Pain/tissue integrity practice questions

Name 3 nursing/medical interventions that prevent postoperative urinary tract infections.

-Avoid indwelling urinary cath. -Prompt removal of foley cath postop day 1 unless surgery on urinary tract. Increase oral fluids. -Assess for postop urinary retention and provide appropriate interventions (bladder scan, straight cath, etc) to avoid urinary stasis

Name 2 reasons why a client with cirrhosis is at increased risk for operative complications

-Decreased ability to metabolize meds (anesthetic agents, postop med such as antibiotics or opioids) -Impaired clotting associated with liver disease. Increased risk of hemorrhage

List variables that increase surgical risk

1. Age (very young and very old) 2. Nutritional status-obesity or malnutrition 3. Preoperative dehydration or hypovolemia 4. Co-morbidities -Blood Coag disorders- may lead to hemorrhage, shock -Renal diseaseDM- increased risk of infection, delayed healing -Liver disease- impaired ability to detoxify meds and increased risk of bleeding 5. Use of certain meds Anticoagulants- increased risk of bleeding Antianxiety, tranquilizers- increased risk of hypotension in combination with anesthesia, opioids Opioids- increased risk of tolerance, poor pain control Steroids- delayed wound healing

Which intervention has priority for the nurse in the surgical holding area? A. Verify the surgical checklist B. Prepare the client's surgical site C. Assist the client to the bathroom D. Restrain the client on the surgery table

A The surgical checklist is assessed when the client arrives in the surgery department holding area where clients wait for a short time before entering the operating room. The surgical site is not prepared until the client and surgery has been verified. The client should have voided prior to being transported.

The nurse received a male client from the postanesthesia care unit. Which assessment data would warrant immediate interventions? A. The client's vital sign are T 97 F, P 108, RR 24, and BP 80/40 B. The client is sleepy but opens the eyes to his name C. The client is complaining of pain 5/10 D. The client has 20ml of urine in the bag

A These are S/S of hypovolemic shock and requires immediate intervention

Client is concerned about robotic procedure. What is not an advantage of robotic procedures? A. less dexterity B. less puncture wounds C. shorter recovery D. less pain

A

Client receiving IV dilaudid PCA pump. What makes you concerned about patient's potential RASS score? A. wife is hitting button for patient B. patient moans with deep breaths C. patient is easy to arouse

A

RN is assessing arm of client. What is a major complication of cellulitis? A. overuse and misuse of systemic antibitoics B. bleeding from biopsy site C. blood culture inaccuracies

A

The client is eight (8) hours postoperative small bowel resection. Which data indicate the client has had a complication from the surgery? A. A hard, rigid, boardlike abdomen. B. High-pitched tinkling bowel sounds. C. Absent bowel sounds. D. Complaints of pain at "6" on the pain scale.

A A hard, rigid, boardlike abdomen is the hallmark sign of peritonitis, which is a life-threatening complication of abdominal surgery. This occurs when the client has a nasogastric tube connected to suction and has minimal peristalsis and is not a complication of the surgery. The client has had general anesthesia for this surgery, and absent bowel sounds at eight (8) hours postoperative does not indicate a complication. The client with this type of surgery is expected to have pain at a "6" or higher on a 1-to-10 scale; this is not considered a complication.

Which nursing intervention is priority for the client experiencing acute pain? A. Assess the client's verbal/nonverbal behavior B. Wait for the client to request pain medication C. Administer pain medication on a scheduled basis D. Teach the client to use only imagery every hour for pain

A Pain is subjective, looking for cues verbal and nonverbally is a priority for pain

The preoperative nurse receives her patient posting for the day. There are four 0800 cases in the hospital's OR. Which patient is a priority based on extent of preoperative care needed? A. An 80-year-old male scheduled for a bowel resection with a history of DVTs, chronic hypertension, and smoking B. A 17-year-old female scheduled for exploratory laparoscopy with a history of increased anesthesia recovery time C. A 40-year-old female scheduled for breast augmentation with no risk factors D. A 60-year-old male scheduled for renal biopsy with a history of chronic renal failure

A The 80-year-old male patient with several pre-existing conditions will most likely need more laboratory work and an electrocardiogram (EKG) due to his age. The next patient to prepare for surgery would be the 60-year-old male patient who also has pre-existing conditions.

