Ch 27 & 30 prep u

The nurse is caring for a client who just returned from the postanesthesia care unit following surgery to repair a fractured arm. Place the following interventions in order of highest priority to lowest priority. 1-Assess for pain and administer prescribed analgesics, if indicated. 2-Measure oxygen saturation. 3-Assess neurovascular status to the affected arm. 4-Place the client in a position that facilitates breathing. 5-Assess dressing for bleeding or other drainage. 6-Measure pulse, blood pressure, respirations, and temperature.

4,6,2,3,5,1

A nurse is caring for a postoperative client and preparing to apply a pneumatic compression device. How does the nurse explain the device to the client prior to application? A) The device fills with air and squeezes the legs, which increases blood flow through the veins of the legs and helps to prevent blood clots. B) The device fills with air and squeezes the legs which increase blood flow through the veins of the legs and should be worn in bed and while ambulating to help prevent blood clots. C) The device fills with air and squeezes the arms, which increases blood flow through the veins of the arms and helps to prevent blood clots. D) The device fills with air supporting the legs during ambulation so blood flow will not pool in the legs and feet, thus preventing blood clots, and squeezes the legs, which increases blood flow through the veins of the legs.

A

A nurse is preparing discharge education for a client with a newborn infant. What is the highest priority item that must be included in the education plan? A) Restrain the infant in a car seat. B) Lock all cabinets that contain cleaning supplies. C) Give warm bottles of formula to the infant. D) Keep all pots and pans in lower cabinets.

A

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take? A) Pull the fire alarm lever. B) Evacuate the unit. C) Confine the fire. D) Extinguish the fire.

A

Surgery can lead to hypothermia. Which client is at greatest risk for hypothermia? A) an older adult man with a fractured hip B) an adolescent having arthroscopic surgery C) a young adult with a fractured leg D) a woman experiencing a cesarean birth

A

The nurse working in the holding area is performing an assessment on a client scheduled for surgery. Which question will the nurse ask prior to the client receiving general anesthesia? A) "When was the last time you had anything to eat or drink?" B) "Can you tell me why you are here this morning?" C) "Do you want me to call the hospital chaplain before you have anesthesia?" D) "Which medications do you take daily?"

A

A 9-month-old infant is scheduled for heart surgery. When preparing this client for surgery, the nurse should consider which surgical risk associated with infants? A) Shock B) Impaired thermoregulation C) Prolonged wound healing D) Surgical site infections

B

A client has presented to the outpatient surgical center for a scheduled procedure. Which action should the nurse perform prior to the procedure? A) Administer analgesia (pain medications). B) Assess the client's allergy status. C) Have the client perform leg exercises every 30 minutes. D) Encourage the client to create an advance directive.

B

A female client age 54 years has been scheduled for a bunionectomy (removal of bone tissue from the base of the great toe) which will be conducted on an ambulatory basis. Which characteristic applies to this type of surgery? A) The surgery will be conducted using moderate sedation rather than general anesthesia. B) The client will be admitted the day of surgery and return home the same day. C) The client must be previously healthy with low surgical risks. D) The surgery is classified as urgent rather than elective.

B

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process? A) The nurse provides an opinion of the physical and mental condition of the client that may have precipitated the incident. B) The nurse details the client's response and the examination and treatment of the client after the incident. C) The nurse adds the information in the safety event report to the client health record. D) The nurse calls the primary health care provider to fill out and sign the safety event report.

B

A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client? A) Keep the client from ambulating until the day after surgery. B) Implement leg exercises and turn the client in bed every 2 hours. C) Position the client in bed with pillows placed under his knees to hasten venous return. D) Keep the client cool and uncovered to prevent elevated temperature.

B

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow? A) Alert the health care provider and the client's family if restraints are ordered by the client's primary nurse. B) Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others. C) Individualize the use of restraints and choose the most easily used device. D) Respond to the past history of the client (including previous falls) to determine the need for restraints.

B

An older adult client underwent a hip replacement and now states to the nurse, "My parents are coming to visit me today. I need to mow the lawn and run errands." The client is trying to get out of the bed. What does the nurse identify is occurring with this client? A) Opioid overuse B) Delirium C) Dementia D) Boredom

B

As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site? A) operative site marking B) procedural pause (time-out) C) informed consent D)preoperative checklist

B

The nurse is caring for a client after breast augmentation. Before performing a bowel assessment, what education will the nurse provide the client? A) "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By pressing on the symphysis pubis, I can check for a return of peristalsis." B) "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By listening for bowel sounds, I can check for a return of peristalsis." C) "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By giving you sips of water periodically, I can promote the return of peristalsis." D) "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By lightly pressing on the abdomen, I can check for a return of peristalsis."

