Fundamentals Quiz 5
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 to this? "An advance directive is a living will. Some people already have one when they come to the hospital." "An advance directive will communicate your wishes for health care postoperatively in case you are unable to do so." "When you are going to have surgery, the hospital likes to have you fill out all paperwork needed beforehand." "We are not sure if you will wake up after surgery so the advance directive will let us know your wishes just in case."
"An advance directive will communicate your wishes for health care postoperatively in case you are unable to do so." Explanation: An advance directive allows the client to communicate instructions for health care postoperatively in case of an inability to do so. Although an advance directive is either a living will or a durable power of attorney for health care, and the hospital does like to determine if the client has them, these are not the best answers to the client's question. The nurse would not want to explain to the client that he or she may not wake up after surgery.
Which statement, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction? "When I can eat again, the best meal would include protein and vitamin C" "I can have a hamburger and French fries as soon as I wake up." "The better I eat before surgery, the more likely I will heal." "I might be sick to my stomach and throw up after surgery."
"I can have a hamburger and French fries as soon as I wake up."
A 70-year-old male is scheduled for surgery. He says to the nurse, "I am so frightened—what if I don't wake up?" What would be the nurse's best response? A- "You have a wonderful doctor." B- "Let's talk about how you are feeling." C- "Everyone wakes up from surgery!" D- "Don't worry, you will be just fine."
"Let's talk about how you are feeling." b. This answer allows the patient to talk about feelings and fears, and is therapeutic.
The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the humidifier? "The humidifier prescribes the concentration of oxygen." "This is a gauge used to regulate the amount of oxygen that a client receives." "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed." "Small water droplets come from this, thus preventing dry mucous membranes."
"Small water droplets come from this, thus preventing dry mucous membranes."
A nurse is caring for a client in the same-day surgery unit. The client asks the nurse, "Do I really need to be put to sleep for this surgery?" Which would be the nurse's best response? "Tell me what you are most worried about." "Have you ever had surgery before?" "You do not have to worry. It will be fine." "I will have the anesthesiologist talk to you."
"Tell me what you are most worried about."
A nurse is explaining pain control methods to a patient undergoing a bowel resection. The patient is interested in the PCA pump and asks the nurse to explain how it works. What would be the nurse's correct response? A- "The pump allows the patient to be completely free of pain during the postoperative period." B- "The pump allows the patient to take unlimited amounts of medication as needed." C- "The pump allows the patient to choose the type of medication given postoperatively." D- "The pump allows the patient to self-administer limited doses of pain medication."
"The pump allows the patient to self-administer limited doses of pain medication." d. PCA infusion pumps allow patients to self-administer doses of pain-relieving medication within health care provider-prescribed time and dose limits. Patients activate the delivery of the medication by pressing a button on a cord connected to the pump or a button directly on the pump.
The licensed practical nurse (LPN) is observed by the registered nurse (RN) engaging in the reinforcement of teaching related to therapeutic deep breathing and coughing with a client who is recovering from abdominal surgery. Which statement by the RN best supports the LPN's role in the implementation of this intervention? "Let me know whether the client reported any pain during the implementation of this respiratory intervention." "Advocating for the client's recovery is an important role LPNs engage in when providing client care." "You served as a good role model while showing the client the proper technique for this intervention." "Be sure to chart your evaluation of the effectiveness of this postoperative intervention on the client's respiratory status."
"You served as a good role model while showing the client the proper technique for this intervention."
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? "I understand; I used to be a smoker also." "You should never smoke when oxygen is in use." "Oxygen is a flammable gas." "An occasional cigarette will not hurt you."
"You should never smoke when oxygen is in use."
The nurse is providing education for a postoperative client regarding pain management. Which teaching point should the nurse include? "All postoperative pain control methods will be given by injection." "Be sure to ask for your PRN medication when the pain becomes severe." "You will receive pain medication by injection as long as you are NPO." "If your pain is not relieved, ask your nurse to order a different medication."
"You will receive pain medication by injection as long as you are NPO."
A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment? 6,000 mL (6,000 × 109/L) 5,850 mL (5,850 × 109/L) 5,000 mL (5,000 × 109/L) 5,550 mL (5,500 × 109/L)
5,850 mL (5,850 × 109/L)
Which surgical client does the nurse in the preoperative setting anticipate having the greatest potential for surgical complications? 6-month-old client who has just been introduced to solid food 50-year-old overweight client with controlled hypertension 40-year-old client with type 2 diabetes mellitus and a history of anxiety 76-year-old client with a history of renal failure and chronic bronchitis
76-year-old client with a history of renal failure and chronic bronchitis The client who is elderly with renal and lung disease has the most risk factors preoperatively for surgery. This client will have concerns over administration of anesthesia and medication, with the kidneys being able to clear these from the body, as well as with the lungs and potential postoperative complications of atelectasis and pneumonia. Clients who are young, have chronic disease, or are obese have risk factors as well, but not as many as the elderly client with both renal and pulmonary disease.
