Med surg test 4
A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment?
Urine specific gravity 1.020
The nurse is caring for a patient admitted to the medical unit with Hypovolemia. The best foods to offer the patient are? (Select all that apply) a. Apple b. Banana c. Orange juice d. Chocolate milk e. Cooked broccoli
b, c, d, e
The nurse is preparing a patient for a surgical procedure. Before admitting the patient into the perioperative suite, what documents must the burse make sure are in the patients chart? (select all that apply) a. electrocardiogram b. signed consent form c. functional status elevation d. renal and liver function tests e. a history and physical examination report
b, e
A 22-yr-old man is admitted to the emergency department with a stab wound to the abdomen. The patient's vital signs are: blood pressure 82/56, pulse 132 beats/min, respirations 28, and temperature 97.9F. Which fluid ordered by the health care provider, should the nurse question? a. 0.45% saline b. 0.9% saline c. Packed red blood cells d. Lactated Ringer's solution
b.
A patient asks a nurse if his family member may accompany him to the surgical area. What is the best response by the nurse? a. "Your family member may not enter the surgical area" b. "Your family member can be with you iun the preoperative holding area" c. "Your family cant be with you until the postanesthesia care unit" d. "Your family is only allowed in the conference room for the preoperative teaching"
b.
A patient being admitted to the same day surgery unit informs the nurse they took kava last evening to sleep. Which nursing action would be most appropriate? a. Tell the patient that using kava to help sleep is often helpful b. Inform the anesthesia care provider of the patients recent use of kava c. Tell the patient that the kava should continue to help the patient to relax before surgery d. Inform the patient about the dangers of taking herbal medicines without consulting a health care provider
b.
A patient having abdominal surgery had an estimated blood loss of 400mL and recieved 300mL of 0.9% normal saline. Postoperatively the patients blood pressure is 70/48 mm Hg. What priority treatment does the nurse anticipate administering? a. blood administration b. IV fluid administration c. an ECG to check circulatory status d. return to surgery to check for internal bleeding
b.
A patient informs the nurse prior to the surgical procedure that she is so nervous about the procedure that she had to take a Xanax last night, but it did not relieve the anxiety. What is the priority action by the nurse? a. Review the surgery with the patient b. Notify the anesthesia care provider c. Administer another dose of Xanax d. Tell the patient that everything will be okay with the surgery
b.
A patient was admitted for a paracentesis to remove ascites fluid. Five letters of fluid was removed. Which IV solution may be used to pull fluid into the intramuscular space after the paracentesis? a. 0.9% sodium chloride b. 25% albumin solution c. Lactated Ringer's solution d. 5% dextrose in 0.45% saline
b.
The surgical team in the operating room performs a surgical time-out just before starting hip replacement surgery. Which action would be aprt of the surgical time-out? a. check the chart for a signed consent form for the procedure b. assess the patients vital signs and O2 sat c. determine if the patient has any questions about the procedure d. have the patient verify the procedure and the location of the surgery
d.
When planning the care of a patient with dehydration, what urine output would the nurse instruct the unlicensed assistive personnel to report? a. 60 mL in 90 minutes b. 1200 mL in 24 hours c. 300 mL per 8-hour shift d. 20 mL for 2 consecutive hours
d.
When scrubbing at the scrub sink, the nurse should: a. scrub from elbows to hands. b. scrub without mechanical friction. c. scrub for a minimum of 10 minutes. d. hold the hands higher than the elbows
d.
Which patient would be at highest risk for hypothermia after surgery? a. a 42 yr old patient who had a laparoscopic appendectomy b. a 38 yr old patient who had a lumpectomy for breast cancer c. a 20 yr old patient with an open reduction of a fractured radius d. a 75 yr old patient with repair of a femoral neck fracture after a fall
d.
While the perioperative nurse is transporting a patient to the operating room for general surgery, the patient states, "I am a Jehovah's Witness, and I am worried about blood transfusions." What would be the best response by the nurse to this patient's statement? a. "I will make sure that you do not receive a blood transfusion during this surgery." b. "Would you like to sign the consent form just in case you need blood during surgery?" c. "Do you have someone I can contact in an emergency if you need a blood transfusion?" d. "Tell me what you would like done if it is determined that you need blood replacement during surgery."
d.
You are caring for a patient admitted with an exacerbation of asthma. After several treatments, the ABG results are pH 7.40, PaCO2 40 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg, and 02 sat of 99% you interpret these results as: a. Metabolic acidosis b. Respiratory acidosis c. Respiratory alkalosis d. Within normal limits
d.