B

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse? A) The type of personal protective equipment used by the nurse during restraint application B) The alternative measures attempted before applying the restraints C) A verbal prescription for the restraints, renewed every 48 hours D) A detailed description of the restraint application process

B

The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock? A) Leave outlets and switches open so air circulates through them. B) Refrain from using extension cords. C) All machines that are used infrequently are to remain plugged in. D) Remove the plug from the wall by pulling the electric cord.

B

The nurse needs to evaluate the effectiveness of a preoperative teaching session with a client scheduled for abdominal surgery. Which client statement indicates the need for further clarification? A) "I will splint my incision while I cough." B) "While my pneumatic compression device is on, I don't need to do leg exercises." C) "Every 2 hours while I am awake, I will take deep breaths and cough." D) "I will sit up in bed before using my incentive spirometer."

B

The nurse recognizes that palliative surgery is performed for what purpose? A) to make or confirm a diagnosis B) to lessen the intensity of an illness C) to remove a part of the body that is diseased D) to restore function to tissue that is traumatized

B

The nurse uses the QSEN competency of Informatics when planning care for clients. What is an example of the use of this skill? A) The nurse checks with the client for priorities when planning client care. B) The nurse researches new technological advances in the treatment of cancer. C) The nurse works collaboratively with a dietitian to devise a client meal plan. D) The nurse orients a visually impaired client to the hospital room.

B

What is the primary role of the nurse in the care of clients who experience domestic violence? A) Identifying health education and counseling measures for the family B) Providing prompt recognition of the potential or actual threat to safety C) Calling the police D) Serving as a witness in court

B

A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should: A) complete an incident report to determine who was primarily responsible for the event. B) hold a facility-wide meeting to identify strategies for making improvements to the safety of residents. C) fill out an incident report, with the goal of preventing a similar event in the future. D) document strategies in the client's health record for preventing future incidents.

C

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order? A) Apply restraints to the hands or wrists, never to the ankles. B) Remove the restraint at least every 4 hours, or according to facility policy. C) Ensure that two fingers can be inserted between the restraint and the client's extremity. D) Use a quick-release knot to tie the restraint to the side rail.

C

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety? A) Run the electrical cord of the pump under the carpet. B) Use an extension cord to provide freedom of movement. C) Obtain a three-prong grounded plug adapter. D) Tape the electrical cord of the pump to the floor.

C

A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan? A) Back to sleep guidelines B) Safety equipment for playing sports C) Childproofing the house D) Smoking cessation

C

A nurse was injured when a client with Alzheimer disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate? A) The client and the client's family will be required to sign the report, acknowledging that they read it before it was filed. B) The report becomes a confidential part of the client's health record once it is reviewed by hospital administration. C) The report provides a detailed and objective account of the circumstances before, during, and after the event. D) The incident report is reviewed by state agencies and the Occupational Safety and Health Administration rather than by hospital administration.

C

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home? A) Most home fires are caused by children playing with matches. B) About 10% of home fire deaths occur in a home without a smoke detector. C) Most people who die in house fires die of smoke inhalation rather than burns. D) Most fatal home fires occur while people are cooking.

C

A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint? A) a geriatric chair with a tray B) a dose of an analgesic C) a dose of an antipsychotic D) side rails

C

The nurse has admitted a client to the postoperative unit following a bowel resection and is providing postoperative health education on coughing and deep breathing. What does the nurse explain to the client about why these actions are important? A) If you continue to breathe shallowly or cough ineffectively, this can lead to acute respiratory distress syndrome. B) If you continue to breathe shallowly or cough ineffectively, this can lead to dizziness, falling, or an inability to ambulate because of shortness of breath. C) If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia. D) If you continue to breathe shallowly or cough ineffectively, this can lead to deep vein thrombosis (DVT) by preventing poor oxygen exchange in the cardiac and peripheral circulatory system.

C

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client? A) Talk with the client's family about taking her home because she is out of control. B) Leave the restraints on and talk with her, explaining that she must calm down. C) Take the restraints off, stay with her, and talk gently to her. D) Sedate her with sleeping pills and leave the restraints on.

C

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first? A) Put the client's bedside rails up. B) Arrange furniture so that the client has something to hold on to. C) Assess the need for assistance with ambulation. D) Apply socks to the client's feet.

C

The nurse is teaching the caregiver of a 8-month-old infant about safety. Which teaching will the nurse include? A) Buy protective sporting equipment. B) Keep medications out of reach. C) Supervise your child on the changing table. D) Peer pressure causes children of this age to take risks.

C

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response? A) "Induce vomiting and call 911 right away." B) "You should not have left your child alone while you showered." C) "Is your child breathing at this time?" D) "Did you leave the household chemical in reach of your child?"

