

The nurse is caring for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 7:00 a.m. (0700). At which time would the nurse assess the client for potential hypoglycemia related to the NPH insulin? A) 8:00 a.m. (0800) B) 4:00 p.m. (1600) C) 8:00 p.m. (2000) D) 11:00 p.m. (2300)

Answer B NPH insulin is an intermediate-acting insulin with an onset of effects typically in 90 minutes and they last for 24 hours. However, the peak of this insulin, which is the time when the insulin is at maximum strength and the blood sugar is at its lowest, is usually around 6 to 8 hours after administration. Therefore, if the nurse administered the NPH insulin at 7:00 a.m., the peak effect would be expected around 1:00 p.m. to 3:00 p.m. However, the risk for hypoglycemia extends beyond the peak and can occur up to 12 hours after administration. Therefore, the nurse should assess the client for potential hypoglycemia related to the NPH insulin at 4:00 p.m. (1600).

A nurse assesses a client with diabetes mellitus. Which assessment finding would 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

Answer B The presence of protein in the urine, also known as proteinuria, is a common sign of kidney damage. In a healthy individual, the kidneys filter waste products from the blood but retain important components such as proteins. However, when the kidneys are damaged, they may allow proteins to leak into the urine. This is particularly common in individuals with diabetes mellitus, as high blood sugar levels can damage the kidneys over time. Therefore, if a nurse assesses a client with diabetes mellitus and finds protein in their urine, this would alert them to potential decreased kidney function. The other options (A, C, and D) are not directly related to kidney function.

The nurse admits a client to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the client's blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the client's skin is cold, moist, and pale. Of what is the client showing signs? A) Hypothermia B) Hypovolemic shock C) Neurogenic shock D) Malignant hyperthermia

Answer B Hypovolemic shock occurs when your body's blood or fluid supply is depleted, and your heart function is compromised. It can be caused by any sort of fluid loss, including diarrhea or dehydration. Hypovolemic shock occurs when intravascular volume is reduced, whether by interstitial fluid loss or blood loss.

The most appropriate explanation by the nurse to explain why a client cannot eat before surgery is a. "Anesthesia works best on an empty stomach." b. "The stomach should be empty to prevent complications." c. "There is not enough time before surgery to digest the food." d. "You will not have to go to the bathroom frequently before surgery."

Answer B If a client undergoing surgery is to receive a general anesthetic, foods and fluids are restricted for 8 hours before surgery. This restriction significantly reduces the possibility of aspiration of gastric contents, which can cause aspiration pneumonia.

The intraoperative nurse is implementing a care plan that addresses the surgical client's risk for vomiting. Interventions that address the potential for vomiting reduce the risk of what subsequent surgical complication? A) Impaired skin integrity B) Hypoxia C) Malignant hyperthermia D) Hypothermia

Answer B If a patient aspirates vomit, they will have symptoms similar to those of asthma, including acute bronchial spasms and wheezing. As a result, it is likely that pneumonitis and pulmonary edema may develop, causing the patient to suffer from severe hypoxia. However, even though aspirated vomitus has the potential to cause choking, the query clearly inquires about the possibility of aspirated vomitus. Malignant hyperthermia, a horrible anesthetic side effect, may cause death if not treated promptly. The intake of vomitus does not cause hypothermia, as previously thought. As a consequence of vomiting, there is no effect on the skin's ability to maintain its structural integrity. If a patient aspirates vomit, they will have symptoms similar to those of asthma, including acute bronchial spasms and wheezing. As a result, it is likely that pneumonitis and pulmonary edema may develop, causing the patient to suffer from severe hypoxia. However, even though aspirated vomitus has the potential to cause choking, the query clearly inquires about the possibility of aspirated vomitus. Malignant hyperthermia, a horrible anesthetic side effect, may cause death if not treated promptly. The intake of vomitus does not cause hypothermia, as previously thought. As a consequence of vomiting, there is no effect on the skin's ability to maintain its structural integrity.

The item most likely to be left in place when the client is sent to the operating room (OR) is a. an engagement ring. b. a hearing aid. c. a wig. d. well-fitting dentures.

Answer B If the client is wearing a hearing aid, the perioperative nurse should be notified. Leaving the hearing aid in place enhances communication in the OR. The nurse should make certain to record that the appliance is in place.