A client is in the preoperative area and states, "I am not sure about having surgery." What is the nurse's best response? A- "Can you tell me what your feelings are about the surgery?" B- "You really need to have this surgery done." C- "I will tell the surgeon you changed your mind." D - "Why wouldn't you want the surgery so you can feel better?"
A- "Can you tell me what your feelings are about the surgery?"
What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? A- Checking the amount of oxygen in the cylinder before using it B- Using a cylinder for a patient transfer that indicates available oxygen is 500 psi C- Placing the oxygen cylinder on the stretcher next to the patient D- Discontinuing oxygen flow by turning the cylinder key counterclockwise until tight
A- Checking the amount of oxygen in the cylinder before using it a. The cylinder must always be checked before use to ensure that enough oxygen is available for the patient. It is unsafe to use a cylinder that reads 500 psi or less because not enough oxygen remains for a patient transfer. A cylinder that is not secured properly may result in injury to the patient. Oxygen flow is discontinued by turning the valve clockwise until it is tight.
Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. A- Closely assess the patient before, during, and after the procedure. B- Hyperoxygenate the patient before and after suctioning. C- Limit the application of suction to 20 to 30 seconds. D- Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. E- Use an appropriate suction pressure (80 to 150 mm Hg). F- Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube.
A- Closely assess the patient before, during, and after the procedure. B- Hyperoxygenate the patient before and after suctioning. D- Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. E- Use an appropriate suction pressure (80 to 150 mm Hg). a, b, d, e. Close assessment of the patient before, during, and after the procedure is necessary to limit negative effects. Risks include hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. The nurse should also take the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80 to 150 mm Hg) will help prevent atelectasis related to the use of high negative pressure. Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage, including epithelial denudement, loss of cilia, edema, and fibrosis.
A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient? A- Dyspnea B- Hypotension C- Decreased respiratory rate D- Decreased pulse rate
A- Dyspnea a. If a problem exists in ventilation, respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. The most common symptoms of hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.
The nurse provides care for a client with pneumonia and acute respiratory distress syndrome whose oxygen saturation fluctuated between 86% and 90% over the past few days. The oxygenation saturation is consistently at 91%. Which step would the nurse take next? A- Provide oxygen for consistent hypoxia B- Encourage use of spirometry to improve oxygenation through the lungs C- Obtain blood for hemoglobin testing to determine oxygen transport level D- Continue to monitor oxygen to ensure the level does not fall below 90%
A- Provide oxygen for consistent hypoxia
A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nurse related to this occurrence? A- Remove the catheter. B- Notify the primary care provider. C- Check that the airway is the appropriate size for the patient. D- Place the patient on his or her back.
A- Remove the catheter. a. When a patient vomits upon suctioning of an oropharyngeal airway, the nurse should remove the catheter; it has probably entered the esophagus inadvertently. If the patient needs to be suctioned again, the nurse should change the catheter, because it is probably contaminated. The nurse should also turn the patient to the side and elevate the head of the bed to prevent aspiration.
A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client? Ambu bag Oxygen tent Oxygen mask Nasal cannula
Ambu bag
A 72-year-old woman who is scheduled for a hip replacement is taking several medications on a regular basis. Which drug category might create a surgical risk for this patient? A- Anticoagulants B- Antacids C- Laxatives D- Sedatives
Anticoagulants a. Anticoagulant drug therapy would increase the risk for hemorrhage during surgery.
The nurse enters a postoperative client's room and finds that the client is bleeding profusely from the surgical incision. What would be the nurse's most appropriate initial response? Apply pressure to the surgical site to decrease bleeding. Assess the client's vital signs. Notify the health care provider. Determine the possible cause of the client's bleeding.
Apply pressure to the surgical site to decrease bleeding.
Which nursing action should the PACU nurse take to prevent postoperative complications in clients? Encourage the client to breathe shallowly to prevent collapse of the alveoli. Assist the client to do leg exercises to increase venous return. Avoid turning the client in bed until the incision is no longer painful. Instruct the client to avoid coughing to prevent injury to the incision.
Assist the client to do leg exercises to increase venous return. Leg exercises increase venous return in order to prevent the postoperative complication of clot formation in the lower extremities. Coughing, while splinting the incision, and deep breathing is encouraged to prevent respiratory complications such as pneumonia and atelectasis. Turning the client stimulates the circulatory and respiratory system, and prevents skin breakdown.
A nurse is educating a preoperative client on how to cough effectively after abdominal surgery. What can the nurse tell the client to do to facilitate coughing? A- "When you cough, cover your nose and mouth with a tissue." B- "Hold a pillow or folded bath blanket over the incision." C- "It would be best if you do not cough until you feel better." D- "Get up and walk before you try to cough."
B- "Hold a pillow or folded bath blanket over the incision."
