NURS 120 Assessment 1 practice

a client who is about to undergo hip arthroplasty tells the nurse she is afraid of not receiving adequate anesthesia during the procedure. which of the following responses should the nurse make?

"can you tell me more about this concern?"

a nurse is providing preoperative teaching to a client who is to undergo an open bowel resection at 1300 next wee. which of the following statements by the clients indicates the need for further teaching?

"i will be able to eat solid food when i wake up from anesthesia" rationale: clients who undergo open abdominal surgery will usually have an NG tube in place. the client will remain NPO until the nurse removes the tube. once it's removed, the client can start to drink clear liquids and progress to more solid fluids as tolerated.

a nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. which of the following postoperative assessments should the nurse give highest priority to?

ABG the post op surgical client may need supplemental oxygen in order to maintain normal blood oxygen levels.

a nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. the nurse notes separation of the wound edges with copious light-brown serous drainage. which of the following actions should the nurse perform first?

Cover the wound with a moist, sterile gauze dressing.

a nurse is caring for a client immediately following a procedure that required spinal anesthesia. which of the following findings indicates the client is experiencing a complication of the anesthesia?

Headache Rationale: When spinal fluid is lost through a leak at the puncture site around the spinal column, a severe headache can occur, which may last several days. This finding is a complication of the anesthesia.

A nurse is planning care for a client who is postoperative. Which of the following statements about pain management should the nurse consider when implementing client care? SATA

Use of analgesics will eventually lead to addiction. Each client's expression of pain may be different and individualized. Patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic range. Pain level and pain tolerance can be assessed using a scale from 0 to 10.

a nurse if completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. which of the following vitamins that promote would healing should the nurse including in the teaching? SATA

Vitamin A Vitamin B12 Vitamin C Vitamin K

a nurse is reviewing the diagnostic test results of an older adult female client who is preoperative for a knee arthoplasty. the nurse should notify the surgeon of which of the following results?

WBC count 20,000/mm WBC range: 5,000-10,000/mm3 hematocrit(women): 37-47% creatinine(w): 0.5-1.2 mg/dL potassium: 3.5-5.0mEq/L

a nurse is caring for 4 postoperative clients. the nurse can delegate obtaining vital signs to an AP for which of the following clients?

a client who is 3 days postoperative following gastric bypass surgery.

a nurse is teaching a client who undergo a bronchoscopy procedure. the provider will use a rigid scope and general anesthesia. the nurse should explain that the client's neck will be in which of the following positions?

a hyperextended position brings the pharynx into alignment with the trachea and allows insertions of the scope far enough to adequately view airway structures and obtain tissue samples.

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 should the nurse take?

auscultate bowel sounds

a nurse is planning care for a client who is postoperative following a thryoidectomy. which of the following interventions should the nurse include in the plan?

check the client's voice every 2 hr. monitor for hoarseness, which is a manifestation of laryngeal nerve damage.

a nurse is caring for a client who is postoperative and has a prescription for antiembolic stockings. which of the following actions should the nurse take?

check the stockings for wrinkles.

a nurse is caring for a client who is 2 days postop following abdominal surgery and observes that the client's wound has eviscerated. after calling for help. which of the following actions should the nurse take first?

cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.

a nurse is caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. how should the nurse dispose of the dressing material?

dispose of the dressing in a biohazardous waste container

a nurse is assessing a client who will undergo abdominal surgery in 2 hr. the client reports being nervous about the surgery, last had food and fluids at 2330 the previous evening, and signed the surgical consent 2 days ago. which of the following is an appropriate nursing action regarding these findings?

document the findings in the clients medical record.

a nurse is developing a plan of care for a client who is postoperative. which of the following interventions should the nurse include in the plan to prevent pulmonary complications?

encourage the use of an incentive spirometer. expands the lungs and promotes gas exchange after surgery which can help prevent pulmonary complications.

a nurse is receiving a client who is immediately postop following hip arthroplasty. which of the following medications should the nurse plan to administer for DVT prophylaxis?

enoxaparin subcutaneous

a nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. which of the following findings should the nurse expect?

fatigue

a nurse is monitoring a child for manifestations of hemorrhage following a tonsillectomy. which of the following findings is a manifestation of this postoperative complication?

frequent swallowing frequent swallowing and throat clearing are signs of hemorrhage after a tonsillectomy.

a nurse is assessing a client in labor who has had epidural anesthesia for pain relief. which of the following findings should the nurse identify as a complication from the epidural block?

hypotension

a nurse is caring for a client 1 day postoperative who has developed atelectasis. which of the following manifestations is an expected finding for this condition?

hypoxemia decreased oxygenation of the red blood cells and cyanosis due to poor oxygen exchange.

a nurse is teaching a client who is preoperative how to deep-breathing exercises and cough effectively after surgery. which of the following statements by the client indicates an understanding of the teaching?

ill splint my incision with a pillow to cough

a nurse is planning care for a client who is postop and at risk for paralytic ileus. which of the following interventions should the nurse plan to take to promote peristalsis?

increase ambulation

a nurse is assessing a client who has developed atelectasis postoperatively. which of the following findings should the nurse expect?

increasing dyspnea

a nurse is reviewing the provider's prescription for a client experiencing a paralytic ileus following an appendectomy. which of the following actions should the nurse expect to take?

insert NG tube

a nurse is providing preoperative teaching for a client who is scheduled for a gastrectomy. which of the following information regarding prevention of postoperative complications should the nurse include in the teaching?

instruct the client about the use of a sequential compression device.

a nurse is assessing a client who has postoperative atelectasis and is hypoxic. which of the following manifestations should the nurse expect?

intercostal retractions rationale: hypoxia is a condition in which the tissues of the body are oxygen-starved. it follows hypoxemia(low oxygen in the blood) and is manifested as substernal or intercostal retractions as the body works harder to draw more oxygen into the lungs.

an assistive personnel (AP) reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. which of the following tasks should the nurse delegate to the AP?

obtain vital signs rationale: within scope of practice

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? SATA

poor nutritional state obesity wound infection

a nurse is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. the nurse should recognize which of the following as an adverse effect of the medication?

respiratory rate 8/min

a nurse is assessing a client's wound dressing, and observes a watery red drainage. the nurse should document this drainage as which of the following?

serosanguineous - watery red drainage (wine) serous: yellowish purulent: thick and odourous sanguineous: bloody

a nurse is changing the dressing of a client who is 1 week postoperative following abdominal surgery and notes the presence of serosanguineous drainage. the nurse should recognize that this is an indication of which of the following circumstances?

serosanguineous drainage at this time is a manifestation of possible dehiscience. drainage beyond 5th postop day is a manifestation of possible dehiscience, provider should be noted.

a nurse is developing a plan of care for a client who is 12 hr postoperative following colon resection. which of the following interventions should the nurse include in the plan to reduce respiratory complicatios?

splint the incision to support coughing every 2 hr. rationale: coughing and splinting may be performed with deep breathing every 1-2 hr after surgery.

a nurse is caring for a client who is postoperative. the nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pain?

the client's self report of pain severity

a nurse is assessing a client who is 48 hr postop following abdominal surgery. which of the following findings should the nurse report to the provider?

yellow-green drainage on the surgical incision. thick yellow-green drainage is indication of infection