Nursing - 309 Exam Set (Iggy 14, 15, 16)

A postoperative patient in the PACU has had an open reduction internal fixation of a left fractured femur. Vital signs are blood pressure 87/49 mmHg, heart rate 100/min sinus rhythm, respirations 22/min, temperature 98.3 F. The Foley catheter has a total amount of 110 mL of clear, yellow urine in the last 4 hours. Which body systems have been assessed by the nurse?

Respiratory, Cardiovascular, Renal/urinary.

A client is extubated in the post anesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress?

Restlessness.

PACU nurse is assessing an older adult post operative patient for pain. Which nonverbal manifestations by the patient suggest pain to the nurse?

Restlessness. Profuse sweating. Confusion. Increased blood pressure.

Which nursing intervention is most appropriate for the patient in the operative setting?

Provide a climate of privacy, comfort, and confidentiality when caring for the patient.

Which signs are considered postoperative complications?

Pulmonary embolism. Hypothermia. Wound evisceration.

Which patient is most at risk for post operative nausea and vomiting (PONV) ?

The patient with a history of motion sickness.

The patient received moderate sedation (conscious sedation) by IV prior to a bronchoscopy procedure. Before allowing the patient to have oral liquids, what must the nurse assess in this patient?

The patient's gag reflex is working.

Normal Glucose (fasting)

70 - 110 mg/dL

The nurse notifies the surgeon of wound drainage. What lab data is important for the nurse to report to the surgeon?

Hemoglobin and hematocrit.

Which definition is appropriate for local anesthesia?

Injection of an anesthetic agent directly into the tissue around an incision, wound, or lesion.

What is the primary purpose of a PACU?

Ongoing critical evaluation and stabilization of the patient.

A patient is requesting moderate sedation for repair of a torn meniscus and has no medical contraindications. How does the nurse respond to this patient's request?

"You can discuss your request for moderate sedation with your surgeon and anesthesiologist."

The patient is scheduled to have minimally invasive surgery for a laparoscopic cholecystectomy. Part of this surgery is the injection of air (insufflation) into the abdomen to separate and better see the organs. What patient teaching must the nurse do about insufflation?

"You may experience some abdominal discomfort from the air injected with the surgery."

Normal Creatinine (Female)

0.5 - 1.1 mg/dL

In the immediate post operative period after a gastrectomy, the client's nasogastric tube is draining a light red liquid. For how long should the nurse expect this type of drainage?

10 to 12 hours

Review of client's prescription states that Lactated Ringer's solution at 75 mL/hour. An infusion pump is not immediately available, so the nurse notes that the infusion tubing has a drop factor of 10 drops/mL and resets the IV. At what rate should the IV infuse?

13 drops per minute.

Normal Sodium Range

136 - 145 mEq/L

The prescription is for 2 grams of cefazolin, which arrives from the pharmacy diluted in 100 mL of normal saline and is to be administered over 30 minutes. At what rate should the infusion pump be set?

200 mL/hour.

Normal Carbon Dioxide

23 - 30 mEq/L

Normal Potassium Range

3.5 - 5.0 mEq/L

The health care team determines a patient's readiness for discharge from the PACU by noting a postanesthesia recovery score of at least 10. After determining that all criteria have been met, the patient is discharged to the hospital unit or home. Review the patient profile after 1 hour in the PACU listed below. Which patient should the nurse expect to be discharged from the PACU first?

42 year old woman, colonoscopy. IV conscious sedation. Awake and alert. Up to bathroom to void. IV discontinued. Resting quietly in chair. VS are within normal limits.

Normal Chloride Range

98 - 106 mEq/L

If a patient experiences a wound dehiscence, which description illustrates what is happening with the wound?

A partial or complete separation of outer layers is present at incision site.

The PACU nurse is assessing a patient transferred in from the OR. Which assessment findings apply to assessment of the cardiovascular system?