You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy? a. Sodium falling to 138 mEq/L b. Potassium rising to 4.1 mEq/L c. Magnesium rising to 2.9 mg/dL d. Phosphorous falling to 2.1 mg/dL
d. (Normal phosphorous range is 3.0-4.5 mg/dL)
A nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and initiates cardiac monitoring. Which of the following findings should the nurse expect during the initial assessment?
lethargy
A patient with dehydration is receiving a hypertonic solution. Which assessments must be done to avoid adverse risks associated with these solutions?
lung sounds, blood pressure, serum sodium level
A patient is admitted with metabolic acidosis. Which system is not functioning normally?
renal system
At 0600, the anesthesiologist prescribes preoperative medications for a patient who is scheduled for surgery at 0730: cefazolin IV to be infused 30 minutes before surgery; midazolam before surgery, and scopolamine patch behind the ear. Which medication should the nurse administer first?
scopolamine this allows the serum level to become therapeutic
A nurse is providing nutritional teaching to a client who has osteoporosis. Which of the following foods should the nurse recommend as being the highest in calcium?
3oz canned salmon
A nurse is assessing four c;lients for fluid balance. The nurse should identify that which of the following clients is exhibiting manifestations of dehydration?
A client who has a temp of 39C (102F)
You are admitting a patient who reports abdominal pain, nausea, vomiting. A proximal bowel obstruction is suspected. Which acid-base imbalance do you anticipate in this patient?
metabolic alkalosis
A nurse is assessing a client who has fluid overload. What should the nurse expect? (Select all that apply)
A. Increased heart rate, B. Increased bp C. Increased respiratory rate
A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hyperkalemia?
Abnormally prominent U wave
A nurse is planning care for someone who has dehydration and is receiving continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care?
Check the clients IV infusion every 8 hours
A nurse is caring for a client who has postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hours. Which of the following electrolyte imbalances should the nurse monitor the client for?
Decreased potassium level
A nurse in a community clinic is assessing an older adult client for manifestations of dehydration. Which of the following findings should the nurse expect?
Furrows on the tongue
A nurse is planning care for a client who is postoperative and at risk for paralytic ileus. Which of the following interventions should the nurse take to promote peristalsis?
Increase ambulation
A nurse is reviewing a provider's prescription for a client experiencing paralytic ileus following an appendectomy. Which of the following actions should the nurse expect to take?
Insert an NG tube
A nurse is assessing a client who is taking chlorothiazide sodium. The nurse recognizes which of the following as a manifestation of hyperkalemia?
Shallow respirations
A nurse is caring for a client who had a total thyroidectomy and a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect?
Tingling of the extremities
A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect?
Weak, irregular pulses
A patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge? (select all that apply) a. vital signs baseline or stable b. minimal nausea and vomiting c. wants to wait to void at home d. responsible adult taking patient home e. comfortable after iv opiod 15 minutes ago
a, b, d
When positioning a patient in preparation for surgery, the nurse understands that injury to the patient can occur because of (select all that apply). a. Loss of pain perception b. Incorrect musculoskeletal alignment c. Vasoconstriction of the peripheral vessels d. Hypovolemia contributing to decreased profusion e. Inability to sense pressure over bony prominences
a, b, d, e
An older woman is admitted to the medical unit with GI bleeding. Assessment findings that indicate fluid volume deficit include: (selesct alll that apply) a. weight loss b. dry oral mucosa c. full bounding pulse d. engorged neck veins e. decreased central venous pressure
a, b, e
An older patient is being prepared for surgery. What assessment data needs to be obtained from the patient? (select all that apply) a. fluid balance history b. attitude about surgery c. foods the patient dislikes d. current mobility problems e. current cognitive function f. patients opinion about the surgery
a, d, e
It is important for the nurse to assess for which manifestations in a patient who has just undergone a total thyroidectomy (select all that apply): a. confusion b. weight gain c. depressed reflexes d. circumoral reflexes e. positive Chvostek's sign
a, d, e
The nurse expects the long-term treatment of a patient with hyperphosphatemia secondary to renal failure will include: a. fluid restriction. b. calcium supplements. c. magnesium supplements. d. increased intake of dairy products.
b.
