NHI II Unit 1 Quiz

Pre-surgical serum electrolyte labs have been completed for the patint. The nurse would identify which of the following as an abnormal value? A. Sodium (Na+) 148 mEq/L B. Potassium (K+) 3.8 mEq/L C. Chloride (Cl-) 101 mEq/L D. Sodium Bicarbonate (HCO3) 26 mEq/L

A. Sodium (Na+) 148 mEq/L Rationale: This value is high. Normal serum sodium level is 135-145 mEq/L

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following of the following findings should the nurse expect? A. Hypertension B. Purpura C. Oliguria D. Bradypnea

C. Oliguria Rationale: Oliguria is present in hypovolemic shock as a result of decreased blood flow to the kidneys. Incorrect A. Hypertension Rationale: Hypotension is a manifestation of hypovolemic shock. B. Purpura Pallor is a manifestation of hypovolemic shock. D. Bradypnea Tachypnea is a manifestation of hypovolemic shock.

A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions is the priority for the nurse to take? A. Provide an antiemetic. B. Make the client NPO. C. Administer a stimulant laxative. D. Auscultate bowel sounds.

D. Auscultate bowel sounds. Rationale: Opioids used in patient controlled analgesia cause adverse effects that include constipation, nausea and vomiting, urinary retention, and pruritus. Nausea and vomiting may occur initially as a side effect but often resolves within 24 to 48 hours of starting the opioid. It is important for the nurse to assess the actual cause of the nausea in order to treat it effectively, which requires an evaluation of the client's bowel sounds and bowel habits. Incorrect A. Provide an antiemetic. Rationale: The nurse should recognize that nausea and vomiting are often transient effects of opioid medications and resolve within the first 24 to 48 hours after starting the opioid. While it is important to provide relief of nausea and vomiting to the client through the administration of a prescribed antiemetic, it is not the first action the nurse should take. B. Make the client NPO. Rationale: The nurse should consider decreasing the client's diet as opioids decrease intestinal peristalsis and may lead to nausea and vomiting; however, it is not the first action the nurse should take. C. Administer a stimulant laxative. Rationale: The nurse should use measures to prevent constipation in the client receiving patient controlled analgesia because opioids can cause constipation which may result in nausea and vomiting; however, it is not the first action the nurse should take.

A client is about to undergo an elective surgical procedure. Which of the following is the role of the nurse providing preoperative care regarding informed consent? A. Obtain the client's consent B. Witness the client's signature C. Explain the risks and benefits of the procedure D. Describe the consequences of forgoing treatment.

B. Witness the client's signature Rationale: It is the nurse's responsibility to witness the client's signing of the consent form, and to verify that the client is consenting voluntarily and appears to be competent to do so. The nurse should also verify that the client understands the information the person performing the procedure gave to the client. Incorrect A. Obtain the client's consent Rationale: It is the responsibility of the provider performing the procedure to obtain the client's consent. C. Explain the risks and benefits of the procedure Rationale: It is the responsibility of the provider performing the procedure to explain the risks and benefits of the procedure. D. Describe the consequences of forgoing treatment. Rationale: It is the responsibility of the provider performing the procedure to describe the consequences of forgoing treatment.

A nurse is contributing to the plan of care for an older adult client who is postoperative following a right hip arthroplasty. Which of the following interventions should the nurse include in the plan? A. Perform the client's personal care activities for her. B. Limit the client's fluid intake. C. Monitor the Homan's sign. D. Maintain adduction of the right hip.

D. Maintain adduction of the right hip. Rationale: The nurse should use an abductor pillow or other device to maintain abduction of the affected hip to prevent dislocation. Incorrect A. Perform the client's personal care activities for her. Rationale: The client should be encouraged to perform all of the activities of ADLs possible, in order to promote independence. This would include grooming (brushing hair and teeth, washing hands and face) and eating meals. B. Limit the client's fluid intake. Rationale: The nurse should encourage the client to drink 2.5 to 3 L of fluid daily in order to maintain hydration, bowel and renal function. C. Monitor the Homan's sign. Rationale: The nurse should monitor the postoperative client for the development of deep vein thrombosis; however, the presence of a positive Homan's sign is an unreliable indicator of this complication.