Absent dorsalis pedis pulse left foot. Monitor shows normal sinus rhythm. Apical pulse 85 beats/minute.

Which interventions must the operating room nurses provide for patient physiological integrity during the intraoperative period?

Apply padding to the OR bed to protect skin integrity. Monitor patient's airway, vital signs, ECG, O2 Sats during and after surgery. Assess and document skin condition before transferring patient to the postanesthesia care unit.

A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. What medication does the nurse anticipate will be prescribed for this client?

Ascorbic acid (Ascorbicap)

The health care provider removed a patient's original surgical dressing 2 days after surgery and is discharging the patient home on daily dressing changes. Which actions does the nurse take for this patient's discharge teaching?

Ask the patient's family or significant other to observe the dressing change. Instruct that the drainage will appear sero-sanguineous. Have the case manager arrange for a home health nurse to ensure that dressing changes are done and there are no complications of infection.

A patient arrives in the PACU. Which action the nurse performs first?

Assess for a patent airway and adequate gas exchange.

The postoperative care of a morbidly obese client is being planned. Which task best utilizes the expertise of the LPN?

Assisting in the planning of toileting, turning, and ambulation.

What action should the nurse take to assess for atelectasis?

Auscultate the client's breath sounds.

After Ms. Jackson ambulates with the physical therapist, the nurse prepares to change the surgical dressing. While obtaining supplies, the nurse review the sterile procedure to be followed. At what step in the procedure should the nurse don sterile gloves?

Before cleansing the client's hip incision.

The nurse transfers a patient to the PACU with an incision and drainage of an abscess in the right groin under general anesthesia. Blood pressure is 80/47 mmHg, heart rate 117/min in sinus tachycardia, respiratory rate 28/min, pulse oximetry reading 93% on oxygen at 3 L nasal cannula, temp is 38.5 C. The Jackson-Pratt drain has 70 mL of a ream colored output. Normal saline is infusing at 150 mL/hr. The surgeon orders a bolus of 500 mL IV over 1 hour of normal saline, two sets of blood cultures, and culture drainage from the Jackson-Pratt drain. The patient's history includes vulva cancer with a needle biopsy of the right groin, hypertension treated with lisinopril (Zestril) 5 mg PO daily, and no known drug allergies. The patient is a full code. Using SBAR, which information should be included in the assessment?

Blood pressure 80/47. Heart rate 117/min. Sinus tachycardia. Respirations 28/min. Pulse oximetry 93% on O2 at 3 L nasal cannula. Temp 38.5 C. Jackson-Pratt drain with 70 mL cream colored output.

The PACU nurse is caring for a postoperative patient. The patient's oxygen stauration drops from 98% to 88%. What is the nurse's priority action?

Call the Rapid Response Team.

A nurse is applying a dressing to a client's surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. What physical principle is applicable for causing the sterile field to become contaminated?

Capillary.

A patient develops respiratory distress after having a left total knee replacement. The patient develops labored breathing and a pulse oximetry reading is 83% on 2 L oxygen via nasal cannula. Which intervention is appropriate for the nurse to delegate to unlicensed assistive personnel?

Check the patient's vital signs.

Which description illustrates the beginning of the postoperative period?

Completion of the surgical procedure and transfer of the patient to the postanesthesia care unit (PACU).

Which duties are within the scope of practice of the circulating nurse in operative setting?

Coordinates, oversees, and participates in the patient's nursing care while the patient is in the operating room.

When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action?

Cover the wound with a sterile towel moistened with normal saline.

The surgical team understands that time is crucial in recognizing and treating an MH crisis. Once recognized, what is the the treatment of choice?

Dantrolene sodium (Dantrium)

After abdominal surgery a client reports pain. What action should the nurse take first?

Determine the characteristics of the pain.

Which medical condition increases a patient's risk for surgical wound infection?

Diabetes Mellitus

Immediately after receiving spinal anesthesia, a client develops hypotension. What physiologic change does the nurse attribute the decreased blood pressure?