A patient has the following ABG results: pH 7.52, PaCO2 30mm Hg, HCO3- 24mEq/L. The nurse determines that these results indicate: a. metabolic acidosis b. metabolic alkalosis c. repiratory acidosis d. respiratory alkalosis
d.
A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply)
A. Poor nutritional status, C. Obesity, E. Wound infection
A nurse is assessing a client who has end stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication that the client is experiencing fluid overload?
The client has a 5 pound weight gain since yesterday
You are caring for a patient admitted with diabetes, malnutrition, and a massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which of the following factors in this patient? (Select all that apply) a. The potassium level may be increased if the patient has nephropathy b. The patient has been eating excessive amounts of foods that increase potassium levels c. The patient may be excreting extra sodium and retaining potassium secondary to malnutrition d. There may be excess potassium being released into the blood as a result of a massive blood transfusion e. The potassium level may be increased because of dehydration that accompanies high blood glucose levels
a, d, e
The nurse is caring for a patient undergoing surgery for a knee replacement. What is critical to the patient's safety during the procedure (select all that apply)? a. Universal protocol is followed b. The ACP is an anesthesiologist c. The patient has adequate health insurance d. The patients family is in the surgery waiting area e. The patients allergies are conveyed to the surgical team
a, e
While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient? (Select all that apply) a. Weakness b. Paraesthesia c. Facial spasms d. Muscle tremors e. Depressed reflexes
a, e
A 17-yr-old patient with a leg fracture who is scheduled for surgery is an emancipated minor. She has a statement from the court for verification. Which intervention is most appropriate? a. witness the permit after the surgeon obtains consent b. call a parent or legal guardian to sign the permit since the patient is under 18 c. notify the hospital attorney that an emancipated minor is consenting to surgery d. obtain verbal consent since written consent is not neccessary for emancipated minors
a.
A 59-yr-old man scheduled for a herniorrhaphy in 2 days reports that he takes ginko daily. What is the priority intervention? a. inform the surgeon, since the procedure may have to be rescheduled b. notify the anethesia care provider, since the herb interferes with anesthetics c. ask the patient if he has noticed any side effects from taking this herbal supplement d. tell the patient to continue to take the herbal supplement up to the day before surgery
a.
A nurse is caring for an unconcious patient who has just been admitted to the PACU after an abdominal hysterectomy. How should the nurse position the patient? a. left lateral position with head supported on a pillow b. prone position with a pillow supporting the abdomen c. supine position with the head of the bed elevated 30 degrees d. semi-fowlers position with the head turned to the right
a.
A patient with a recent diagnosis of prostate cancer is scheduled for a radical prostatectomy. Before signing the consent, the patient tells the nurse " I am not sure if this surgery is safe", Which response by the nurse is most appropriate? a. "Tell me what you know about your surgery and the risks involved" b. "Any surgery has risks, but we will be here to take good care of you" c. "You seem anxious. After you sign the consent, i can give you a sedative." d. " You do not need to be concerned. Your surgeon has not had any complaints."
a.
A surgical patient's premedication regimen includes midazolam. What are the most likely desired effects of this medication? a. monitored anesthesia care and amnesia b. potentiates volatile agents to speed induction c. analgesia and prevention of intraoperative vomiting d. relaxes skeletal muscles and facilitates endotracheal intubation
a.
After admitting a postoperative patient to the clinical unit, which assessment data require the most immediate attention? a. O2 saturation of 85% b. Respiratory rate of 13/min c. Temperature of 100.4F d. Blood pressure of 90/60 mm Hg
a.
An alert patient does not want to have a tracheostomy inserted because of extended endotracheal intubation, although family members state that they want it done. What action should the nurse take? a. advocate for the patients rights b. try to change the patients mind c. call surgery to cancel the procedure d. tell the family they cannot interfere
a.
An over weight patient (BMI 28.1) is scheduled for a laparoscopic cholecystectomy at an outpatient surgery setting. The nurse knows that: a. surgery will involve multiple small incisions b. this setting is not appropriate for this procedure c. surgery will involve removing part of the liver d. the patient will need special preparation because of obesity
a.
During administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between ECF and the cells is: a. osmosis b. diffusion c. active transport d. facilitated diffusion
a.
In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes? a. Administering adequate analgesics to promote relief or control of pain b. Asking the patient to demonstrate the postoperative exercises every 1 hour c. Giving the patient positive feedback when the activities are performed correctly d. Warning the patient about possible complications if the activities are not performed
a.