The nurse recommends treatment with transdermal fentanyl for which patient? A. Severe pain due to cancer metastasis to bone B. Postoperative pain after gastric bypass C. Intermittent lower back pain associated with lumbar strain D. Initial treatment for migraine headaches

A Transdermal fentanyl is indicated only for persistent severe pain in patients who are already opioid tolerant. Use in nontolerant patients can cause fatal respiratory depression. The patch should not be used in children under 2 years old, or in anyone under 18 who weighs less than 110 pounds. Also, the patch should not be used for postop pain, intermittent pain, or pain that responds to a less powerful analgesic.

The circulating nurse assesses tachycardia and hypotension during surgery in a client. Which interventions should the nurse implement? A. Prepare ice packs and mix dantrolene sodium B. Request defibrillator be brought into OR C. Draw a PTT and prepare a heparin drip D. Obtain a finger stick blood glucose immediately

A Unexplained tachycardia, hypotension and elevated temp are signs of malignant hyperthermia

The OR nurse is completing a perioperative assessment for a patient who is scheduled for exploratory surgery. Which of the following interventions must be completed prior to this patient going into the OR? (Select all that apply.) A. Verify operative consent has been signed B. Assure allergy and ID bands are in place C. Removal of patient's personal clothing D. Determine evidence of advance directive E. Validate completed patient history and physical examination F. Determine NPO status (last food/fluid consumed)

ABCDEF All listed information is necessary in order to develop an appropriate and individualized plan of care

Which symptoms are common in the initial stage of opioid withdrawal? SATA A. Excess tearing B. Yawning C. Stomach cramps D. Muscle aches E. Perspiration

ABCE

The client has undergone an abdominal perineal resection of the colon for colon cancer with a left lower quadrant colostomy. Which interventions should the nurse implement? Select all that apply. A. Assess the stoma for color every four (4) hours and prn. B. Encourage the client to turn, cough, and deep breathe every two (2) hours. C. Maintain the head of the bed 30 to 40 degrees elevated at all times. D. Auscultate for bowel sounds every four (4) hours. E. Administer pain medications sparingly to prevent addiction

ABD The colostomy stoma should be assessed to determine circulation to the stoma at least every four (4) hours. A purple or bluish purple indicates that the circulation to the stoma is impaired and is a medical emergency. This is an extensive surgery requiring the client to be under general anesthesia for several hours. Turning, coughing, and deep-breathing exercises done at least every two (2) hours helps to prevent pneumonia. The client is not allowed to sit on the perineal area for several days and should be maintained in a side-lying position when possible. The nurse should assess for bowel activity at regularly scheduled intervals. Pain medication is administered to control the client's pain; the nurse is concerned with client comfort, not addiction. Poorly controlled pain is more likely to result in drug- seeking behavior than adequately treated pain

A client is in the operating room having surgery to replace a hip. Prior to starting the surgery, there is confusion on the X-ray. The surgical team requests a "time-out". When can surgery continue? SATA A. The surgeon verifies the correct procedure B. The surgeon verifies the correct surgical site C. The nurse establishes a sterile field D. The surgical team identifies the client using two sources of identification E. Another X- ray is preformed

ABD When a time out is called, the team must read back and verify the correct site, and surgery, and identify the client again.