Dilation of blood vessels.

Which characteristics are appropriate to the anesthetic agent ketamine HCL?

Dissociative emergence reactions; can induce nausea and vomiting.

The nurse determines that Ms. Jackson's bowel sounds are hypoactive. What action should the nurse implement in response to this finding?

Document the assessment finding in the chart.

The nurse observes that the hemovac drain is full of sanguineous drainage. What action should the nurse implement first?

Empty the drain and measure the amount of drainage.

A client experiences abdominal distention following surgery. Which nursing actions are appropriate?

Encouraging ambulation. Auscultating bowel sounds.

You are responsible for the care of a postoperative patient with a thoracotomy. The patient has been given the nursing diagnosis of Activity Intolerance. Which action should you delegate to the UAP?

Encouraging, monitoring , and recording nutritional intake.

Which patient would be a candidate for moderate sedation?

Endoscopy. closed fracture reduction. Cardiac catheterization. Cardioversion.

To avoid electrical safety problems during surgery, what does the nurse do?

Ensures proper placement of the grounding pads.

After an abdominal cholecystectomy, a client has a T-tube attached to a collection device. On the day of surgery, at 10:30 PM, 300 mL of bile is emptied from the collection bag. At 06:30 AM the next day, the bag contains 60 mL of bile. What should the nurse consider in response to this information?

Mechanical problems may have developed with the T-tube.

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions?

Frequent changes of position.

A 49 year old patient is in the PACU following a frontal craniotomy for repair of a ruptured cerebral aneurysm. The nurse assesses that the patient's eyes open on verbal stimulation. Pupils are equal, reactive to light, and diameter is 3 mm. The patient's hand grasps are equal and strong. The patient's hand grasps are equal and strong. When the nurse asks the patient to state name, the patient states names correctly. The patient has had one episode of nausea and vomiting. Incision edges are dry and approximated with sutures. Lung sounds are slightly diminished per auscultation and the nurse observes the patient is using abdominal accessory muscles to breathe. Which body systems has the nurse assessed?

Gastrointestinal. Neurologic. Integumentary. Respiratory.

Patient is prescribed a transfusion of 2 units of packed red blood cells as soon as possible. Once the first unit of packed red blood cells as is ready the nurse obtains the blood from the blood bank. When the nurse enters the room to begin the transfusion, the UAP is giving them a partial bath. What action should the nurse take?

Hang the transfusion of packed cells while the UAP continues to complete the client's personal care.

On which concern should the nurse focus when caring for a client after abdominal surgery?

Identifying signs of bleeding

Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus?

Impaired neural functioning.

In which situations is regional anesthesia used instead of general anesthesia?

In patients who have had an adverse reaction to general anesthesia. In some cases when pain management after surgery is enhanced by regional anesthesia. In patients with serious medical problems. When the patient has a preference and a choice is possible.

The nurse teaches Ms. Jackson safe transfer techniques and consults with the physical therapist to begin ambulation activities as soon as possible. What is the rationale for the inclusion of these actions in Ms. Jackson's plan of care?

Increased mobility will promote an improved sense of control.

During surgery, what things do anesthesia personnel monitor, measure and assess?

Intake and output. Cardiopulmonary function. Level of anesthesia. Vital Signs.

What criteria guide the handoff report when a patient is transferred from the OR to the PACU?

It is a two way verbal interaction. The language is clear. Standardized reports help avoid omissions. Receiving nurse repeats information to verify what was said.

A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure?

Keeps the area free of microorganisms.

While assessing the patient, the nurse observes that the surgical dressing is in place on her left hip, with no visible drainage. How should the nurse document this finding?

Left hip dressing clean, dry and intact.

To reduce the incidence of patients with a known history of malignant hyperthermia. What best practices are put in place in the OR?

List of medications available for emergency treatment of MH. Dedicated MH cart with treatment medications. Treatment before, during, and after surgery if the patient has a known history or risk. Additional nursing support on call if MH develops. Available MH hotline number.