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who expresses concerns about the ability to breathe easier. The nurse will suggest which position to help alleviate the client's dyspnea? A- Supine with one pillow B- High Fowler's position C- Lying with the head slightly lowered D- Side-lying with head slightly elevated
B- High Fowler's position
An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? A- Tilt the patient's head forward. B- Hold the mask tightly over the patient's nose and mouth. C- Pull the patient's jaw backward. D- Compress the bag twice the normal respiratory rate for the patient.
B- Hold the mask tightly over the patient's nose and mouth. b. With the patient's head tilted back, jaw pulled forward, and airway cleared, the mask is held tightly over the patient's nose and mouth. The bag also fits easily over tracheostomy and endotracheal tubes. The operator's other hand compresses the bag at a rate that approximates normal respiratory rate (e.g., 16 to 20 breaths/min in adults).
A nurse is caring for an older adult following hip surgery. When teaching the client to use an incentive spirometer, the nurse should explain that this reduces the risk of what complication? A- DVT B- Pneumonia C- Bronchitis D- Asthma
B- Pneumonia
A nurse is caring for a patient who has been hospitalized for an acute asthma exacerbation. Which testing method might the nurse use to measure the patient's oxygen saturation? A- Thoracentesis B- Pulse oximetry C- Diffusion capacity D- Maximal respiratory pressure
B- Pulse oximetry b. Pulse oximetry is used to obtain baseline information about the patient's oxygen saturation level and is also performed for patients with asthma. Diffusion capacity estimates the patient's ability to absorb alveolar gases and determines if a gas exchange problem exists. Maximal respiratory pressures help evaluate neuromuscular causes of respiratory dysfunction. Both tests are usually performed by a respiratory therapist. The physician or other advanced practice professional can perform a thoracentesis at the bedside with the nurse assisting, or in the radiology department.
A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. A- Refrain from exercise. B- Reduce anxiety. C- Eat meals 1 to 2 hours prior to breathing treatments. D- Eat a high-protein/high-calorie diet. E- Maintain a high-Fowler's position when possible. F- Drink 2 to 3 pints of clear fluids daily.
B- Reduce anxiety. D- Eat a high-protein/high-calorie diet. E- Maintain a high-Fowler's position when possible. b, d, e. When caring for patients with COPD, it is important to create an environment that is likely to reduce anxiety and ensure that they eat a high-protein/high-calorie diet. People with dyspnea and orthopnea are most comfortable in a high-Fowler's position because accessory muscles can easily be used to promote respiration. Patients with COPD should pace physical activities and schedule frequent rest periods to conserve energy. Meals should be eaten 1 to 2 hours after breathing treatments and exercises, and drinking 2 to 3 quarts (1.9 to 2.9 L) of clear fluids daily is recommended.
The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective? A- clubbing of fingers B- SpO2 96% C- heart rate 110 beats/minute D- respirations 26 breaths/minute
B- SpO2 96%
A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the chosen catheter? A- The age of the patient B- The size of the endotracheal tube C- The type of secretions to be suctioned D- The height and weight of the patient
B- The size of the endotracheal tube b. The nurse would base the size of the suctioning catheter on the size of the endotracheal tube. The external diameter of the suction catheter should not exceed half of the internal diameter of the endotracheal tube. Larger catheters can contribute to trauma and hypoxemia.
A nurse is instructing a client in how to perform leg exercises following surgery. The client asks the nurse, "Why do I have to do these exercises?" Which is the health reason the nurse should mention? A- To improve the efficiency of the heart B- To increase venous return of blood to the heart C- To increase flexibility in the joints D- To strengthen the leg muscles
B- To increase venous return of blood to the heart
What is the most important risk factor in pulmonary disease? A- dangerous chemicals in the workplace B- active and passive cigarette smoke C- loss of the ozone layer of the atmosphere D- air pollution from vehicles
B- active and passive cigarette smoke
A patient tells the nurse she is having pain in her right lower leg. How does the nurse determine if the patient has developed a deep vein thrombosis (DVT)? A- By palpating the skin over the tibia and fibula B- By documenting daily calf circumference measurements C- By recording vital signs obtained four times a day D- By noting difficulty with ambulation
By documenting daily calf circumference measurements b. Manifestations of DVT are pain and cramping in the calf or thigh of the involved extremity, redness and swelling in the affected area, elevated temperature, and an increase in the diameter of the involved extremity. This increase in extremity circumference (typically the calf) is the most significant sign of a DVT and the provider should be notified. The priority for the patient with a known DVT is preventing a clot from breaking loose and becoming a VTE that propagates (travels) to the heart, brain, or lungs called a pulmonary embolism. Thrombophlebitis is an inflammation of a vein associated with thrombus (blood clot) formation. Thrombophlebitis is typically superficial and, in patients without an underlying condition, is often related to IV catheters.