Proper informed consent includes the following: (Select all that apply.) A. Procedure name B. Reason for surgery C. Number of instruments to be used D. Consent to administer blood products E. Alternatives to surgery

ABE Rationale: The number of instruments is not relevant to informed consent. Consent to administer blood products is very often on its own form

The nurse should report the following findings from a patient's history as an increased risk for DVTs postoperatively. (Select all that apply.) A. History of smoking B. Age C. History of DVTs with previous pregnancy D. Borderline hypertension E. Allergies

ACD History of smoking causes vasoconstriction in a patient, which could be a perfect setting for a deep vein thrombosis (DVT). Decreased vessel size can lead to platelet and red blood cell clumping and lead to DVT. Any time there is a history of the DVT the patient requires prophylaxis before surgery. Hypertension causes injury to vessel walls. The body will place platelets and red blood cells over the injured vessel walls to protect the area. This will be the beginning of a DVT. Allergies or age are not implicated in clot formation

A client is being transferred from the recovery room to the med surg floor. The recovery nurse should report which information to the med surg nurse? SATA A. Type of surgery B. Name of insurance provider C. Current vital signs D. Names of all surgeons participated E. Amount of blood loss F. Fluids infusing including rate and type of solution

ACEF It is important to report the clients status, and what treatments and medications included during surgery. It is not necessary to include the insurance provider or all the surgeons present

RN is talking to client about cellulitis. What description is not correct? A. an occur in many different settings, typical unilateral B. caused by gram-positive bacteria such as Staph. A, Strep. P C. infection of dermis and subcutaneous tissues D. collection of pus within the dermis and subcutaneous tissue

D

The nurse understands the immediate postoperative assessment upon admission to the PACU includes which of the following? (Select all that apply.) A. Medical history B. Full system review C. Neurological assessment D. Blood pressure E. Surgical site drainage

CDE Immediate assessment priorities include vital signs, neurological assessment or LOC, and surgical site assessment checking for bleeding and/or drainage. A full system review will come after it is determined the patient is stabilized postoperatively. The medical history is done preoperatively.

Client is ready to discharge. What action BEST tells the RN the client can empty the drain properly? A. reading discharge instructions B. return demonstration C. have significant other to empty the drain

B

Client is ready to have PICC line placed. What is most important task performed in the intra-op phase? A. assessment of drain tubes placed B. surgical time-out C. understanding of surgical procedure D. Reviewing previous surgery Hx

B

Client just came back from oral surgery procedure. What is the priority assessment while in PACU? A. O2 Sat B. LOC C. pain D. RR

B

The nurse is caring for a client who has developed tolerance to the prescribed opioid. The client asks what tolerance means. What is the best description? A. Different medications are needed to provide the same relief B. Higher doses of the medication are needed to achieve the same effect C. The maximum dose has been delivered of a particular medication D. There is no additional way to provide pain relief

B

Which of these tests is used to rule out pneumonia? A. ct SCAN B. chest xray C. MRI

B

Which population is most likely at risk for inadequate pain control? A. Alert and oriented x3 mute client B. current history of cocaine use C. proficient bilingual client

B

An example of an acceptable time-out is: A. Name, medical history, and procedure B. Name, birthday, and procedure including site C. Birthday, Social Security number, and surgeon's name D. Allergies, medical history, and procedure site

B Rationale: The name, birthdate, and the procedure, including the site are the best response. Allergies, medical history, and Social Security number are important but not part of the time out

The charge nurse receives morning laboratory and respiratory data on the clients. Which data requires immediate intervention? A. ABG results of pH 7.35, Paco2 56, Hco3 29, Pao2 78 for a client diagnosed with COPD. B. Pulse oximetry reading of 89% on a two-day postsurgical total knee replacement client. C. Hgb of 9 g/dL and Hct of 28% on a client who is receiving the second unit of blood. D. B-type natriuretic peptide (BNP) of 100 on a client diagnosed with stage 4 congestive heart failure.

B The body has compensated for the abnormally high level of carbon dioxide (acid) in the blood by holding on to the base (Hco3) and the pH is within normal range. This is an expected blood gas for the client with COPD. This pulse oximetry reading indicates an arterial blood oxygen of less than 60. The client should be seen immediately to prevent respiratory failure. This client is receiving blood to correct the lower levels of H&H. A BNP of less than 100 is considered WNL. A BNP of 100 would not be a concern to report for a client in stage 4 of heart failure.

The nurse is completing the preoperative checklist. Which laboratory value should be reported to the health care provider immediately? A. Hemoglobin 13.1g/dL B. Glucose 60mg/dL C. Potassium 3.8mEq/L D. White blood cells 6 X 10^3

B All the labs are normal but glucose.