A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction. The client has a nasogastric tube in place. Which of the following actions should the nurse include in the clients plan of care? (Select all that apply.) A. Perform leg exercises every 2 hr. B. Encourage hourly use of an incentive spirometer while awake. C. Document the color, consistency, and amount of nasogastric drainage. D. Irrigate the nasogastric tube every 4 to 8 hr. E. Maintain bed rest for 48 hr following surgery.

Correct A. Perform leg exercises every 2 hr is correct. Rationale: Postoperative clients should frequently perform leg exercises, independently or with assistance, to prevent skin breakdown. B. Encourage hourly use of an incentive spirometer while awake is correct. Rationale: Postoperative clients should be encouraged to use the incentive spirometer ten times each hour while awake to prevent atelectasis. C. Document the color, consistency, and amount of nasogastric drainage is correct. Rationale: Documenting the color, consistency, and amount of nasogastric drainage is appropriate to include in the client's plan of care. Incorrect D. Irrigate the nasogastric tube every 4 to 8 hr is incorrect. Rationale: Following abdominal surgery, the NG tube should not be moved or irrigated unless prescribed by the provider. E. Maintain bed rest for 48 hr following surgery is incorrect. Rationale: Maintaining bed rest following surgery should not be included in the plan of care. Early ambulation prevents distention and improves intestinal mobility.

A nurse is obtaining informed consent from a client prior to surgery. Which of the following is necessary for informed consent to be valid? (Select all that apply.) A. Client's ability to pay for the consented surgical procedure B. Client's ability to read the consent form C. Disclosure of the treatment is provided D. Client understands the surgical procedure E. Voluntary consent is given

Correct C. Disclosure of the treatment is provided is correct. Rationale: The client should be informed of treatment that is to be provided as well as the risks involved. Informed consent protects the client, the provider, the institution, and the employees. D. Client understands the surgical procedure is correct. Rationale: The client should understand the surgical procedure as well as the risks. Informed consent protects the client, the provider, the institution, and the employees. E. Voluntary consent is given is correct. Rationale: The client should give voluntary consent for the procedure without influence. Informed consent protects the client, provider, the institution, and the employees. Incorrect A. Client's ability to pay for the consented surgical procedure Rationale: The client's ability to pay for the consented surgical procedure is not related to informed consent. B. Client's ability to read the consent form Rationale: It is not necessary for the client to personally read the consent form.

The client has just returned to her room from the PACU. Upon arrival the nurse notices that the patient is still groggy from anesthesia and has IV fluids infusing in her left arm. As you assist the client with settling into bed the nurse knows that it is most important to: A. Avoid dislodging the IV from the vein. B. Elevate her knees to prevent strain on her surgical incision. C. Have her deep breathe and cough immediately. D. Assess her vital signs every 15 minutes for that first hour.

D. Assess her vital signs every 15 minutes for that first hour. Rationale: Using the airway, breathing, and circulation priority framework, the intervention having the highest priority is assessment of vital signs every 15 minutes for the first hour after arrival from the PACU.

A nurse is caring for a client who reports feeling anxious about abdominal surgery the next day. Which of the following actions should the nurse plan to take? A. Explain that there is no need to worry. B. Suggest that the client talk to his provider. C. Ask the client to focus on the current day's care tasks. D. Encourage the client to verbalize his concerns.

D. Encourage the client to verbalize his concerns. Rationale: This response by the nurse acknowledges the client's emotions and provides an opportunity for open therapeutic communication. Incorrect A. Explain that there is no need to worry. Rationale: This response by the nurse provides false reassurance and does not acknowledge the client's emotions; therefore, this response creates a barrier to therapeutic communication. B. Suggest that the client talk to his provider. Rationale: This response by the nurse represents refusal to discuss the client's negative emotions and can make the client feel rejected; therefore, this response creates a barrier to therapeutic communication. C. Ask the client to focus on the current day's care tasks. Rationale: This response by the nurse represents refusal to discuss the client's negative emotions and can make the client feel rejected; therefore, this response creates a barrier to therapeutic communication.

In caring for a post-op patient, the physician has ordered a clear liquid diet, advance as tolerated. In planning to initiate this diet, which item would be of highest priority to have available at the bedside? A. Crash cart B. A Straw C. A cardiac monitor D. Suction equipment

D. Suction equipment Rationale: In initiating a clear liquid diet following surgery, the client may be at risk for aspiration due to impaired gag or swallow reflexes, in addition to aspiration secondary to vomiting. Suction equipment should be kept available at the bedside.