The circulating nurse is caring for a patient during a colon resection. What observation made by the nurse is immediately recognized as a violation of aseptic technique? a. a glove contacts the leg of the table that supports the sterile field b. the cuff of the scrub nurses sterile gown contacts the sterile field c. the sterile field was established at 0650 and the current time is 0900 d. a contamination item is removed from the field and the area is marked off
a.
The lungs act as an acid-base buffer by: a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. b. increasing respiratory rate and depth when CO2 levels in the blood are low, reducing base load c. decreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. d. decreasing respiratory rate and depth when CO2 levels in the blood are low, increasing acid load.
a.
The nurse determines a postoperative patient has a bronchial obstrcution from retained secretions and an oxygen saturation of 87%. What condition does the nurse suspect is occuring? a. atelectasis b. bronchospasm c. hypoventilation d. pulmonary embolism
a.
The nurse gave midazolam to a patient during a colonoscopy. What nursing action is appropriate if the patients respiratory rate changes from 14 to 3 breaths/min? a. administer flumazenil b. give a dose of naloxone c. started oxygen at 4 L/min per cannula d. place the patient with the head of bed up
a.
The nurse is providing discharge teaching to a patient who has had a laparoscopic cholecystectomy at an ambulatory surgican center. Which statement, if made by the patient, indicated understanding of the discharge instructions? a. "I will have someone stay with me for 24 hours in case I feel dizzy" b. "I should wait for the pain to be severe before taking the medication" c. "Because I did not have general anesthesia, I will be able to drive home" d. "It is expected after this surgery to have a temperature up to 102.4F"
a.
The nurse's primary responsibility for the care of the patient undergoing surgery is: a. developing an individualized plan of nursing care for the patient. b. carrying out specific tasks related to surgical policies and procedures. c. ensuring that the patient has been assessed for safe administration of anesthesia. d. performing a preoperative history and physical assessment to identify patient needs.
a.
The nursing care for a patient with hyponatremia and fluid volume excess includes a. fluid restriction b. administration of hypotonic IV fluids c. administration of a cation-exchange resin d. placement of an indwelling urinary catheter
a.
The patient is having a mole removed that has changed appearance. What does the nurse teach the patient about the reason for this surgical procedure? a. It will prevent cancer b. It will alleviate symptoms c. It will cure the patients cancer d. It will provide cosmetic improvement
a.
The perioperative nurse needs to monitor the patient for hallucinations and agitation when which anesthetic agent is administered? a. ketamine b. halothane c. thiopental d. nitrous oxide
a.
What serum potassium result best supports the rationale for administering a stat dose of IV potassium chloride 20 mEq in 200 mL of normal saline over 2 hours? a. 3.1 mEq/L b. 3.5 mEq/L c. 4.6 mEq/L d. 5.3 mEq/L
a.
When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On the assessment, the patient is in respiratory distress and the vital signs show hypotension and tachycardia. The nurse suspects that the patient may be experiencing what complication? a. Air embolism b. Catheter occlusion c. Insertion site trauma d. Precipitate build up in lumen
a.
Which statements are appropriate to include when teaching a patient about hypercalcemia? a. Have the patient restrict fluid intake to less than 2000mL/day b. Renal calculi may occur as a complication of hypercalcemia c. Weight bearing exercises can help keep calcium in the bones d. The patient should increase daily fluid intake of 3000mL-4000mL e. Any heartburn can be managed with an as needed calcium-containing antacid
b, c, d
Activities that the nurse might perform in the role of a scrub nurse during surgery include (select all that apply) a. Checking electrical equipment b. Preparing the instrument table c. Assisting with draping the patient d. Passing instruments to the surgeon and assistants e. Documenting activities occurring in the operating room
b, c, d
A patient who normally takes 40 units of glargine insulin (long acting) at bedtime asks the nurse what to do about her dose the night before the surgery. The best response would be to have her a. skip her insulin altogether the night before the surgery b. get instructions from her surgeon or HCP on any insulin adjustments c. take her usual dose at bedtime and then take half her usual insulin dose d. eat a moderate meal before bedtime and then take half her usual insulin dose.
b.
Lorazepan (Ativan) 1mg IV is ordered for a patient before surgery. What is the most appropriate action for the nurse to take before administing the medication? a. ask the patient about an allergy to iodine or shellfish b. encourage or assist the patient to the bathroom to void c. explain that the medication is used to prevent postoperative nausea d. check the laboratory results for the most recent serum potassium level
b.