A patient arrives at the PACU and the nurse notes a respiratory rate of 10 with sternal retractions. The report from anesthesia personnel indicates that the patient had received fentanyl during surgery. What is the nurse's best priority first action?

Maintain an open airway through positioning and suction if needed.

What is the priority nursing intervention for a client during the immediate postoperative period?

Maintaining a patent airway.

A patient with breast cancer is scheduled for a left mastectomy. The patient has informed the surgeon and nurse that she is a Jehovah's Witness and does not want any blood transfusions. In preparation for intraoperative care of this patient, what measures does the nurse take?

Make provider aware of patient's request for no blood transfusions. Ensure autotransfusion device is in place intraoperatively.

Which are interventions for the med surg nurse to use in preventing hypoxemia for the postoperative patient?

Monitor the patient's oxygen saturation. Encourage the patient to cough and breathe deeply. Get the patient up ambulating as soon as possible.

After undergoing a modified radical mastectomy, a client is transferred to the postanesthesia care unit. Which nursing action is best to delegate to an experienced LPN?

Monitoring the client's dressing for any signs of bleeding.

A patient has an MH incident during surgery. To whom does the nurse report this incident?

North American Malignant Hyperthermia Registry.

The patient in the OR holding area tells the nurse that his surgery is for the right foot. The patient's chart states that the surgery is for his left foot. What is the nurse's best action?

Notify the surgeon immediately before the patient goes into the OR about his discrepancy.

During the postoperative assessment, the nurse observes Ms. Jackson's surgical site. The left hip dressing has a moderate amount of sanguineous drainage. What actions should the nurse implement?

Observe the linens under the hip. Mark the amount of drainage on the dressing.

A client reports severe pain 2 days after surgery. Which INITIAL action should the nurse take after assessing the character of the pain?

Obtain the vital signs.

When assessing the older postoperative patient for hydration status, where must the nurse assess for tenting of the skin?

On the forehead. ON the sternum.

The nurse is assessing a postoperative patient's gastrointestinal system. What is the best indicator that peristaltic activity has resumed?

Passing of flatus or stool.

Which factors may lead to an anesthetic overdose in a patient?

Patient who is older. Slowed metabolism and drug elimination. Liver or kidney disease.

Which nursing interventions will prevent the potential intraoperative complication of radial joint stiffness, pain, and inflammation?

Place pillow or foam padding under bony prominences. Maintain good body alignment. Slightly flex joints and support with pillows, trochanter rolls, and pads.

Following surgery, your patient is admitted to the PACU. The operative report indicates that the patient had a left hip replacement under general anesthesia. The initial nursing assessment reveals that the patient is not responding to verbal stimuli. Her vital signs are T 97.6 F, Pulse 88, Respirations 14, BP 130/70. What action should the nurse implement first?

Position the client on her side.

The nurse is teaching incisional care to patient who has been discharged after abdominal surgery. Which priority instruction must the nurse include?

Practice proper handwashing.

A nurse in the postanesthesia care unit observes that after an abdominal cholecystectomy a client has serosanguineous drainage on the abdominal dressing. What is the next best nursing action?

Reinforce the dressing.

The morning after a patient's lower leg surgery, the nurse notes that the dressing is wet from drainage. The surgeon has not yet been in to see the patient on rounds. What does the nurse do about the dressing?

Reinforces the dressing by adding dry, sterile dressing material on top of the existing dressing.

A patient cared for in the PACU has had a colostomy placed for treatment of Crohn's disease. The nurse assesses that an abdominal dressing is 25% saturated with serosanguineous drainage and notes that the incision is intact. An IV is infusing with D5/lactated Ringer's at 100 mL/hr through a 20-g peripheral IV access. Auscultation of abdomen reveals hypoactive bowel sounds in all four quadrants, abdomen soft, and no distention. Foley catheter is in place an draining yellow urine with sediment, 375 mL output in FOley bag. Which body systems have been assessed by the nurse?