The nurse is discussing macrovascular complications of diabetes with a client. The nurse would address what topic during this dialogue? A) The need for frequent eye examinations for clients with diabetes B) The fact that clients with diabetes have an elevated risk of myocardial infarction C) The relationship between kidney function and blood glucose levels D) The need to monitor urine for the presence of albumin

Answer B Macrovascular complications of diabetes include an elevated risk of myocardial infarction (heart attack). This is due to the fact that diabetes can cause atherosclerosis, or hardening of the arteries. This process can narrow the arteries and reduce blood flow to the heart, which can lead to a heart attack. Therefore, it is important for clients with diabetes to be aware of this risk and to take steps to reduce their risk, such as exercising and eating a healthy diet. They should also be sure to monitor their blood sugar levels carefully and to take their medications as prescribed. If you have diabetes, it is important to talk to your doctor about your risk of developing cardiovascular disease. There are steps you can take to reduce your risk, and it is important to be aware of the signs and symptoms of a heart attack so that you can seek medical help if necessary.

A client with type 2 diabetes has been managing his blood glucose levels using diet and metformin. Following an ordered increase in the client's daily dose of metformin, the nurse should prioritize which of the following assessments? A) Monitoring the client's neutrophil levels B) Assessing the client for signs of impaired liver function C) Monitoring the client's level of consciousness and behavior D) Reviewing the client's creatinine and BUN levels

Answer B Metformin is a medication used to control blood sugar levels in type 2 diabetes. One of the potential side effects of metformin is lactic acidosis, a serious condition that can occur if your body builds up too much lactic acid. This can be more likely to happen if your liver is not working normally. Therefore, it is important for the nurse to monitor for signs of impaired liver function when a client's dose of metformin is increased. Monitoring the client's neutrophil levels is not directly related to the use of metformin.

The client who has received ondansetron (Zofran) asks, "What will the drug do?" The nurse should base a reply on the knowledge that ondansetron a. controls intraoperative secretions. b. produces an antiemetic effect. c. promotes rapid sedation. d. relieves postoperative pain.

Answer B Ondansetron is given to reduce emesis

Verification that all required documentation is completed is an important function of the intraoperative nurse. The intraoperative nurse should confirm that the client's accompanying documentation includes which of the following? A) Discharge planning B) Informed consent C) Analgesia prescription D) Educational resources

Answer B One key importance of informed consent is the fact that creates clear understanding that in turn builds confidence between the nurses and doctor and their patient. In addition to this, it enables a patient to make informed decisions decisions about their treatment with clear communication about the risks and options involved. Informed consent can also save doctors and nurses from facing legal action.

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 (3.3 mmol/L)?" How would 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."

Answer B The brain is one of the few organs in the body that relies almost exclusively on glucose for its energy needs. Unlike other tissues, the brain cannot store glucose and therefore requires a constant supply. If blood glucose levels drop too low (below 70 mg/dL or 3.9 mmol/L), the brain may not have enough glucose to function properly, leading to symptoms of hypoglycemia. Therefore, it is important for individuals with diabetes to maintain their blood glucose levels within a certain range to ensure adequate glucose supply to the brain.

A medical nurse is caring for a client with type 1 diabetes. The client's medication administration record includes the administration of regular insulin three times daily. Knowing that the client's lunch tray will arrive at 11:45 AM, when should the nurse administer the client's insulin? A) 10:45 AM B) 11:15 AM C) 11:45 AM D) 11:50 AM

Answer B The most effective time to give insulin to a patient is approximately thirty minutes before they eat. Because the lunch tray for the client is scheduled to arrive at 11:45 AM, the nurse should start giving the insulin to the patient at 11:15 AM. This will allow the insulin to have time to work before the client eats, which will assist in maintaining good control over the client's blood sugar levels.

A postoperative client rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the client is experiencing a hemorrhage. What should be the nurse's first action? A) Leave and promptly notify the physician. B) Quickly attempt to determine the cause of hemorrhage. C) Begin resuscitation. D) Put the client in the Trendelenburg position.

Answer B The nurse suspects that the client is experiencing a hemorrhage. Determining the cause of hemorrhage and transfusing blood or blood products are the initial nursing interventions. Options A, C, and D are incorrect because they are not the initial actions that should be taken.

The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the client do? A) Sit in a chair for 10 minutes prior to ambulating. B) Drink plenty of fluids to increase circulating blood volume. C) Stand upright for 2 to 3 minutes prior to ambulating. D) Perform range-of-motion exercises for each joint.

Answer B The patient should drink plenty of water to increase circulating blood volume. Keep the patient hydrated to prevent low blood pressure or orthostatic hypotension that is common after a surgical operation.

Preoperative assessment data that should be reported to the surgeon include. a. complaining of mild anxiety. b. having a sore throat. c. potassium level within normal range. d. using acetaminophen for headaches.

Answer B Any pre-existing infection can adversely affect surgical outcome and should be reported preoperatively. Manifestations of infection include coughing, sore throat, and increased temperature. An elective procedure might need to be canceled because of an infection

A client scheduled for a dilation and evacuation following a miscarriage is visibly upset and states that she is frightened and does not know what to expect. The perioperative nurse best demonstrates understanding of the situation by saying a. "I'll give you something to help you relax." b. "Let me explain what is going to happen." c. "This is a simple procedure; it will be over in no time." d. "You're still young, and you can have more children."