The nurse is caring for a Native American patient 2 days after a thoracotomy for a tumor resection. What would be the most appropriate action if the patient does not report any pain? a. contact the health care provider b. identify possible reasons for denying pain c. administer the prescribed pain medication d. assess the renal and liver function test results
b.
The nurse is circulating for a surgical procedure. What clinical manifestation would indicate to the nurse that the patient may be experiencing malignant hyperthermia? a. Hypocapnia b. Muscle rigidity c. Decreased body temperature d. Confusion upon arousal from anesthesia
b.
The nurse is positioning a patient after a surgical procedure. What is the best position unless contraindicated, for this patient to be placed in to prevent respiratory complications? a. supine b. lateral c. semi-fowlers d. high-fowlers
b.
The nurse is working on a surgical floor and is preparing to recieve a postoperative patient from the PACU. What should the nurses initial action be upon the patients arrival? a. assess the patients pain b. obtain the patients vital signs c. check the rate of the IV infusion d. review the surgeons postoperative orders
b.
The patient tells the nurse in the preoperative setting that she has noticed she has a reaction when wearing rubber gloves. What is the most appropriate action? a. notify the surgeon so that the surgery can be cancelled b. ask additional questions to assess for a possible latex allergy c. notify the OR staff at once so they can use latex free supplies d. no action is needed because the patients rubber sensitivity has no bearing on surgery
b.
Which preoperative patient has the greatest risk of bleeding as a result of prescribed medication? a. a woman who takes metoprolol for the treatment of hypertension b. a man who is taking clopidogrel after the placement of a coronary artery stent c. a man whose type 1 diabetes is controlled with insulin injections four times daily d. a man who recently started taking finasteride for the treatment of benign prostatic hyperplasia
b.
You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following ABG results: pH 7.33, PaCO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 sat 92%. What is the correct interpretation of these results? a. Fully compensated respiratory alkalosis b. Partially compensated respiratory acidosis c. Normal acid-base balance with hypodermic d. Normal acid-base balance with hypercapnea
b.
You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. You should hold a medication from which classification until you consult with the health care provider? a. Antibiotics b. Loop diuretics c. Bronchodilators d. Antihypertensives
b.
Discharge criteria for the Phase II patient include (select all that apply) a. No nausea or vomiting b. Ability to drive self home c. No respiratory depression d. Written discharge instructions understood e. Opioid pain medications given 45 minutes ago
c, d, e
Which intraoperative nursing responsibilities should be performed by the scrub nurse (select all that apply)? a. Documenting intraoperative care b. Keeping track of irrigation solutions for monitoring of blood loss c. Passing instruments and supplies to the surgeon by anticipating his or her needs d. Coordinating the flow and activities of members of the surgical team in the surgical suite e. Performing the count of sponges, needles, and instruments used during the surgical procedure
c, e
A 50-yr-old woman with hypertension has a serum potassium level that has acutely risen to 6.2 mEq/L. Which type of order, if written by the health care provider, should the nurse question? a. Limit foods high in potassium b. Calcium gluconate IV piggyback c. Give potassium sparing diuretics daily d. Administer intravenous insulin and glucose
c.
A patient is admitted to the postanesthesia care unit after abdominal surgery. Which assessment, if made by the nurse, is the best indicator of respiratory depression? a. increased respiratory rate b. decreased oxygen saturation c. increased carbon dioxide pressure d. frequent PVCs
c.
A patient requests that the nurse give his hearing aid to a family member so it will not be lost in surgery. What is the appropriate action by the nurse? a. give the hearing aid to the wife as he wishes b. tape the hearing aid to his ear to prevent loss c. encourage the patient to wear it for surgery d. tell the surgery nurse that he has his hearing aid out
c.
Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks the nurse to get up to go to the bathroom to urinate. Which of the following is the most appropriate action for the nurse to take? a. Assist patient to bathroom and stay next to door to assist patient back to bed when done. b. Allow patient to go to the bathroom since the onset of the medication will be more than 5 minutes. c. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety. d. Ask patient to hold the urine for a short period of time since a urinary catheter will be placed in the operating room.
c.
IV induction for general anesthesia is the method of choice for most patients because: a. the patient is not intubated. b. the agents are nonexplosive. c. induction is rapid and pleasant. d. emergence is longer but with fewer complications.
c.