A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended? A- A postoperative adult B- An adult with COPD C- A teenager with cystic fibrosis D- A child with pneumonia
C- A teenager with cystic fibrosis c. Chest physiotherapy may help loosen and mobilize secretions, increasing mucus clearance. This is especially helpful for patients with large amounts of secretions or an ineffective cough, such as patients with cystic fibrosis. Chest physiotherapy has limited evidence for its effectiveness and is not recommended for use in numerous patient populations, including children with pneumonia, adults with COPD, and postoperative adults (Andrews et al., 2013; Lisy, 2014; Strickland et al., 2013).
A student is assessing a postoperative client who has developed pneumonia. The plan of care includes positioning the client in the Fowler's or semi-Fowler's position. What is the rationale for this position? A- The client will be more comfortable and have less pain. B- It increases blood flow to the heart. C- It promotes full aeration of the lungs. D- It facilitates nursing assessments of skin color and temperature.
C- It promotes full aeration of the lungs.
A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? A- Instruct the assistant to notify the primary care provider. B- Assess the patient's vital signs. C- Remove the tape, adjust the depth to ordered depth and reapply the tape. D- No action is required as depth will adjust automatically.
C- Remove the tape, adjust the depth to ordered depth and reapply the tape. c. The tube depth should be maintained at the same level unless otherwise ordered by the health care provider. If the depth changes, the nurse should remove the tape, adjust the tube to ordered depth, and reapply the tape.
A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? A- The nurse assures that the oxygen is flowing into the prongs. B- The nurse adjusts the fit of the cannula so it fits snug and tight against the skin. C- The nurse encourages the patient to breathe through the nose with the mouth closed. D- The nurse adjusts the flow rate to 6 L/min or more.
C- The nurse encourages the patient to breathe through the nose with the mouth closed. c. The nurse should encourage the patient to breathe through the nose with the mouth closed. The nurse should assure that the oxygen is flowing out of the prongs prior to inserting them into the patient's nostrils. The nurse should adjust the fit of the cannula so it is snug but not tight against the skin. The nurse should adjust the flow rate as ordered.
In which client would the nurse assess for a depressed respiratory system? A- a client taking insulin for diabetes B- a client taking antibiotics for a urinary tract infection C- a client taking opioids for cancer pain D- a client taking amlodipine for hypertension
C- a client taking opioids for cancer pain
A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. A- "I will be careful not to shake up the canister before using it." B- "I will hold the canister upside down when using it." C- "I will inhale the medication through my nose." D- "I will continue to inhale when the cold propellant is in my throat." E- "I will only inhale one spray with one breath." F- "I will activate the device while continuing to inhale."
D- "I will continue to inhale when the cold propellant is in my throat." E- "I will only inhale one spray with one breath." F- "I will activate the device while continuing to inhale." d, e, f. Common mistakes that patients make when using MDIs include failing to shake the canister, holding the inhaler upside down, inhaling through the nose rather than the mouth, inhaling too rapidly, stopping the inhalation when the cold propellant is felt in the throat, failing to hold their breath after inhalation, and inhaling two sprays with one breath.
A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? A- The patient vomits during suctioning. B- The secretions appear to be stomach contents. C- The catheter touches an unsterile surface. D- A nosebleed is noted with continued suctioning.
D- A nosebleed is noted with continued suctioning. d. When nosebleed (epistaxis) is noted with continued suctioning, the nurse should notify the health care provider and anticipate the need for a nasal trumpet. The nasal trumpet will protect the nasal mucosa from further trauma related to suctioning.
A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient? A- Assist with bathing and hygiene tasks even if the patient feels capable of performing them alone. B- Teach the patient not to talk about the procedure, just to perform it at the best of his or her ability. C- Teach the patient to take short shallow breaths when performing hygiene measures. D- Group personal care activities into smaller steps, allowing rest periods between activities.
D- Group personal care activities into smaller steps, allowing rest periods between activities. d. For a patient who is too fatigued to complete daily hygiene on his or her own, the nurse should group personal care activities into smaller steps and allow rest periods between the activities. The nurse should assist with bathing and hygiene tasks as needed and only when the patient has difficulty. The nurse should encourage the patient to voice feelings and concerns about self-care deficits, and teach the patient to coordinate diaphragmatic breathing with the activity.
A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? A- Notify the health care provider. B- Apply an occlusive dressing on the site. C- Assess the patient for signs of respiratory distress. D- Put on gloves and insert the chest tube in a bottle of sterile saline.
D- Put on gloves and insert the chest tube in a bottle of sterile saline. d. When a chest tube becomes separated from the drainage device, the nurse should submerge the end in water, creating a water seal, but allowing air to escape, until a new drainage unit can be attached. This is done instead of clamping to prevent another pneumothorax. Then the nurse should assess vital signs and notify the health care provider.