C

Which level of health care provider may make the decision to apply physical restraints to a client? A) senior personal care assistant B) LPN team leader C) nurse practitioner D) RN nurse manager

C

A nurse is interacting with a client in the outpatient surgical unit intraoperatively. What is the nurse's priority responsibility? A) Educating the client about postoperative protocols B) Providing emotional support for the client and family C) Establishing a nurse-client rapport D) Client safety

D

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective? A) "I will leave all doors open after rescuing clients." B) "I will sound the alarm before I start moving a client from a room." C) "I know that nurses are the only ones who can extinguish a fire." D) "I will rescue clients from harm before doing anything else."

D

Upon admission for an appendectomy, the client provides the nurse with a document that specifies instructions for his health care team to follow in the event he is unable to communicate these wishes postoperatively. This document is best known as: A) a Patient's Bill of Rights. B) an insurance card. C) an informed consent. D) an advance directive.

D

Which item would alert the home care nurse to a safety hazard threatening a young child? A) Three blankets in a crib B) A gated stairway C) Padded child safety seat D) Dangling blind cords

D

Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk? A) Social pressure B) Normal rebellion C) Past experience D) Poor judgment

A

A nurse is making a home visit for a client with several home safety concerns. On which safety concept(s) would the nurse advise the client? Select all that apply. A) Ensure appropriate lighting in hallways and entrances to the home. B) Store prescription medications on the counter. C) Check the batteries in all smoke detectors. D) Remove extension cords from open spaces. E) Remove throw rugs from high traffic areas.

A, C, D, E

The nurse is caring for a 4-month-old client on the pediatric unit following repair of an umbilical hernia repair. The infant just woke up from anesthesia and is crying. What would be appropriate initial interventions? Select all that apply. A) Have the parent hold the infant in a rocking chair. B) Administer 0.1 mg/kg morphine IV. C) Restrain the infant's hands to avoid pulling on the suture line D) Use distraction with a stuffed toy E) Offer a pacifier.

A, D, E

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation? A) CMS may choose to divert clients to other health care facilities in the future. B) CMS will bear the hospital's costs if the client chooses to sue the hospital. C) The hospital must bear any costs incurred for treating the client's injury. D) The hospital will be fined by CMS because the client developed a pressure injury.

C

When educating families on fire safety, it is important to: A) account for all members and then exit. B) use extension cords to prevent shock. C) have a meeting place outside the home. D) keep a fire extinguisher in a closet.

C

Which nurse would be at the highest risk of causing a hazardous situation? A) A nurse who has placed a client in the bed with three side rails up B) nurse who is administering medications to four clients C) A nurse who has worked 32 hours of overtime this week D) A nurse who is transferred to another unit to assist with care

C

Which statement, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction? A) "The better I eat before surgery, the more likely I will heal." B) "When I can eat again, the best meal would include protein and vitamin C" C) "I can have a hamburger and French fries as soon as I wake up." D) "I might be sick to my stomach and throw up after surgery."

C

A nurse is performing safety assessments in a health care facility. Which statements reflect considerations a nurse should keep in mind when assessing a client for safety? Select all that apply. A) Fires are responsible for most hospital incidents. B) Between 15% and 25% of falls result in fractures or soft tissue injury. C) A person with a history of falls is likely to fall again. D) Some people are more at risk for accidents than others. E) A medication regimen that includes diuretics or analgesics places an individual at risk for falls.

C, D, E

A client had an open cholecystectomy (gallbladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the client has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding? A) Immediately administer a cleansing enema. B) Contact the physician to come assess the client. C) Increase the rate of the client's intravenous infusion. D) Monitor the client closely and promote fluid intake.

D

A client who is scheduled to undergo coronary bypass surgery in a week asks the nurse whether he should discontinue taking his cholesterol medicine ahead of the surgery. Which should be the nurse's response? A) "Yes—you should be off all of your medications for 24 hours before surgery." B) "No—you should stay on your normal medication schedule before the surgery." C) "You should stay on your cholesterol medicine but stop taking all other medications 12 hours before surgery." D) "I will need to check with your health care provider about that."

D

The nurse assists a client to turn in the bed. The client has just returned from abdominal surgery. How does the nurse instruct the client? A) "Raise the head of the bed before turning." B) "Change your position frequently." C) "Wait for assistance before moving in bed." D) "Use a pillow to splint the incision."

D

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What nursing diagnosis would provide the clearest justification for the use of physical restraints during this client's care? A) Chronic Confusion Related to Long-Standing Alcohol Use B) Impaired Bed Mobility Related to Muscle Wasting C) Noncompliance Related to Medication Regimen D) Risk for Injury Related to Agitation

D

The nurse is preparing a client for surgery and asks if the client has an advance directive. The client asks "What is an advance directive?" What is the nurse's best response? A) "An advance directive is a living will. Some people already have one when they come to the hospital." B) "We are not sure if you will wake up after surgery, so the advance directive will let us know your wishes just in case." C) "When you are going to have surgery, the hospital likes to have you fill out all paperwork needed beforehand." D) "An advance directive will communicate your wishes for health care postoperatively in case you are unable to do so."

D