In caring for the postoperative patient on the clinical unit after transfer from the postanesthesia care unit, which care can ther nurse delegate to the unlicensed assistive personnel? a. monitor the patients pain b. obtain the admission vital signs c. assist the patient to take deep breaths and cough d. change the dressing when there is excess drainage
c.
Proper attire for the semirestricted area of the surgery department is: a. street clothing b. surgical attire and head cover c. surgical attire, head cover, and mask. d. street clothing with the addition of shoe covers
c.
The nurse in an ambulatory surgery center has administered the following preoperative medications to a 42-year-old female patient scheduled for general surgery: diazepam (Valium), cefazolin (Ancef), and famotidine (Pepcid). What mode of transportation to the operating room (OR) would be the most appropriate for the nurse to arrange for this patient? a. Seated in a wheelchair accompanied by a responsible family member b. Ambulatory and accompanied by a hospital escort and a family member c. Stretcher with side rails up and accompanied by OR transportation personnel d. Ambulatory accompanied by an OR staff member or transportation personnel
c.
The nurse is doing a preoperative assessment on a male patient who has type 2 diabetes; wighs 146; and is 5 feet 8, inches tall. Which patient assessment. Which patient assessment is a priority related to anesthesia? a. hemoglobin A1C of 8.5% b. several seasonal allergies c. a body mass index of 48.8 kg/m2 d. a history of post op vomiting
c.
The nurse is performing a preoperative assessment for a patient scheduled for a surgical procedure. What is the rationale for the nurses careful documentation of the patients current medication list? a. some medications may alter the patients perceptions about surgery b. many anethetics alter renal and hepatic function, causing toxicity of other drugs c. some medications may interact with anesthetics, altering the potency and effect of the drugs d. routine medications are withheld the day of surgery, rewuiring dosage and schedule adjustments after surgery
c.
The nurse is providing preoperative teaching to a group of patients. Which patient should the nurse plan to teach coughing and deep breathing exercises? a. A 20-yr-old man who is scheduled for a tonsillectomy b. A 30-yr-old woman who is scheduled for a transsphenoidal hypophysectomy c. A 40-yr-old woman who is scheduled for a cholecystectomy d. A 50-yr-old man who is scheduled for an evacuation of a subdural hematoma
c.
The nurse should be alert for which manifestations n a patient receiving a loop diuretic? a. Restlessness and agitation b. Paresthesias and irritability c. Weak, irregular pulse and poor muscle tone d. Increased blood pressure and muscle spasms
c.
The perioperative nurse is reviewing the chart of a patient who is being admitted into the operating room for a laminectomy. What information obtained from the chart review should the nurse discuss with the anethesia care provider? a. the patients mother has contact dermatitis related to a latex allergy. b. the patients grandmother developed hypothemia during a craniotomy. c. the patients father developed a high temperature during a recent surgery. d. the patients brother developed nausea after surgery with general anesthia
c.
The perioperative nurse is supervising the surgical technologist before the arrival of the patient in the operating room for an exploratory laparotomy. Which action, if taken by the surgical technologist, would require the nurse to intervene? a. the surgical technologist always holds hands away from the body and above the elbows b. the surgical technologist scrubs the fingers and hands first followed by the forearms and elbows. c. After a surgical scrub, the surgical technologist puts on a sterile gown and one pair of sterile gloves d. when wearing a sterile gown and gloves, the surgical technologist organizes the equipment on the sterile field
c.
The typical fluid replacement for the patient with a fluid volume deficit is: a. dextran b. 0.45% saline c. lactated Ringer's solution d. 5% dextrose in 0.45% saline
c.
What action is most important for the nurse to take when caring for a patient with a subclavian triple-lumen catheter? a. Change the injection cap after the administration of IV medications b. Use a 5-mL syringe to flush the catheter between medications and after use c. During removal of the catheter, have the patient perform the Valsalva maneuver d. If resistance is met when flushing, use the push-pause technique to dislodge the clot
c.
What are the priority interventions the nurse performs when admitting a patient to the PACU? a. Assess the surgical site, noting presence and character of drainage. b. Assess the amount of urine output and the presence of bladder distension c. Assess for airway patency and quality of respirations and obtain vital signs d. Review results of intraoperative laboratory values and medications received
c.
When assessing a patient admitted with nausea and vomiting, which finding best supports the nursing diagnosis of deficient fluid volume? a. Polyuria b. Bradycardia c. Restlessness d. Difficulty breathing
c.