The nurse receives the pre-operative bloodwork report from my client who is scheduled to undergo surgery. Which laboratory findings should the nurse report to the surgeon and anesthesiologist? A. Red blood cells 4.5 million B. Creatinine 2.6 mg/dL C. Hemoglobin 14.2 g/dL D. BUN 15mg/dL

B The creatinine level is above normal and could indicate that the kidneys aren't filtering effectively and could cause complications with anesthesia and medications

The nurse is removing staples from an abdominal incision and the client sneezes and the incision splits open, exposing the intestines. What should the nurse do first? A. Press the emergency alarm for resuscitation team B. Cover the organs with sterile dressings moistened with sterile normal saline C. Have all visitors leave the room D. Call the surgeon to come to the client's room immediately

B When a wound eviscerates, the nurse should cover the open area with sterile dressings with sterile normal saline then call the surgeon to take the client back to the OR.

The nurse is receiving a client from the postanesthesia care unit (PACU). Which interventions should the nurse implement? Select all that apply. A. Ambulate the client to the bathroom to void. B. Take the client's vital signs to compare with PACU data. C. Monitor all lines into and out of the client's body. D. Assess the client's surgical site. E. Push the client's PCA button to treat for pain during movement.

BCD The client should not be ambulated until the nurse has a chance to assess for the client's ability to ambulate safely.The nurse should assess the vital signs from PACU with the current vital signs to be sure that the client is stable. The nurse should assess the intravenous lines, indwelling catheters, and tubes upon receiving the client.The nurse must assess the surgical site for bleeding to know if the client is actually stable or not. Only the client should push the PCA pump's button; otherwise the client may receive an overdose of medication.

What symptoms demonstrate opioid withdrawal in 12-72 hours? Select all that apply. A. Hunger B. N/V/D C. Muscle twitching D. Insomnia E. Muscle aches

BCDE

The nurse is caring for a client who had surgery 4 days ago. The client has nausea and vomiting, distended abdomen, and absent bowel sounds. What nursing/medical interventions would the nurse anticipate? SATA A. Prepare for surgical intervention B. Make NPO C. Nasogastric tube to low intermittent suction D. Bedrest with bathroom privileges E. Encourage ambulation F. Low fiber bland diet

BCE Manifestations of postop ileus. Make NPO, NGT for gastric decompression. Ambulation

Client is receiving oral pain med for pain 9 out of 10 at 11am. When is next follow up? A. 11:15 B. 12:15 C. 12:00 D. 11:45

C

RN assessing surgical site of client fresh from Sx. What is not indicative of risk for surgical site infection? A. WBC of 100 B. taking steroids for asthma C. moderate serosangious output from drain D. being 100 years old

C

The nurse is assessing the patient's surgical dressing. What is not considered an emergency situation? A. Sx dressing is saturated through multiple reinforcements B. organ tissue is protruding out of the exposed wound C. wound bed edges are slightly separated with scarce drainage

C

The male client in the day surgery unit complains of difficulty urinating postoperatively. Which intervention should the nurse implement? A. Insert a indwelling catheter B. Increase the IV fluids rate C. Assist the client to stand to void D. Encourage the client to increase fluids

C Helping the client to stand will offer assistance to void. It is the least invasive option.

In preparing an in-service about pain management, the nurse includes which finding as the most serious adverse effect of opioids? A. Profound sedation B. Suppressed cardiac automaticity C. Respiratory depression D. Hyperthermia

C Respiratory depression is the most serious adverse effect of the opioids. At equianalgesic doses, all of the pure opioid agonists depress respiration to the same extent. Death following overdose is almost always from respiratory arrest

At the peak of opioid withdrawal, the nurse should anticipate which symptom to occur? A. Cardiac arrest B. Delusions C. Mania D. Violent kicking motions

D

The home health nurse must see all of the following clients. Which client should the nurse assess first? A. The client who is postoperative from an open cholecystectomy who has green drainage coming from the T-tube. B. The client diagnosed with congestive heart failure who complains of shortness of breath while fixing meals. C. The client diagnosed with AIDS dementia whose family called and reported that the client is vomiting "coffee grounds stuff." D. The client diagnosed with end-stage liver failure who has gained three (3) pounds and is not able to wear house shoes.