Answer B Fear of the unknown is one of the most prevalent causes of preoperative anxiety. The client should understand what the preoperative, intraoperative, and postoperative course entails

The methodology likely to be most effective in meeting a client's teaching/learning needs preoperatively is a. teaching only the client. b. teaching the client and family. c. using brief verbal instructions. d. using only written instructions.

Answer B The nurse should determine learning needs preoperatively and teach both the client and the family before surgery if possible. Preferably, the nurse should provide both written and oral instructions. Good teaching techniques will help ensure the client retains the information during this stressful period.

A client calls the Telehealth nurse on the third postoperative day and describes a "giving way" sensation in the abdomen that occurred after coughing. To assess for a possible evisceration, the nurse asks if a. bright-red bleeding from the wound edges is seen. b. fascia or internal organs are visible. c. fecal material is draining from the wound site. d. large amounts of pus are draining.

Answer B Evisceration occurs when an abdominal incision opens, with visible fascia or internal organs.

During the operative period, a client under general anesthesia experiences masseter muscle rigidity. The nurse-anesthetist recognizes this to be a manifestation of a. excessive heat loss. b. malignant hyperthermia. c. need for increased muscle relaxant. d. onset of anesthesia.

Answer B Initial manifestations of malignant hyperthermia are increased end-tidal carbon dioxide volume, masseter (jaw) muscle rigidity, cardiac dysrhythmias, and hypermetabolic state.

The nurse explains to the postoperative ambulatory surgery client that his discharge will be delayed because of his a. blood pressure of 108/64 mm Hg. b. inability to void. c. mild incisional discomfort. d. pulse rate of 92 beats/min.

Answer B Same-day surgery clients cannot be discharged until they are able to tolerate fluids by mouth, can ambulate with a steady gait and without orthostatic hypotension, have pain controlled with oral analgesics, and have voided. The vital signs in options a and d might be baseline for the client.

In the first 3 days after surgery, the nurse would anticipate the fluid and electrolyte adjustment of a. elevated hematocrit level. b. fluid retention. c. increase in serum potassium level. d. increased urine output.

Answer B The stress response to surgery stimulates the secretion of antidiuretic hormone (ADH) and aldosterone, which cause fluid retention.

The PACU nurse notes that a client is beginning to become increasingly restless. Nursing assessment includes blood pressure measurements dropping from 120/82 to 90/60 mm Hg, with heart rate increased to 120 beats/min, and dressings dry and intact. Which action by the nurse takes priority? a. Increase rate of intravenous (IV) fluids. b. Increase rate of oxygen (O2) delivery. c. Notify the surgeon. d. Place the client in the Trendelenburg position.

Answer B When a client appears to be going into shock, the PACU nurse applies O2 or increases the rate of O2 delivery, and then raises the client's legs above heart level, increases IV flow rate (unless contraindicated), and notifies the surgeon or anesthesiologist.

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."

Answer C

The health care provider has explained to a client that the client has developed diabetic neuropathy in his right foot. Later that day, the client asks the nurse what causes diabetic neuropathy. What would be the nurse's best response? A) "Research has shown that diabetic neuropathy is caused by fluctuations in blood sugar that have gone on for years." B) "The cause is not known for sure but it is thought to have something to do with ketoacidosis." C) "The cause is not known for sure but it is thought to involve elevated blood glucose levels over a period of years." D) "Research has shown that diabetic neuropathy is caused by a combination of elevated glucose and ketone levels."

Answer C

The preoperative assessment finding that the nurse would report to the surgeon for preoperative treatment is: a. hemoglobin concentration of 13.5 mg/dl. b. partial thromboplastin time of 25 seconds. c. potassium level of 3.0 mEq/L. d. sodium level of 140 mEq/L.

Answer C Electrolyte imbalances increase operative risk. Preoperative laboratory results should be checked to see if they are within the normal range. The other three lab values are within normal range.

The nurse is caring for a client on the medical-surgical unit postoperative day 5. During each client assessment, the nurse evaluates the client for infection. Which of the following would be most indicative of infection? A) Presence of an indwelling urinary catheter B) Rectal temperature of 99.5°F (37.5°C) C) Red, warm, tender incision D) White blood cell (WBC) count of 8,000/mL

Answer C Because red warm incision is the indicator of post operative infections. In addition, the fever of 100 F is normal due to inflammation, presence of in dwelling urinary catheter alone is not indicator of infection, and the WBC is in normal ranges.