When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. What is the priority action by the nurse? a. recheck in 1 hour for increased drainage b. notify the surgeon of a potential hemorrhage c. assess the patients blood pressure and heart rate d. remove the sressing and assess the surgical incision
c.
When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shit to occur because of the fluid volume deficit? a. Fluid movement from the blood vessels into the cells b. Fluid movement from the interstitial space into the cells c. Fluid movement from the interstitial spaces into the plasma d. Fluid movements from the blood vessels into intersitial spaces
c.
When planning care for stable adult patients, the oral intake that is adequate to meet daily fluid needs is: a. 500-1500 mL b. 1200-2200 mL c. 2000-3000 mL d. 3000-4000 mL
c.
When reviewing the preoperative forms, the nurse notices that the informed consent form is not present or signed. What action should the nurse take? a. Have the patient sign the consent form b. Have the family sign the form for the patient c. Call the surgeon to obtain consent for the surgery d. Teach the patient about the surgery and get verbal permission
c.
Which nursing intervention is most appropriate when caring for a patient with dehydration? a. Monitor skin turgor every shift b. Auscultate lung sounds every 2 hours c. Monitor daily weight and intake and output d. Encourage the patient to reduce sodium intake
c.
Which patient is at greatest risk for developing hypermagnesesmia? a. 83-year old man with lung cancer and hypertension b. 65-year old woman with hypertension taking b-adrenergic blockers. c. 42-year old woman with systemic lupus erythematosus and renal failure. d. 50-year old man with benign prostatic hyperplasia and a urinary tract infection
c.
While performing preoperative teaching, the patient asks when she needs to stop drinking water before the surgery. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, the nurse tells the patient that: a. She must be NPO after breakfast. b. She needs to be NPO after midnight. c. She can drink clear liquids up to 2 hours before surgery. d. She can drink clear liquids up until she is taken to the OR.
c.
You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00am assessment of the patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 am. What is the priority nursing intervention? a. Slow the rate to keep vein open until next bag is due at noon b. Notify the health care provider and complete an incident report c. Listen to the patients lung sounds and assess respiratory status d. Assess the patients cardiovascular status by checking pulse and blood pressure
c.
You receive a providers prescription to change a patients IV from 5% dextrose in 0.45% saline with 40 mEq KCI/L to 5% dextrose in 0.9% saline with 20 mEq KCI/L. Which serum laboratory values best support the rationale for this IV order change? a. Sodium, 136 mEq/L; potassium, 3.6 mEq/L b. Sodium, 145 mEq/L; potassium, 4.8 mEq/L c. Sodium 135 mEq/L; potassium, 4.5 mEq/L d. Sodium 144mEq/L; potassium, 3.7 mEq/L
c.
An older adult patient has been admitted before having surgery for a bilateral mastectomy and breast reconstruction. What information should the nurse include in the patients preoperative teaching? (Select all that apply) a. Various options for reconstructive surgery b. The risks and benefits of her particular surgery c. Risk factors for breast cancer and the role of screening d. Where in the hospital she will be taken after the surgery is over e. How to perform post op deep breathing and coughing exercises
d, e
An older adult patient has been admitted before having surgery for a bilateral mastectomy and breast reconstruction. What information should the nurse include in the patients preoperative teaching? (select all that apply) a. various options for reconstructive surgery b. the risks and benefits of her particular surgery c. risk factors for breast cancer and the role of screening d. where in the hospital she will be taken after the surgery is over e. how to perform postop deep breathing and coughing exercises
d, e
A 70-kg postoperative patient has an average urine output of 25 mL/hr during the first 8 hours. The priority nursing intervention(s) given this assessment would be to: a. perform a straight catheterization to measure the amount of urine in the bladder b. notify the physician and anticipate obtaining blood work to evaluate renal function c. continue to monitor the patient because this is a normal finding during this time period d. evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound
d.
A nurse is assigned to provide preoperative teaching to a patient scheduled for coronary artery bypass surgery who only speaks spanish. What is the best method for the nurse to teach the patient how to use an incentive spirometer? a. Give the patient a pamplet written in spanish with directions on the use of the incentive spirometer b. Ask another spanish speaking paitne in the preop area to translate as the nurse describes the procedure c. Notify the postoperative unit to have a spanish speaking nurse provide the teaching on the incentive spirometer after surgery d. Have the hospital interpreter available while the nurse demonstrates and the patient returns the demonstration
d.