C The T-tube is inserted into the common bile duct to drain bile until healing occurs, and bile is green, so this is expected. The client with CHF would be expected to experience dyspnea on exertion. Coffee-ground emesis indicates gastrointestinal bleeding, and this client should be seen first. The client in end-stage liver failure is unable to assimilate protein from the diet, which leads to fluid volume retention and resulting weight gain. This is expected for this client.

The client is complaining of incisional pain. Which intervention should the nurse implement first? A. Administer the pain medication STAT. B. Determine when the last pain medication was given. C. Assess the client's pulse and blood pressure. D. Teach the client distraction techniques to address pain.

C The pain medication should be administered as soon as possible but not before assessing for complications which might be causing painThe nurse must not administer the medication too close to the last dose, but this is not the first intervention the nurse would implement. The first step of the nursing process is to assess, and the nurse must determine if this is routine postoperative pain the client should have or if this is a complication which requires immediate intervention. Decreased blood pressure and increased pulse indicates hemorrhaging. Teaching distraction techniques is an appropriate intervention, but the nurse should medicate the client.

The nurse chooses which pain scale to most effectively assess pain in an older patient with limited vision? A. FACES scale B. Numeric scale C. Verbal scale D. Visual scale

C Verbal rating scales are more effective with older people than the more common numeric rating scales. The Wong-Baker scale is used with children, and the FACES pain scale is used with older adults with expressive aphasia. Numerical rating scales become more difficult to use as patients age, with a higher frequency of incomplete or unscoreable responses. Visual scales are not as effective in older adults often due to changes in vision.

On the day of surgery, a client has been breathing room air. The vital signs are normal, and the 02 sat is 89%. What should the nurse do first? A. Lower the head of the bed B. Notify the HCP C. Assist the client to take several deep breaths and cough D. Administer oxygen by nasal cannula at 2L/min

C Deep breathing and coughing will help to increase lung expansion and prevent the accumulation of secretions. This the first action before calling the HCP

When the nurse asks the client who is having abdominal surgery today if they understand the procedure, the client replies "No, not really; I talked about several different things with my surgeon, and I am just not sure." What should the nurse do next? A. Teach the client all the details of the planned procedure B. Utilize a second witness when the client signs consent C. Notify surgeon of the client's expressed lack of understanding D. Administer the prescribed preoperative narcotic or sedative

C It is the surgeons responsibility to discuss the planned procedure and review the risks, benefits, and alternatives.

After teaching the client how to use the PCA pump, the nurse determines that the client understands the use of the PCA when the client makes which statement? A. "It is OK for my family to press the button for me if I'm too tired to do it myself." B. "I should wait until the pain is really bad before I push the button to get more pain medicine." C. "The medicine will only give me the prescribed amount of pain medication even if I push the button too soon" D. "I have to be careful about pushing the button too many times or I will overdose

C The client must be able to verbalize understanding about receiving no more pain medication than the prescribed amount. Only the client should push the button. The client should administer the pain medication when pain is first noticed, before pain is out of control. The pump is controlled so overdosing is not a concern

Which fluids would not have delayed fluids restrictions? A. A bronchoscopy under local anesthesia B. A transurethral resection of a bladder tumor under general anesthesia C. A repair of carpal tunnel syndrome under local anesthesia D. An inguinal herniorraphy with spinal and IV conscious sedation

C The client who's gag reflex has not been anesthetized is the answer. The client is receiving local anesthesia in the wrist.