Renal/urinary. Gastrointestinal. Integumentary.

Once the OR team has assembled in the room, the circulating nurse calls for a time out. What action should the nurse take during the time out?

Review the scheduled procedure, site, and client.

Patient is transferred to a stretcher and taken to the OR. The nurse assists patient off the stretcher and onto the OR table. After general anesthesia is induced the nurse positions patient. Which nursing diagnosis has the highest priority at this time?

Risk for perioperative-positioning injury

Which nursing interventions are appropriate during stage 2 of anesthesia?

Shield patient from extra noise and physical stimuli. Protect the patient's extremities. Assist anesthesia personnel as needed. Stay with patient.

Which clinical features are found in an MH crisis?

Sinus tachycardia. Tightness and rigidity of the patient's jaw area. Lowering BP. Skin mottling and cyanosis. Tachypnea.

The nurse is assisting Ms. Jackson to the bedside commode on the second postoperative day. Ms. Jackson states, "I have never had to depend on anyone before. I like to take care of myself. I feel so helpless." In response to these remarks, the nurse plans care for Ms. Jackson based on the identification of which nursing diagnosis?

Situational low self esteem.

While cleansing the incision, the nurse observes that the staples are intact, but a 2 cm gap has opened at the bottom of the incision. How should the nurse document this finding?

Small area of dehiscence at bottom of incision.

Steps to take for caring for wound evisceration.

Stay calm and stay with the client. Put the client into semi Fowler position with knees slightly flexed. Check the vital signs, especially blood pressure and pulse. Have a colleague gather sterile supplies and contact the physician. Cover the intestine with sterile moistened gauze. Prepare the client for surgery as ordered.

The nurse is caring for a patient who has had abdominal surgery. After a hard sneeze, the patient reports pain in the surgical area, and the nurse immediately sees that the patient has a wound evisceration. What priority action must the nurse do first?

The nurse calls for help and stays with the patient.

The med surg nurse is caring for a post op patient whose lab values reveal an increase in band cells (immature neutrophils). What is the nurse's best interpretation of this value?

The patient is developing an infection.

The nurse on the med surg unit is caring for a post operative patient. Which assessment criteria indicate to the nurse that the patient is experiencing respiratory difficulty?

The patient is using accessory muscles to breath. The patient makes a high pitched crowing sound when breathing. The patient's respiratory rate is 26/min.

Which intervention for postsurgical care of a patient is correct?

The patient should splint the surgical wound for support and comfort when getting out of bed.

A patient who is 2 days post op for abdominal surgery states, "I coughed and heard something pop." The nurse's immediate assessment reveals an opened incision with a portion of large intestine protruding. Which statements apply to this clinical situation?

This is an emergency situation. The wound must be kept moist with normal saline-soaked sterile dressings. Incision evisceration has occurred.

What techniques are essential to performing a proper surgical scrub of the hands by the surgeon, assistants, and scrub nurse?

Use a broad-spectrum, surgical antimicrobial solution. Hold hands higher than the elbows during the scrub and rinse. Scrub for 3-5 minutes, followed by a rinse with water.

carboxylhemoglobin

carbon monoxide on oxygen binding sites

autologous donations

patient donates parts of body to self

Perioperative experience includes

preoperative, intraoperative, postoperative

A post operative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis?

Diminished breath sounds on auscultation.

A patient experience MH immediately after induction of anesthesia. What is the nurse anesthetist's first priority action?

Stop all inhalation anesthetic agents and succinylcholine.

Ms. Jackson is currently receiving Lactated Ringer's solution IV at a rate of 75 mL/hour. In transfusing the 250 mL unit of packed red blood cells, what action should the nurse implement?

Stop the IV solution and transfuse the packed cells at 125 mL/hour via tubing connected to a bag of saline solution.

The acute, life-threatening complication of MH results from the use of which agents?

Succinylcholine and inhalation agents.