A patient having an open reduction internal fixation (ORIF) of a left lower leg fracture will receive regional anesthesia during the procedure. As the patient is prepared in the operating room, what should the nurse implement to maintain patient safety during surgery that is directly related to the type of anesthesia being used? a. apply grounding pad to unaffected leg. b. assess peripheral pulses and skin color. c. verify the last oral intake before surgery. d. ensure a smooth surface under the patient.
d.
A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse he thinks he is going to "throw up". A priority nursing intervention is to: a. Increase the rate of the IV fluids b. Give antiemetic medication as ordered c. Obtain vital signs, including O2 saturation d. Position patient in lateral recovery position
d.
A patient is being prepared for a surgical procedure. What is the priority intervention by the nurse prior to the start of the procedure according to the National Patient Safety Goal (NPSG)? a. prevention of infection b. improved staff communication c. identify patients at risk for suicide d. patient, surgical procedure, and site are checked
d.
A patient is having elective facial cosmetic surgery and will be staying in the facility for 24 hours after the surgery. What is the nurses postoperative priority for this patient? a. manage patient pain b. control the bleeding c. maintain fluid balance d. manage oxygenation status
d.
A patient is scheduled for surgery requiring general anesthesia at an ambulatory surgical center. The nurse asks him when he ate last. He replies that he had a light breakfast a coulple of hours before coming to the surgery center. What should the nurse do first? a. tell the patient to come back tomorrow since he ate a meal b. have the patient void before giving any preop medication c. proceed with preop checklist, including site identification d. notify the anesthesia care provider of when and what the patient ate last
d.
A priority nursing intervention to aid a preoperative patient in coping with fear of postoperative pain would be to: a. inform the patient that pain medication will be available b. teach the patient to use guided imagery to help manage pain c. describe the type of pain expected with the patients particular surgery. d. explain the pain management plan, including the use of a pain rating scale
d.
An older adult patient is having surgery. What risk area will the nurse ened to be especially aware of for this patient during surgery? a. sterility b. paralysis c. urine output d. skin integrity
d.
An older adult patient undergoing coronary artery bypass graft (CABG) surgery has just experienced intraoperative vomiting. The nurse should consequently anticipate the use of which drug? a. fentanyl b. medasolam c. meperidine d. ondansetron
d.
An older adult patient who had surgery has signs of delirium. What priority action would benefit this patient? a. review the chart for intraoperative complications b. check which medications were used for anesthesia c. assess the effectiveness of the analgesics recieved d. check the preoperative assessment for previous delirium or dementia
d.
During the postoperative care of a 76-year-old patient, the nurse monitors the patient's intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because: a. older adults have an impaired thirst mechanism and need reminding to drink fluids b. water accounts for a greater percentage of body weight in the older adult than in younger adults c. older adults are more likely than younger adults to lose extracellular fluid during surgical procedures d. small losses of fluid are more significant because body fluids account for only about 50% of body weight in older adults
d.
Early ambulation is ordered in the postoperative plan of care, but the patient refuses to get up and walk. What teaching should the nurse provide to the patient about the reason for early ambulation? a. "Early walking keeps your legs limber and strong." b. "Early ambulation will help you be ready to go home" c. "Early ambulation will help you get rid of your syncope and severe pain." d. "Early walking is the best way to prevent postoperative complications"
d.
In which surgical area will the patients surgical skin scrub prep be performed for surgery, and what clothing is appropriate for the nursing performing the scrub to wear? a. surgical suite wearing a lab coat b. postanesthesia care unit (PACU) wearing scrubs c. preoperative holding area wearing street clothes d. operating room wearing surgical attire and masks
d.
Preoperative considerations for older adults include (select all that apply) a. only using large-print educational materials b. speaking louder for patients with hearing aids c. recognizing that sensory deficits may be present d. providing warm blankets to prevent hypothermia e. teaching important information early in the morning
d.
The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to: a. apply warm moist compress to the insertion site b. try to force 10mL of normal saline into the device c. place the patient on the left side with the head down d. hav the patient change positions, raise arm, and cough
d.
The nurse on a med surg unit identifies which patient as having the highest risk for metabolic alkalosis? a. A patient with a traumatic brain injury b. A patient with type 1 diabetes mellitus c. A patient with acute respiratory failure d. A patient with nasogastric tube suction
d.
The patient is going to have a colonoscopy. Which type of anesthesia should the nurse expect to be used? a. local anesthesia b. moderate sedation c. general anesthesia d. monitored anesthesia care (MAC)
d.