A client newly diagnosed with type 2 diabetes is attending a nutrition class. What general guideline should the nurse teach the clients at this class? A) Low fat generally indicates low sugar. B) Protein should constitute 30% to 40% of caloric intake. C) Most calories should be derived from carbohydrates. D) Animal fats should be eliminated from the diet.

Answer C Currently, the ADA and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) recommend that for all levels of caloric intake, 50% to 60% of calories should be derived from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein.Low fat does not automatically mean low sugar. Dietary animal does not need to be eliminated from the diet.

The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following abdominal surgery. The client is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication? A) Sepsis B) Infection C) Pulmonary embolism D) Hematoma

Answer C Hospitals most often use external pneumatic compression devices for people who are less active while recovering from illness or surgery. This inactivity could lead to deep vein thrombosis (DVT) — a blood clot that can be dangerous or even deadly. DVT usually forms in one of the veins of the thigh or lower leg. DVT can potentially lead to pulmonary embolism.

An older adult client with type 2 diabetes is brought to the emergency department by his daughter. The client is found to have a blood glucose level of 600 mg/dL (33.3 mmol/L). The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? A) Administration of antihypertensive medications B) Administering sodium bicarbonate intravenously C) Reversing acidosis by administering insulin D) Fluid and electrolyte replacement

Answer C Hyperglycemic hyperosmolar syndrome (HHS) is a serious complication of diabetes that involves extremely high blood sugar levels without the presence of ketones. The primary treatment for HHS is to lower blood glucose levels, which can be achieved by administering insulin. This helps to reverse the hyperglycemia and the associated acidosis. Administering antihypertensive medications (option A) would not directly address the high blood glucose levels, and sodium bicarbonate (option B) is typically used to treat metabolic acidosis, not hyperglycemia. Therefore, the priority nursing action would be to administer insulin to lower the client's blood glucose levels.

The nurse is caring for an 82-year-old female client in the PACU. The woman begins to awaken and responds to her name, but is confused, restless, and agitated. What principle should guide the nurse's subsequent assessment? A) Postoperative confusion in older adults is an indication of impaired oxygenation or possibly a stroke during surgery. B) Confusion, restlessness, and agitation are expected postoperative findings in older adults and they will diminish in time. C) Postoperative confusion is common in the older adult client, but it could also indicate a significant blood loss. D) Confusion, restlessness, and agitation indicate an underlying cognitive deficit such as dementia.

Answer C It is usual for elderly people to feel tired or out of sorts shortly after undergoing anesthesia-assisted surgery. Patients who have significant abnormalities in mental function, such as bewilderment, disorientation, chronic drowsiness, hallucinations, agitation, or violence, may be suffering from post-operative delirium. According to the American Geriatric Society, the most common complication of surgery for older people is post-operative delirium, which affects up to 50% of individuals who have surgery. If not diagnosed and treated promptly, post-operative delirium can lead to long-term health concerns, including cognitive and functional impairment. Patients encounter hazards such as physical injury, hospitalization, and transfer to long-term care facilities. Symptoms might emerge anywhere from a few hours to a few weeks following surgery. Unfortunately, post-operative delirium symptoms are frequently misdiagnosed as dementia, an umbrella term for irreversible illnesses that involve memory loss and reduced cognitive function. While there are some similarities in symptoms, delirium is not the same as dementia and may be averted in around 40% of instances.

The nurse is performing wound care on a postsurgical client. Which of the following practices violates the principles of surgical asepsis? A) Holding sterile objects above the level of the nurse's waist B) Considering a 1 inch (2.5 cm) edge around the sterile field as being contaminated C) Pouring solution onto a sterile field cloth D) Opening the outermost flap of a sterile package away from the body

Answer C Letters A, B and D are all correct. But letter C is questionable. We don't wet the sterile field cloth intentionally. Instead, we pour sterile solution onto sterile containers. And according to the principles of surgical asepsis, we have to keep the sterile surface dry and avoid splashes when pouring solutions.

The nurse just received a postoperative client from the PACU to the medical-surgical unit. The client is an 84-year-old woman who had surgery for a left hip replacement. What concern should the nurse prioritize for this client in the first few hours on the unit? A) Beginning early ambulation B) Maintaining clean dressings on the surgical site C) Close monitoring of neurologic status D) Resumption of normal oral intake

Answer C Neuromonitoring's goals are to: identify worsening neurological function and secondary insults that may benefit from certain treatments; and increase pathophysiological understanding of brain disease in critical illness. give physiological data to help guide and personalize therapy help with forecasting. A neurological assessment is used to discover neurological disease or injury in your patient, monitor its progression to define the type of therapy you'll deliver, and assess the patient's reaction to your interventions. Keeping an eye on vital signs including blood pressure, pulse, and breathing is also important in pacu . Keep an eye out for any indicators of difficulties. Take the temperature of the patient. Examine for swallowing or gagging.