Which lab result would require immediate intervention by the nurse for a client who is scheduled for surgery? A. Calcium 9.2 mg/dL B. INR 1.0 D. HGB 10.5 g/dL D. Platelet 80,000 cells/mcL

D

Which medication is not acceptable for a NPO patient? A. coreg oral B. labetalol oral C. digoxin oral D. pantoprazole oral

D

which is not a treatment option for malignant hyperthermia? A. meds B. fluids C. ice D. potassium

D

You are preparing a patient for surgery and have asked her to verify her information on her patient identification band. She tells you that the birth date is incorrect on her identification band. The most appropriate action by the nurse at this time is which of the following? A. Cross out the birth date and put the correct one in its place with the nurse's initials. B. Ask the family members to validate the patient's birth date. C. Call the surgeon's office to validate the birth date. D. Ask the admissions office to please send a corrected identification band.

D It is imperative that the patient enters the operating room with all information absolutely correct. The admissions office must send a new identification band. Crossing out the incorrect date and replacing it with the new one is not within policy. A new official ID band with all correct information is necessary for patient safety

The nurse is preparing a client for surgery. Which intervention should the nurse implement first? A. Check the permit for the spouse's signature B. Take and document intake and output C. Administer the "on call" sedative D. Complete the preoperative checklist

D The clients signature, not the spouse's, should be on the surgical permit. Intake and output is important but not the first intervention. The sedative should be administered after the surgical checklist is completed. Completing the preoperative checklist has the highest priority to ensure all details are completed without omissions

To prevent circulatory complications in the immediate postoperative period for a patient who has had an exploratory laparotomy, which nursing action is of the highest priority? A. Administering pain medication B. Applying antiembolism stockings C. Encouraging coughing and deep breathing every 2 hours D. Monitoring vital signs every hour until stable

D The priority for this patient is further assessment through monitoring of the patient's vital signs. The other responses are appropriate but are secondary to the assessment

The nurse is caring for the client recovering from intestinal surgery. Which assessment finding requires immediate intervention? A. Presence of thin, pink drainage in the Jackson Pratt. B. Guarding when the nurse touches the abdomen. C. Tenderness around the surgical site during palpation. D. Complaints of chills and feeling feverish.

D Thin pink drainage is expected in the Jackson Pratt (JP) bulb. Guarding is a normal occurrence when touching a tender area on the abdomen and does not require immediate intervention. Tenderness around the surgical site is a normal finding and does not require intervention. Complaints of chills, sudden onset of fever, tachycardia, nausea, and hiccups are symptoms of peritonitis, which is a lifethreatening complication.

The client received Narcan, a narcotic antagonist, following a colonoscopy. Which action by the nurse has the highest priority? A. Document the occurrence in the nurse's notes. B. Prepare to administer narcotic medication IV. C. Administer oxygen via nasal cannula. D. Assess the client every 15 to 30 minutes.

D This should be documented in the client's nurse's notes because this is a prn medication, but it is not the priority medication. The nurse would not administer another narcotic, which is what caused the need for Narcan in the first place. Oxygen will not help reverse respiratory depression secondary to a narcotic overdose. Narcan is administered when the client has received too much of a narcotic. Narcan has a short half-life of about 30 minutes and the client will be at risk for respiratory depression for several hours; therefore, the nurse should assess the client frequently.

On the fourth day after surgery, a client's incision is red and inflamed. There is moderate drainage. The client's temperature is 102 F. The total WBC's is 13,000. What should the nurse do first? A. Encourage the client to increase the fluid intake B. Cleanse the site with soap and water C. Place an absorbent dressing over site D. Call the HCP

D The findings indicate an infection. The nurse should first call the HCP to get an order for treatment. Fluids would be helpful, but not treat the infection

A client has been unable to void since having abdominal surgery 7 hours ago. What should the nurse do first? A. Encourage the client to increase oral fluid intake B. Insert a intermittent urinary catheter C. Use an ultrasound bladder scanner to determine the volume in bladder D. Assist the client up to the toilet to attempt to void

D The nurse should first assist the client to a comfortable position to void prior to resorting to other strategies.

Which nursing intervention is most important in preventing postoperative complications? A. Progessive diet planning B. Pain management C. Bowel and elimination monitoring D. Early ambulation

D early ambulation is the most significant general nursing measure to prevent postoperative complications