Meg surg unit 2
The nurse is caring for a patient undergoing surgery with the nursing diagnosis of deficient knowledge related to lack of previous surgical experience. What nursing intervention is appropriate?
Determine pt anxiety levels Provide pt with verbal and written materials Document pt understanding and teaching provided Include family members in teaching Identify knowledge deficiencies
Which clinical manifestation would be the priority concern when caring for this PACU patient after hip arthroplasty?
Fluid loss
The nurse is caring for a client who is postoperative following a pelvic exenteration, and the surgeon changes the client's diet from nothing by mouth (NPO) status to clear liquids. The nurse would check which priority item before administering the diet?
Bowel sounds "Use of an incentive spirometer will help prevent pneumonia."
The nurse is assisting in the care of a preoperative patient. The patient states, "I'm really afraid I won't make it through this surgery." Which action by the nurse is appropriate?
Call the surgeon to talk to pt
The nurse is changing the abdominal dressing on a client following a suprapubic prostatectomy. A wound drain is in place in the abdominal wound. Which nursing action would be appropriate during the dressing change?
Checking the wound site for drainage from the drain
The nurse is changing the abdominal dressing on a client following abdominal surgery. The nurse notes that the incision line is separated and the appearance of underlying tissue is noted. Wound dehiscence is suspected. Which is the appropriate initial nursing action?
Apply a sterile dressing soaked with sterile normal saline to the wound.
The RN receives a telephone call from someone in the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to assist the RN to take which action first on arrival of the client?
Assess the patency of the airway.
The practical nurse (LPN) is assisting a patient in the operating room. What actions can the LPN assist with?
Helping pt on to operating table Applying monitoring equipment to pt Remove body hair
The nurse is caring for a patient receiving a spinal block. Which symptom would most concern the nurse?
Hypotension
The nurse is assisting with the care of a malnourished patient being prepared for surgery. Which statement by the patient regarding nutrition would indicate adequate teaching?
I should take a vitamin with zinc vitamin C in it after surgery
The nurse is assisting a coworker in preparing a patient for surgery. Which statement by the coworker would warrant intervention by the nurse?
I will let the pt keep their nail polish
The nurse is assisting in the care of a patient after open heart surgery. Which action by the other nurse would warrant intervention?
Instructing pt to preform deep coughing every 30 minutes
The nurse is assisting in the care of a patient receiving an inhaled anesthetic. Which is a potential complication of inhaled anesthetics?
Laryngospasm
The nurse is assisting during general surgery for a patient. The nurse notes tachycardia, muscle rigidity, respiratory acidosis, and hyperthermia. The nurse suspects which complication of surgery?
Malignant hyperthe
The nurse is assisting in the care of a patient undergoing anesthesia. Which medication would the nurse expect to be ordered by the health-care provider?
Midazolam
The student nurse is changing an abdominal dressing on a client with an open incision and notes the presence of sanguineous drainage. Which nursing action would be appropriate?
Notify the registered nurse.
The nurse is assisting in the discharge of an elderly patient after surgery. Which intervention best facilitates teaching in elderly patients?
Speak slowly and in a low tone
The nurse is reinforcing preoperative teaching with a client about the use of an incentive spirometer. The nurse needs to include which piece of information in discussions with the client?
The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees
The nurse is reviewing informed consent with a coworker. Which statement by the coworker would concern the nurse?
This protects the hospital from all lawsuits
The nurse is assisting with a patient just arriving to the surgical department. Place in order the priority of actions starting with highest priority first
Verify pt name, age, allergies and consent Alleviate anxiety Confirm surgical site Begin prophylactic antibiotics
A preoperative client expresses anxiety to the nurse about their upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?
"Can you share with me what you've been told about your surgery?"
The nurse is preparing the client for transfer to the operating room (OR) because of an emergency situation. The nurse would take which actions in the care of the client?
Ensure that the client has voided. Verify the time that the client last ate or drank. Assist the client by contacting family members the client wants notified.
The nurse is reinforcing instructions to a client and family regarding home care following cataract removal with lens implantation in the left eye. The nurse would plan to provide the client with instructions to contact the surgeon promptly for which signs or symptoms?
New floaters Increasing redness in the eye
The nurse is caring for a patient preparing for surgery. Which finding would concern the nurse?
Positive pregnancy test