A responsibility of the nurse is the administration of preoperative medications to patients. Which statements describe the action of these medications? Select all that apply. A- Diazepam is given to alleviate anxiety. B- Ranitidine is given to facilitate patient sedation. C- Atropine is given to decrease oral secretions. D- Morphine is given to depress respiratory function. E- Cimetidine is given to prevent laryngospasm. F- Fentanyl citrate-droperidol is given to facilitate a sense of calm
Diazepam is given to alleviate anxiety. Atropine is given to decrease oral secretions. Fentanyl citrate-droperidol is given to facilitate a sense of calm a, c, f. Sedatives, such as diazepam, midazolam, or lorazepam, are given to alleviate anxiety and decrease recall of events related to surgery. Anticholinergics, such as atropine and glycopyrrolate are given to decrease pulmonary and oral secretions and to prevent laryngospasm. Neuroleptanalgesic agents, such as fentanyl citrate-droperidol are given to cause a general state of calm and sleepiness. Histamine-2 receptor blockers, such as cimetidine and ranitidine, are given to decrease gastric acidity and volume. Narcotic analgesics, such as morphine, are given to facilitate patient sedation and relaxation and to decrease the amount of anesthetic agent needed.
What is a potential complication of oxygen use through nasal cannulas? Restlessness Hepatotoxicity Dry Nasal and Upper Airway Mucosa Decreased Urine Output Cyanosis Arrhythmias
Dry Nasal and Upper Airway Mucosa Dried out Nasal and Upper Airway Mucosa Oxygen can dry out mucosal membranes. If patients will be on oxygen for an extended time or high concentrations will be given, a humidifier should be introduced into the system to help decrease airway irritation.
Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat? Snack on high-carbohydrate foods frequently. Eat one large meal at noon. Contact the physician for nutrition shake. Eat smaller meals that are high in protein.
Eat smaller meals that are high in protein.
A tonsillectomy is an example of a surgical procedure classified as urgent. TRUE FALSE
FALSE
Cough suppressants are drugs that facilitate the removal of respiratory tract secretions by reducing the viscosity of the secretions. TRUE FALSE
FALSE
Respiration is the process by which oxygenated capillary blood passes through body tissue. TRUE FALSE
FALSE
While assessing a patient in the PACU, a nurse notes increased wound drainage, restlessness, a decreasing blood pressure, and an increase in the pulse rate. The nurse interprets these findings as most likely indicating: Thrombophlebitis Atelectasis Infection Hemorrhage
Hemorrhage d. Increased wound drainage, restlessness, decreasing blood pressure, and increasing pulse rate are assessment findings that indicate hemorrhage. Thrombophlebitis is an inflammation of a vein associated with thrombus (blood clot) formation. Thrombophlebitis is typically superficial and, in patients without an underlying condition, is often related to IV catheters. Manifestations of atelectasis include decreased lung sounds over the affected area, dyspnea, cyanosis, crackles, restlessness, and apprehension. Signs of infection include elevated white blood count and fever.
When prescribing oxygen, which of the following is the most appropriate consideration? Monitor For B6 Deficiency Home Education Monitor Urine Output NPO 6-12 Hours Monitor Glutathione Levels Monitor Blood Culture
Home Education Home-use Educator Teach the patient to monitor their oxygen tank level at home and when to notify the agency for a refill. It is important to avoid an extra long oxygen tube, because this can be a tripping hazard for the patient and others. Also educate the patient on how to secure the oxygen cylinder and to always have it in an appropriate holder.
A nurse is caring for an obese patient who has had surgery. The nurse monitors this patient for what postoperative complication? A- Anesthetic agent interactions B- Impaired wound healing C- Hemorrhage D- Gas pains
Impaired wound healing b. Fatty tissue has a poor blood supply and, therefore, has less resistance to infection. As a result, postoperative complications of delayed wound healing, wound infection, and disruption in the integrity of the wound are more common. Patients with a large habitual intake of alcohol require larger doses of anesthetic agents and postoperative analgesics, increasing the risk for drug-related complications. Patients who use illicit drugs are at risk for interactions with anesthetic agents. These are specific to the illicit drug used and should be noted on the medical record for safe anesthetic management. Patients taking anticoagulants are at increased risk for hemorrhage. Gas pains are a common postoperative discomfort.
A nurse is explaining the rationale for performing leg exercises after surgery. Which reason would the nurse include in the explanation? A- Promote respiratory function B- Maintain functional abilities C- Provide diversional activities D- Increase venous return
Increase venous return d. Leg exercises assist in preventing muscle weakness, promote venous return, and decrease complications related to venous stasis. As a result, the patient has a decreased risk for thrombophlebitis, DVT, and emboli.
Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen? It decreases dry mucous membranes via delivering small water droplets. It prescribes oxygen concentration. It regulates the amount of oxygen received. It determines whether the client is getting enough oxygen.
It determines whether the client is getting enough oxygen.
When using oxygen, which of the following is the most appropriate recommendation? Keep Floors Dry Oxygen In Use Sign Contact Precautions Positive Room Pressure Negative Room Pressure Droplet Precautions
Keep Floors Dry- Oxygen In Use Sign Oxygen In Use Sign Make sure your agency has proper signs hanging, informing visitors of the risk of having an open flame. Instruct people not to smoke near areas where oxygen is in use.