The nurse is caring for a client after abdominal surgery in the PACU. The client's blood pressure has increased and the client is restless. The client's oxygen saturation is 97%. What cause for this change in status should the nurse first suspect? A) Hypothermia B) Shock C) Pain D) Hypoxia

Answer C The client is restless and the blood pressure has increased. The client's oxygen saturation is 97%. Pain causes blood pressure to rise, but the oxygen saturation does not change. The client may be restless because of pain from the surgery. In addition, it is not normal for the blood pressure to go up immediately after surgery. This is called a tachycardia, and it usually occurs later after surgery when pain begins to subside.

A student with diabetes tells the school nurse that he is feeling nervous and hungry. The nurse assesses the child and finds he has tachycardia and is diaphoretic with a blood glucose level of 50 mg/dL (2.8 mmol/L). What should the school nurse administer? A) A combination of protein and carbohydrates, such as a small cup of yogurt B) Two teaspoons of sugar dissolved in a cup of apple juice C) Half a cup of juice followed by cheese and crackers D) Half a sandwich with a protein-based filling

Answer C The student's symptoms and blood glucose level indicate hypoglycemia, which is a condition where blood sugar levels are too low. The immediate treatment for hypoglycemia is to consume a source of fast-acting sugar, such as juice, to quickly raise blood sugar levels. This is followed by a snack containing protein and carbohydrates, like cheese and crackers, to help stabilize blood sugar levels and prevent them from dropping again. Therefore, the best option is to give the student half a cup of juice followed by cheese and crackers.

A diabetes educator is teaching a client about type 2 diabetes. The educator recognizes that the client understands the primary treatment for type 2 diabetes when the client states what? A) "I read that a pancreas transplant will provide a cure for my diabetes." B) "I will take my oral antidiabetic agents when my morning blood sugar is high." C) "I will make sure to follow the weight-loss plan designed by the dietitian." D) "I will make sure I call the diabetes educator when I have questions about my insulin."

Answer C This option is correct because obesity and insulin resistance are related, weight loss is the main type 2 diabetes treatment.

A diabetes nurse educator is presenting current recommendations for levels of caloric intake. What should the nurse describe? A) 10% of calories from carbohydrates, 50% from fat, and the remaining 40% from protein B) 10% to 20% of calories from carbohydrates, 20% to 30% from fat, and the remaining 50% to 60% from protein C) 20% to 30% of calories from carbohydrates, 50% to 60% from fat, and the remaining 10% to 20% from protein D) 50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein

Answer C the most appropriate answer as it falls within the recommended ranges for carbohydrates, fat, and protein intake for individuals with diabetes. It's important to note that these recommendations may vary depending on an individual's specific health condition, age, activity level, and other factors, and it's always best to consult with a healthcare professional for personalized dietary recommendations.

During the preoperative interview, the client's statement that would alert the nurse to an increased risk during surgery is "I a. am a reformed smoker; I haven't had a cigarette in 10 years." b. rarely eat red meat; it usually makes me feel bloated." c. take a couple of aspirin every day for my headaches." d. take a large assortment of vitamins daily."

Answer C Many clients take aspirin and other over-the-counter (OTC) medications that may increase the risk of bleeding.

The nurse explains to a preoperative class of six clients awaiting surgery that studies indicate the primary benefit of the class is to a. distribute information to the most individuals in a short time. b. explain legal responsibilities. c. promote a less complicated postoperative course. d. provide uniform information.

Answer C Numerous research studies have supported the value of preoperative instruction in reducing both the incidence of postoperative complications and the length of hospital stay

The nurse will plan preoperative teaching about how to cough and deep breathe for a. 1 week before the procedure. b. immediately postoperatively. c. the afternoon before surgery. d. the nurse's first discussion about the surgery.

Answer C The timing of preoperative teaching is highly individualized. Ideally there will be enough time for the nurse to give instructions and answer questions. Often the client is admitted on the day of surgery. It is imperative that the client receives instructions before this time so that the nurse can simply reinforce instructions and answer questions. But if the teaching is done too far in advance, the client will forget the information

On the preoperative assessment, the nurse notes the suggestion of susceptibility to malignant hyperthermia during surgery in the client's statement that a. "I frequently have numbness and tingling in my hands." b. "I usually feel very warm and tend to perspire heavily." c. "My mother died from anesthesia problems." d. "On occasion I've had muscle tenderness around my jaw."

Answer C A concern relative to the development of malignant hyperthermia can be made if a client has a personal or family history of anesthesia problems

The PACU nurse is informed that the client being admitted has not recovered his pharyngeal reflex. The nursing action that should receive greatest priority is to a. check for the gag reflex frequently. b. maintain an oral airway. c. remain with the client at all times. d. suction the client frequently.

