Fundamentals- Quiz #8 (Exam 3 Material)

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

"I'll practice these now and try to start them as soon as I can after my surgery."

A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include? Mix your medications with your enteral feeding." "Mix all the crushed medications prior to dissolving them in cola." "Push tablets through the tube slowly." "Flush the tube before and after each medication."

"Mix all the crushed medications prior to dissolving them in cola." (I think this is incorrect)

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

"You will be awake and will not have sensation of the procedure."

The nurse is providing care to a postoperative client who has a Jackson-Pratt (JP) drain. The nurse notes the JP drain is expanded and full of sanguineous fluid. Place in order the steps the nurse will now perform. Use all options. A. Don clean gloves. B. Empty the JP's contents into a graduated collection container. C. Compress the chamber and replace the JP cap. D. Note the amount of output as well as color. E. Remove gloves and sanitize or wash hands.

A, B, C, D, E

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

Administer prescribed pain medication 30 minutes before deliberately attempting to cough.

The nurse is providing care to an older adult client. Which interventions will the nurse perform to protect the client's skin? Select all that apply. Apply moisturizing lotion to feet and hands daily. Wash the perineal area every day. Minimize the use of any tape to the skin. Provide a bed bath every day. Offer fluids every hour while the client is awake.

Apply moisturizing lotion to feet and hands daily. Wash the perineal area every day. Minimize the use of any tape to the skin. Offer fluids every hour while the client is awake.

Which nursing intervention occurs in the postoperative phase of the surgical experience? teaching deep breathing exercises Airway/oxygen therapy/pulse oximetry reviewing the meaning of p.r.n. orders for pain medications putting in IV lines and administering fluids

Airway/oxygen therapy/pulse oximetry

The alert and oriented client has just been notified of a terminal cancer diagnosis and the need for surgery to extend life. The client tells the nurse, "I am leaving. I am not having the surgery." The client refuses to wait and talk to the primary care provider. What is an appropriate action by the nurse? Request the primary care provider to prescribe a medication that would sedate the client. Ask for a referral for the client to be declared incompetent. Have security personnel stationed outside the client's room to prevent the client from leaving. Ask the client to sign a form that the client is being discharged against medical advice.

Ask the client to sign a form that the client is being discharged against medical advice.

The older adult client reports back pain, and an aquathermia heating pad has been prescribed for comfort. What actions will the nurse perform to provide a safe application of heat therapy for this client? Select all that apply. Set the temperature on the unit to the maximum heat setting. Apply the heating pad to the client's back for intervals of 1 hour. Assess the client's skin prior to application of heat. Ensure the aquathermia unit contains water to the appropriate level. Instruct the client to lie on the pad to keep the pad in its proper position.

Assess the client's skin prior to application of heat. Ensure the aquathermia unit contains water to the appropriate level.

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

Conduct a nursing assessment.

The client has a wound on the ankle that the nurse has cleansed and dressed. The nurse now needs to apply a conforming bandage to keep the dressing in place. What technique will the nurse use to apply the bandage? Figure-of-eight turn Spiral turn Circular turn only Recurrent bandaging

Figure-of-eight turn

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

Force fluids for an adult client who has a urine output of less than 30 mL per hour.

The client has an infected nonhealing wound in which negative-pressure wound therapy (NPWT) has been applied. What actions would the nurse employ for this client? Select all that apply. Measure and record the amount of drainage each shift. Assess for a problem if the machine alarms. Empty or replace the canister on the machine when full or nearly full. Disconnect the machine for 2 hours daily to allow the client to bathe and ambulate Change the wound dressing every day.

Measure and record the amount of drainage each shift. Assess for a problem if the machine alarms. Empty or replace the canister on the machine when full or nearly full.

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

Monitor respirations and breath sounds.

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

Monitor the client for complications.

While receiving a report, the nurse learns that a client has paraplegia. The nurse will plan care for this client based upon the understanding that the client has which of the following? Paralysis affecting one-half of the body Weakness affecting one-half of the body Paralysis of the legs and arms Paralysis of the legs

Paralysis of the legs

What are functions of the skin? Select all that apply. Sensation Protection Vitamin C production Temperature regulation Immunologic

Temperature regulation Immunologic Sensation Protection

The nurse is providing care to a team of clients. Which clients are at risk for injury to the skin? Select all that apply. The client who has a temperature of 40° C and is perspiring The client who has a body mass index (BMI) of 34 The ambulatory client who is recovering from an endoscopic procedure for abdominal pain The client who is experiencing an allergic reaction and is scratching the skin The client who is emaciated from self-induced vomiting and food deprivation

The client who has a temperature of 40° C and is perspiring The client who has a body mass index (BMI) of 34 The client who is experiencing an allergic reaction and is scratching the skin The client who is emaciated from self-induced vomiting and food deprivation

The nurse is working with a group of clients. Which of the following clients are at risk for a skin alteration? Select all that apply. The client who has paralysis and is unable to move in bed, and the nurse provides turning every 2 hours The client who is newly diagnosed as having diabetes and requires management education of the disease The client who experienced numbness in the right arm that has resolved after several hours The client who has experienced vomiting and diarrhea for several days with a loss of 12 pounds in weight The client who is a roofer and spends a lot of time outdoors participating in sports

The client who has paralysis and is unable to move in bed, and the nurse provides turning every 2 hours The client who is newly diagnosed as having diabetes and requires management education of the disease The client who has experienced vomiting and diarrhea for several days with a loss of 12 pounds in weight The client who is a roofer and spends a lot of time outdoors participating in sports

The nurse has started an intravenous catheter in the client's hand. What type of dressing will the nurse use to secure the IV catheter? Hydrocolloid dressing Transparent film 2 × 2 gauze Hydrogel sheet

Transparent film

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

cardiac problems.

Which intervention is of major importance during preoperative education? performing skills necessary for gastrointestinal preparation telling the client not to worry or be afraid of surgery discussing the site and extent of the surgical incision encouraging the client to identify and verbalize fears

encouraging the client to identify and verbalize fears

A nurse caring for a postoperative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as: sanguineous. serosanguineous. serous. purulent.

serosanguineous.

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections? All are correct - which 1 is the most correct? proper intake of food and fluids adequate sleep and rest taking medications as prescribed thorough hand hygiene

thorough hand hygiene