Which surgical clients will return to activities in their everyday lives more quickly? Open-heart surgery Vaginal hysterectomy Right nephrectomy Laparoscopic cholecystectomy
Laparoscopic cholecystectomy
A scrub nurse is assisting a surgeon with a kidney transplant. What are the patient responsibilities of the scrub nurse? Select all that apply. A- Maintaining sterile technique B- Draping and handling instruments and supplies C- Identifying and assessing the patient on admission D- Integrating case management E- Preparing the skin at the surgical site F- Providing exposure of the operative area
Maintaining sterile technique Draping and handling instruments and supplies a, b. The scrub nurse is a member of the sterile team who maintains sterile technique while draping and handling instruments and supplies. Two duties of the circulating nurse are to identify and assess the patient on admission to the OR and prepare the skin at the surgical site. The RNFA actively assists the surgeon by providing exposure of the operative area. The APRN coordinates care activities, collaborates with physicians and nurses in all phases of perioperative and postanesthesia care, and integrates case management, critical paths, and research into care of the surgical patient.
A perioperative nurse is preparing a patient for surgery for treatment of a ruptured spleen as the result of an automobile crash. For what type of surgery would the nurse prepare this patient? Minor, Diagnostic Minor, Elective Major, Emergency Major, Palliative
Major, Emergency
Which of the following oxygen delivery methods is most likely used to deliver an FiO2 of 24% to 44% with a flow of 1 to 6L/min? Venturi-Mask Simple Face Mask N95 Mask Complex Face Mask Non-Rebreather Mask Nasal Cannula
Nasal Cannula Nasal Cannula Nasal cannulas are the most widely used method of delivering oxygen. At 1L/min nasal cannulas deliver an FiO2 of 24%. Every 1L you can add 4%, all the way to 6L/min for an FiO2 of 44%. Oxygen should be humidified if you will be administering greater than 3L/min.
When using oxygen, which of the following is the most appropriate recommendation? NPO 6-12 Hours Monitor Glutathione Levels No IV Medications Vitamin K Supplementation No Electrical Sparks Patients May Smoke
No Electrical Sparks No-sign at Electrical Sparks Oxygen is a highly combustible gas that can cause an explosion in certain situations. Make sure that the bag valve mask is removed from the bedside before a shock is delivered during resuscitation efforts.
Which of the following oxygen delivery methods is most likely used to deliver an FiO2 of up to 95% at 8-15L/min? Oxygen Transfusion Assisted Ventilation Non-Rebreather Mask Nasal Cannula Blow By Venturi-Mask
Non-Rebreather Mask Non-Rebreather Mask This mask has a valve on the exhalation port and between the reservoir bag and mask. The valves prevent room air from coming into the system. This method delivers an FiO2 up to 95% at 8-15L/min. Make sure that the reservoir remains at least ½ full on inspirations.
The healthy adult client is given a narcotic prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do first? Immediately have the client sign the consent form. Ask the client if he still wants to proceed with the procedure. Have the client's family member sign the consent form. Notify the physician of the oversight.
Notify the physician of the oversight.
Which nursing action will best promote pain management for a client in the postoperative phase? Dimming the lights Breathing into a paper bag Providing food and medication Performing relaxation techniques
Performing relaxation techniques
The outpatient surgery nurse is preparing to discharge a client who has recovered from surgery. Which actions should the nurse plan to carry out before the client is discharged? Select all that apply. Ask the client to list home medications and allergies. Provide written postoperative instructions. Provide instructions about caring for the intravenous (IV) catheter that will remain in place until the postoperative appointment. Provide verbal postoperative instructions. Provide contact information to schedule a postoperative appointment with the surgeon. Provide a sterile specimen cup and instructions about collecting a routine postoperative urine sample.
Provide written postoperative instructions. Provide verbal postoperative instructions. Provide contact information to schedule a postoperative appointment with the surgeon.
A nurse is preparing a patient for a cesarean section and teaches her the effects of the regional anesthesia she will be receiving. Which effects would the nurse expect? Select all that apply. A- Loss of consciousness B- Relaxation of skeletal muscles C- Reduction or loss of reflex action D- Localized loss of sensation E- Prolonged pain relief after other anesthesia wears off F- Infiltrates the underlying tissues in an operative area
Reduction or loss of reflex action Localized loss of sensation c, d. A localized loss of sensation and possible loss of reflexes occur with a regional anesthetic. Loss of consciousness and relaxation of skeletal muscles occur with general anesthesia. Prolonged pain relief after other anesthesia wears off and infiltration of the underlying tissues in an operative area occur with topical anesthesia.
The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign? Apical pulse Urinary intake and output Respiratory rate and depth Orthostatic blood pressure
Respiratory rate and depth
A patient had a surgical procedure that necessitated a thoracic incision. The nurse anticipates that the patient will have a higher risk for postoperative complications involving which body system? A- Respiratory system B- Circulatory system C- Digestive system D- Nervous system
Respiratory system a. A thoracic incision makes it more painful for the patient to take deep breaths or cough. Shallow respirations and ineffective coughing increase the risk for respiratory complications.