Answer C Clients admitted to the PACU without pharyngeal (gag) reflex are positioned on their side. The immediate assessment includes the ABCs: airway, breathing, circulation. An impaired gag reflex could impair breathing. The nurse stays at the bedside until the client's pharyngeal reflex returns. The nurse would monitor for return of the reflex and would be prepared to suction the client's secretions if needed. An oral airway may or may not be used.

A client is receiving anesthesia and is being inducted just before an operation. The most appropriate action by the nurse at this time is to a. apply wrist and leg restraints to ensure client safety. b. begin counting supplies with the surgical technician or scrub nurse. c. ensure all conversation in the operating room is appropriate. d. monitor the client for agitation and struggling.

Answer C During the induction phase of anesthesia, the last sense to be depressed is hearing. The nurse acting as the client's advocate will ensure that the room is quiet and all conversation is appropriate during this phase and throughout the operation.

The nursing action that should receive highest priority when a client returns from the OR to the PACU is a. checking the postoperative orders. b. observing the operative site. c. positioning the client. d. receiving the report from OR personnel.

Answer C The client is received in the PACU on a bed or stretcher. Proper positioning is necessary to ensure airway patency in a sedated, unconscious, or semiconscious client.

Which action should receive high priority in an elderly client being placed on the operating room table? a. Attach the client to a cardiac monitor. b. Ensure that the correct operative site is exposed. c. Provide extra padding for joints and bony prominences. d. Understand which anesthetic agents are being used.

Answer C The elderly tend to have a decrease in lean body mass, increased spinal compression, and an increased incidence of arthritis and osteoporosis, so extra padding is a precaution that the nurse should ensure for the elderly client to prevent injury.

After administration of preoperative medications, the nurse takes the precaution of a. confirming that the client has voided. b. monitoring vital signs every 15 minutes. c. placing the client in bed with the rails up. d. transporting the client immediately to the OR.

Answer C The nurse instructs the client not to get up without assistance because medications may cause drowsiness or dizziness.

The nurse should complete a detailed cognitive assessment on an elderly client before surgery because (Select all that apply) a. confusion and psychosis are commonly seen in postoperative elderly clients. b. elders often experience intraoperative strokes. c. neurologic changes resulting from surgery can last longer in an older client. d. temporarily impaired cognition can be mistaken for a neurologic event.

Answer C, D The effects of an operation and its associated medications can cause temporary cognitive deficits that can be mistakenly attributed to permanent conditions in the elderly, such as stroke or dementia. These temporary changes are seen in most clients and are considered normal, but may last longer in an elderly client than in younger clients. The nurse should conduct and document a thorough neurologic status exam preoperatively, and nurses who encounter the client postoperatively should use those data as a baseline. Psychosis is not a common condition seen in the elderly, nor do they experience intraoperative strokes on a frequent basis

A nurse teaches a client with type 1 diabetes mellitus. Which statement would the nurse include in this client's teaching to decrease the client's insulin needs? A) "Limit your fluid intake to 2 L a day." B) "Animal organ meat is high in insulin." C) "Limit your carbohydrate intake to 80 g a day." D) "Walk at a moderate pace for 1 mile daily."

Answer D

A nurse teaches a patient about self-monitoring of blood glucose levels. Which statement would 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."

Answer D

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."

Answer D

The nurse is caring for a newly admitted older adult who has a blood glucose of 300 mg/dL (16.7 mmol/L), a urine output of 185 mL in the past 8 hours, and a blood urea nitrogen (BUN) of 44 mg/dL (15.7 mmol/L). What diabetic complication does the nurse suspect? A) Diabetic ketoacidosis (DKA) B) Severe hypoglycemia C) Chronic kidney disease (CKD) D) Hyperglycemic-hyperosmolar state (HHS

Answer D

The nurse is packing a client's abdominal wound with sterile, half-inch Iodoform gauze. During the procedure, the nurse drops some of the gauze onto the client's abdomen 2 inches (5 cm) away from the wound. What should the nurse do? A) Apply povidone-iodine (Betadine) to that section of the gauze and continue packing the wound. B) Pick up the gauze and continue packing the wound after irrigating the abdominal wound with Betadine solution. C) Continue packing the wound and inform the physician that an antibiotic is needed. D) Discard the gauze packing and repack the wound with new Iodoform gauze.

Answer D

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 would 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."