Which of the following oxygen delivery methods is most likely used to deliver an FiO2 of 40% to 60% oxygen with a flow of 6 to 12L/min? Venturi-Mask Non-Rebreather Mask Complex Face Mask Oropharynx Cannula Nasal Cannula Simple Face Mask
Simple Face Mask Simple Face Mask Simple face mask can deliver an FiO2 of 40% to 60% oxygen with a flow of 6 to 12L/min. It can be used in patients that are in mild respiratory distress. If a simple mask has a reservoir bag on it, it is called a partial rebreather mask. Partial rebreather masks deliver an FiO2 of 50% to 60%.
When using oxygen, which of the following is the most appropriate recommendation? Six Feet Away from Open Flames Administer at Bedtime Check for Penicillin Allergy NPO 6-12 Hours No NSAIDs Patients may Smoke
Six Feet Away from Open Flames Six Foot Tape-measure From Flames Educate patients not to smoke when using oxygen and to stay away from open flames. Oxygen is very combustible when introduced to an open flame.
What is a potential complication of oxygen use, especially through nasal cannula? Skin Irritation Neurotoxicity Dyspnea on Exertion Hypertension Cyanosis Decreased Urine Output
Skin Irritation Skin Irritation Skin breakdown can occur around the ears and in the nostril (nasal cannula use). It is important to assess for skin breakdown while performing a daily assessment. Gauze can be wrapped around the tube or strap to decrease pressure and irritation.
Atelectasis is the incomplete expansion or collapse of alveoli with retained mucus, involving a portion of the lung and resulting in poor gas exchange. TRUE FALSE
TRUE
Evidence-based guidelines for the management of acute surgical pain are based on the principle that "the pain reported by the patient is the determining factor of pain control." TRUE FALSE
TRUE
Normal breath sounds include vesicular, bronchial, and bronchovesicular sounds. TRUE FALSE
TRUE
Patients who experience dyspnea and feelings of panic can often reduce these symptoms by using pursed-lip breathing. TRUE FALSE
TRUE
The type of shock most commonly seen in postoperative patients is hypovolemic shock, which occurs from a decrease in blood volume. TRUE FALSE
TRUE
patients with fluid, blood, or air in the pleural space require a chest tube to drain these substances and allow the compressed lung to re-expand TRUE OR FALSE
TRUE
Which factors indicate that the nurse should stop delivery of breaths via a manual resuscitation bag and mask device? Select all that apply. The client has been intubated and is connected to a mechanical ventilator. The client has a return of spontaneous breathing at 15 breaths per minute. The health care provider has ended the cardiopulmonary resuscitation effort. The client's oxygen saturation has improved to 95% during use of the device. Another nurse has begun chest compressions at a rate of 100 per minute.
The client has been intubated and is connected to a mechanical ventilator. The client has a return of spontaneous breathing at 15 breaths per minute. The health care provider has ended the cardiopulmonary resuscitation effort.
A nurse has been asked to witness a patient signature on an informed consent form for surgery. What information should be included on the form? Select all that apply. A- The option of nontreatment B- The underlying disease process and its natural course C- Notice that once the form is signed, the patient cannot withdraw the consent D- Explanation of the guaranteed outcome of the procedure or treatment E- Name and qualifications of the provider of the procedure or treatment F- Explanation of the risks and benefits of the procedure or treatment
The option of nontreatment The underlying disease process and its natural course Name and qualifications of the provider of the procedure or treatment Explanation of the risks and benefits of the procedure or treatment a, b, e, f. The information contained in informed consent includes the description of the procedure or treatment, potential alternative therapies, and the option of nontreatment, the underlying disease process and its natural course, the name and qualifications of the health care provider performing the procedure or treatment, explanation of the risks and benefits, explanation that the patient has the right to refuse treatment and consent can be withdrawn, and explanation of expected (not guaranteed) outcome, recovery, and rehabilitation plan and course.
A client has arrived to the postanesthesia care unit (PACU) and is drowsy with a respiratory rate of 12 breaths per minute. What would be an accurate interpretation by the nurse? The client needs to have the neurologic status fully evaluated. The client should be returned to the operating room for further evaluation. The procedural physician should be notified immediately of client findings. This is an expected finding in the immediate postoperative period.
This is an expected finding in the immediate postoperative period.
A client has arrived to the postanesthesia care unit (PACU) and is drowsy with a respiratory rate of 12 breaths per minute. What would be an accurate interpretation by the nurse? The client needs to have the neurologic status fully evaluated. The procedural physician should be notified immediately of client findings. The client should be returned to the operating room for further evaluation. This is an expected finding in the immediate postoperative period.
This is an expected finding in the immediate postoperative period.
Older adults often have reduced vital capacity as a result of normal physiologic changes. Which nursing intervention would be most important for the postoperative care of an older surgical patient specific to this change? A- Take and record vital signs every shift B- Turn, cough, and deep breathe every 4 hours C- Encourage increased intake of oral fluids D- Assess bowel sounds daily
Turn, cough, and deep breathe every 4 hours b. Reduced vital capacity in older adults increases the risk for respiratory complications, including pneumonia and atelectasis. Having the patient turn, cough, and deep breathe every 4 hours maintains respiratory function and helps to prevent complications.
Which of the following oxygen delivery methods is most likely used to deliver a precise FiO2 to the patient ranging from 24% to 60%? Venturi-Cannula Partial Rebreather Mask Venturi-Mask Valtrix Mask Simple Face Mask Non-Rebreather Mask
Venturi-Mask Ventura with Venturi Mask Venturi Mask allows providers to set a specific FiO2 to be delivered to the patient. Venturi masks have, what is called, an air entrainer that allows oxygen to be mixed with the room air. This can deliver a precise FiO2 to the patient ranging from 24% to 60%.
A nurse is providing teaching for a patient scheduled to have same-day surgery. Which teaching method would be most effective in preoperative teaching for ambulatory surgery? A- Lecture B- Discussion C- Audiovisuals D- Written instructions
Written instructions d. Written instructions are most effective in providing information for same-day surgery.
Incomplete lung expansion or the collapse of alveoli, known as ______________, prevents pressure changes and the exchange of gas by diffusion in the lungs.
atelectasis
A nurse is reinforcing wound edges and applying a blinder to the separated incisions of a client after a surgery. Which postoperative complication has the client developed? evisceration shock dehiscence hypoxemia
c) Dehiscence Feedback: The nurse is taking care of a client with dehiscence. Hypoxemia develops when there is inadequate oxygenation of blood. Evisceration occurs when there is protrusion of abdominal organs through a separated wound. A client has shock when there is inadequate blood flow.
The nurse is caring for a client who has been admitted to an acute care unit after surgery. When reviewing the client chart, what information will the nurse expect to find in the intraoperative record? completion of skin preparation initial assessment by anesthesiologist vital signs assessment every hour performance of incentive spirometry
completion of skin preparation
The nurse has been waiting until after the administration of a toddler's anesthesia before removing the child's clothing and applying monitoring equipment. Doing these actions after the administration of anesthesia will: prevent anxiety. provide more accurate baseline vital signs. minimize blood loss. enhance thermoregulation.
d) prevent anxiety. Relaxation can be enhanced by removing the child's clothing, applying the grounding pad, and applying monitoring devices after the child is anesthetized. This action has no effect on vital signs, thermoregulation, or blood loss.
Oxygen and carbon dioxide move between the alveoli and the blood by: diffusion. hyperosmolar pressure. negative pressure. osmosis.
diffusion
the movement of gas or particles from an area of higher pressure or concentration to an area of lower pressure or concentration is known as ____________, which is influenced by any change in surface area
diffusion
Two common forms of advance directives include a living will and a ____________________ power of attorney for health care.
durable
The three phases of general anesthesia are ________________ , maintenance, and emergence.
induction
A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered? nasal cannula simple oxygen mask Venturi mask partial rebreather mask
nasal cannula
The _________________ oxygen mask delivers the highest concentration of oxygen, via a mask, to a spontaneously breathing patient.
nonrebreather
Nursing care provided for the patient before, during, and after surgery is called _______________ nursing.
perioperative
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? operative site marking preoperative checklist informed consent procedural pause (time-out)
procedural pause (time-out)
When reviewing data collection on a client with a cardiac output of 2.5 liter/minute, the nurse inspects the client for which symptom? increased urine output weight loss rapid respirations strong, rapid pulse
rapid respirations
When preparing a client who has diabetes mellitus for surgery, the nurse should be aware of what surgical risk associated with this disease? altered metabolism and excretion of drugs fluid and electrolyte imbalance respiratory depression from anesthesia slow wound healing
slow wound healing
Injecting a local anesthetic into the subarachnoid space through a lumbar puncture is known as __________________ anesthesia, which causes sensory, motor, and autonomic blockage.
spinal
A detergent-like phospholipid, known as _______________________ , reduces the surface tension between the moist membranes of the alveoli, preventing their collapse.
surfactant
The nurse is caring for a client who has a percutaneous tracheostomy (PCT) following a skydiving accident. Which oxygen delivery device will the nurse select? nasal cannula simple mask face tent tracheostomy collar
tracheostomy collar
often heard in patients with asthma, ____________ are continuous, musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions or tumors
wheezes
A nurse is discussing a surgical procedure with a client who needs to sign his informed consent. Which of these tasks is part of the nursing role? explaining to the client about potential risks of having the surgery describing how the client will benefit from the surgical procedure witnessing the client signature with their consent for surgery determining for the client what other treatment options exist
witnessing the client signature with their consent for surgery