Answer D

A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. What action would the nurse take? A) Administration of oxygen via facemask B) Intravenous administration of 10% glucose C) Implementation of seizure precautions D) Administration of intravenous insulin

Answer D Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones. It develops when your body is unable to produce enough insulin. Insulin is a hormone that helps sugar (glucose) enter cells to produce energy. Without enough insulin, your body begins to break down fat as fuel, which leads to a buildup of ketones in the blood, causing it to become acidic. Kussmaul respirations (deep, rapid breathing) are a symptom of DKA, not a cause, so treating the symptom (with oxygen, for example) will not solve the problem. The most effective treatment is to give insulin, which will help to lower blood sugar levels, reduce ketone production, and correct the acidosis.

A nurse reviews the chart and new prescriptions for a client with diabetic ketoacidosis: Vital Signs and Assessment Blood pressure: 90/62 mm Hg Pulse: 120 beats/min Respiratory rate: 28 breaths/min Urine output: 20 mL/hr via catheter Laboratory Results Serum potassium: 2.6 mEq/L (2.6 mmol/L) Medications Potassium chloride 40 mEq/L (40 mmol/L) IV bolus STAT Increase IV fluid to 100 mL/hr What action would the nurse take? A) Administer the potassium and then consult with the primary health care provider about the fluid prescription. B) Increase the intravenous rate and then consult with the primary health care provider about the potassium prescription. C) Administer the potassium first before increasing the infusion flow rate for the client. D) Increase the intravenous flow rate before administering the potassium to the client.

Answer D The client's serum potassium level is 2.6 mEq/L, which is below the normal range of 3.5 to 5.0 mEq/L, indicating hypokalemia. However, before administering potassium, it's important to ensure adequate kidney function, which is indicated by urine output. The client's urine output is low (20 mL/hr), suggesting possible kidney dysfunction. Increasing the intravenous fluid rate can help improve kidney function and urine output. Once urine output is adequate, potassium can be safely administered. Administering potassium without ensuring adequate kidney function can lead to hyperkalemia, which can cause serious heart problems. Therefore, the nurse should first increase the intravenous flow rate before administering the potassium to the client.

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. What action would 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

Answer D The spongy, swelling area at the site the client uses most frequently for insulin injection is likely lipohypertrophy, a common minor complication of diabetes mellitus due to repeated insulin injections at the same site. The best action for the nurse to take is to teach the client to rotate injection sites (D). This will help prevent further lipohypertrophy and ensure more effective insulin absorption. Applying ice (A) is not typically recommended for lipohypertrophy. Consulting the provider for a new administration route (B) may not be necessary if the client can simply rotate injection sites. Assessing for signs of cellulitis (C) may be appropriate if there are signs of infection, but the question does not indicate this.

A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which would alert the nurse to intervene immediately? A) Serum chloride level of 98 mEq/L (98 mmol/L) B) Serum calcium level of 8.8 mg/dL (2.2 mmol/L) C) Serum sodium level of 132 mEq (132 mmol/L) D) Serum potassium level of 2.5 mEq/L (2.5 mmol/L)

Answer D he nurse would intervene immediately if the client's serum potassium level was 2.5 mEq/L (2.5 mmol/L) because this could indicate a serious electrolyte imbalance. If the potassium level is too low, it can cause muscle weakness, paralysis, and even cardiac arrest. Therefore, it is important to closely monitor a client's potassium level when they are receiving intravenous insulin, as this can cause potassium levels to drop. If the nurse notices that the client's potassium level is 2.5 mEq/L (2.5 mmol/L), they would take immediate action to correct the imbalance. This may involve giving the client potassium supplements or IV fluids.

The PACU nurse is caring for a male client who had a hernia repair. The client's blood pressure is now 164/92 mm Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following surgery? A) Dysrhythmias, blood loss, and hyperthermia B) Electrolyte imbalances and neurologic changes C) A parasympathetic reaction and low blood volumes D) Pain, hypoxia, or bladder distention

Answer D For patients who typically have normal blood pressure, it can be very alarming to have an increased blood pressure after a surgery, however, an increase in blood pressure is a common issue after a surgery. Experiencing pain is common after surgeries, pain is the easiest way to increase the blood pressure. Mild to moderate pain causes an increase in blood pressure to some individuals. Another cause of hypertension after surgery is hypoxia. During surgery, a patient may experience an incomplete lung expansion, reduced chest wall and diaphragmatic activity due to the surgical injury, pain, and the use of anesthesia. This will result to a decrease in oxygen levels in the blood which results to an increase in blood pressure. Other possible cause of increase in blood pressure is bladder distention. Due to the use of anesthesia during surgery, the bladder muscles are not able to contract strong enough to empty the bladder leading to bladder distention. Inability to completely empty the bladder means there is an accumulation of fluid in the body which results to an increase in blood volume, an increased volume will also lead to an increase in blood pressure.

The recovery room nurse is admitting a client from the OR following the client's successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted client? A) Heart rate and rhythm B) Skin integrity C) Core body temperature D) Airway patency

Answer D In doing a post-operative assessment, the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach must be followed. First, life-threatening airway problems, such as airway obstruction, must always be assessed and treated. The next one would be breathing problems, then circulatory, then any potential or current disabilities, and lastly risk exposure. Using this approach, the healthcare provider is able to pinpoint and identify any life-threatening situations that need immediate intervention.

An adult client is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The client's vital signs and level of consciousness have stabilized, but the client then reports severe nausea and begins to retch. What should the nurse do next? A) Administer a dose of IV analgesic. B) Apply a cool cloth to the client's forehead. C) Offer the client a small amount of ice chips. D) Turn the client completely to one side.

Answer D The nurse should turn the client completely to one side to decrease the risk of aspiration.

The nurse's aide notifies the nurse that a client has decreased oxygen saturation levels. The nurse assesses the client and finds that he is tachypneic, has crackles on auscultation, and his sputum is frothy and pink. The nurse should suspect what complication? A) Pulmonary embolism B) Atelectasis C) Laryngospasm D) Flash pulmonary edema

Answer D This option is correct because Pulmonary edema usually presents with crackles, dyspnea which is compensated by tachypnea. The edema develops and produces fluid which will affect the alveoli furtherly producing a characteristic frothy pink sputum.

The nurse is admitting a client to the medical-surgical unit from the PACU. In order to help the client clear secretions and help prevent pneumonia, the nurse should encourage the client to A) eat a balanced diet that is high in protein. B) limit activity for the first 72 hours. C) take medications as prescribed. D) use the incentive spirometer every 2 hours.

Answer D This option is correct because using the incentive spirometer every 2 hours post operation helps preserve the lungs' integrity and keep the lungs clear. Deep breathing supports the movement of secretions and assists in opening lung spaces that may have become collapsed post operation.

For a client admitted to the PACU with an oral airway in place, the nursing intervention that would be inappropriate is. a. allowing the client to spit out the airway. b. removing the airway when the client becomes responsive. c. suctioning the client's secretions as needed. d. taping the airway in place, so it does not fall out.

Answer D Airways should not be taped in place. When clients awaken and the gag reflex returns, they may spit out the airway.

The nurse notes that a client's wound is beginning to eviscerate while ambulating. The nurse's initial intervention is to a. cover the wound with moistened, sterile saline dressings. b. notify the surgeon immediately. c. replace the protruding loops of bowel using sterile gloves. d. return the client to bed as quickly as possible.

Answer D Evisceration constitutes an emergency. The nurse returns the client to bed, does not attempt to replace the organs, covers the wound with dressings moistened in sterile normal saline, and notifies the surgeon

The nurse caring for a client who had spinal anesthesia will ensure that the plan of care includes. a. administering oxygen to reduce the hypoxia produced by spinal anesthesia. b. elevating the client's feet to increase the blood pressure. c. elevating the head of the bed to decrease nausea. d. instructing the client to remain flat in bed for 6 hours.

Answer D One complication of spinal anesthesia is loss of cerebrospinal fluid, which cushions the brain. Clients can complain of severe headaches should this occur. Therefore the client is instructed to lie flat for 6 to 8 hours. Other interventions designed to replace fluids and indirectly replace lost spinal fluid include methods to increase fluid intake

To lessen the postoperative complication of thrombophlebitis, the nurse would a. assist the client to sit up in bed after surgery. b. maintain the legs in an elevated position. c. massage the client's legs. d. remind the client to exercise the legs and feet.

Answer D Postoperative extremity exercise helps to prevent circulatory problems (e.g., thrombophlebitis) by facilitating venous return to the heart.

During preoperative teaching, the nurse advises the client who smokes on an important health promotion measure to take before elective surgery, which is to a. ask the physician for nicotine patches. b. cut down by half the amount smoked per day. c. increase fluid intake to reduce risk of thrombosis. d. stop smoking at once.

Answer D Smoking can cause postoperative complications including thrombosis formation and respiratory problems. The best health promotion measure this client can take is to stop smoking at once. Using nicotine patches or gum is not appropriate as nicotine still enters the bloodstream where it continues to act as a potent vasoconstrictor

When teaching the proper method of coughing, the nurse should instruct the client to a. breathe in and out through the nose. b. deep-breathe after coughing. c. relax the abdominal muscles. d. splint the incision.

Answer D Splinting minimizes pressure and helps to control pain when the person is coughing.

Assessing unilateral leg edema and warmth in a postoperative client complaining of pain, the surgical unit nurse suspects the complication of a. hypovolemia. b. myocardial infarction. c. pneumonia. d. thrombophlebitis.

Answer D Thrombus can form in any blood vessel, and the nurse should be alert to any complaints of extremity pain, unilateral edema, or warmth.