PERIOP

A nurse is caring for a client who is postoperative following an appendectomy and is prescribed D3 lactated Ringer's at 150mL/hr by continuous IV infusion for 12 hr. The drop factor of the manual IV tubing is 20 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

50

A nurse is caring for a client who is postop following knee arthroplasty and has a new prescription for enoxaparin 1 mg/kg/dose subq every 12 hr. The client weighs 185 lb. How many mg should the nurse administer per dose?

84.1 2.2lb x 185lb 1kg. x x kg

A nurse is caring for a client who is postop following knee arthroplasty and has a continuous passive motion (CPM) machine. Which of the following actions should the nurse take? A. Store the CPM machine on the floor when not in use. B. Use a special pillow to rotate the affected knee internally. C. Set the CPM to fully flex the knee joint. D. Apply ice to the operative knee.

Apply ice to the operative knee. The nurse should apply ice to the client's operative knee to reduce edema postoperatively, which will decrease pain and bruising.

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? A. Raise the head of the client's bed 15° to 20°. B. Place the client supine with knees bent. C. Assess the client for manifestations of shock. D. Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.

Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation. According to evidence-based practice, the nurse should first cover the area with a sterile dressing moistened with normal saline to protect the client's internal organs. The nurse should not attempt to reinsert the client's organs or viscera.

A nurse is assessing a client 1 day postoperative following abdominal surgery. Suddenly the client reports a pulling sensation and pain in his surgical incision. Which of the following actions should the nurse take? A. Have the client lie flat in bed. B. Use sterile gauze to place gentle pressure on the exposed organs. C. Cover the area with saline-soaked sterile dressings. D. Apply an abdominal binder.

Cover the area with saline-soaked sterile dressings. The nurse should cover the wound with a sterile, saline-soaked dressing to keep the exposed organs and tissues moist.

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 2230 the previous evening, and signed the surgical consent 2 days ago. Which of the following is an appropriate nursing action regarding these findings? A. Call the anesthesiologist to sedate the client. B. Notify the surgeon of the client's food and fluid consumption. C. Witness the surgical consent. D. Document the findings in the client's medical record.

Document the findings in the client's medical record. Whenever a nurse collects data from a client, documentation is essential. However, in this case, all these findings are expectations for a client who is preoperative, so there is no need for the nurse to take any action other than documenting.

A nurse is caring for a client who is postop following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus? A. Positive Kernig's sign B. Positive Homan's sign C. Dull, aching calf pain D. Soft, pliable calf muscle

Dull, aching calf pain Dull, aching calf pain is a sign of deep-vein thrombosis. Other manifestations are edema, warmth, and redness in the calf.

A nurse is assessing a client who is 24 hr postop following an open reduction and internal fixation to repair a fracture of the femur. Which of the following assessment findings is an early manifestation of fat embolism syndrome (FES)? A. Dyspnea B. Red-brown petechiae C. Headache D. Agitation

Dyspnea Dyspnea is an early manifestation of FES that occurs due to hypoxemia.

A nurse is caring for a client who is postoperative following hip arthroplasty. The nurse should anticipate which of the following prescriptions for this client? A. Aspirin B. Clopidogrel C. Enoxaparin D. Alteplase

Enoxaparin The nurse should anticipate a prescription for enoxaparin as prophylaxis therapy for venous thromboembolism. Clients following hip arthroplasty are usually on anticoagulants for 3 to 6 weeks after surgery.

A nurse is caring for a client who is postop following an open cholecystectomy. Which of the following actions should the nurse take when caring for the client's JP drain? A. Measure the drainage every hour for the first 8 hr postoperative. B. Secure the drain to the client's bed sheet. C. Expel the air from the JP bulb after emptying to re-establish suction. D. Remove the JP drain when the drainage has ceased, covering the opening with sterile gauze.

Expel the air from the JP bulb after emptying to re-establish suction. With the drainage and the air removed and the bulb tightly closed, the system works to exert gentle negative pressure, facilitating the removal of accumulated fluid from the surgical area.

A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postop. Which of the following surgical procedures places the client at risk for DVT? A. Myringotomy B. Laparoscopic appendectomy C. Hip arthroplasty D. Cataract extraction

Hip arthroplasty

A nurse is caring for a client who is 1 day postop following total hip arthroplasty. It is 0830 and the client is schedule for PT at 0900. Which of the following interventions should the nurse take? A. Encourage the client to use full weight bearing. B. Identify the client's pain level and medicate if needed. C. Teach the client which positions to avoid during PT. D. Perform the client's morning care.

Identify the client's pain level and medicate if needed. The client should have adequate pain medication and pain relief 20 to 30 min before the PT session so he can work effectively with the therapist.

A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect? A. Facial flushing B. Increasing dyspnea C. Decreasing respiratory rate D. Friction rub

Increasing dyspnea The postoperative client is at increased risk for developing atelectasis because of a blunted cough reflex or shallow breathing due to anesthesia, opioids or pain medication. Common manifestations include shortness of breath and pleural pain.

A nurse is providing preop teaching for a client who is scheduled for a gastrectomy. Which of the following information regarding prevention of postop complications should the nurse include in the teaching? A. Teach the client how to use the PCA pump. B. Instruct the client about the use of a sequential compression device. C. Discuss the visitation policy. D. Review the pain scale.

Instruct the client about the use of a sequential compression device. The nurse should instruct the client about the use of a sequential compression device to prevent deep-vein thrombosis, a postoperative complication.

A nurse is assessing a client who has postop atelectasis and is hypoxic. Which of the following manifestations should the nurse expect? A. Bradycardia B. Bradypnea C. Lethargy D. Intercostal retractions

Intercostal retractions 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.

A nurse is preparing to administer nalbuphine to a postop client who is experiencing pain. The nurse should monitor the client for which of the following potential adverse effects of this medication? A. Miosis B. Joint pain C. Diarrhea D. Oliguria

Miosis Adverse effects of nalbuphine include visual disturbances such as miosis, blurred vision, and diplopia.

An AP reports to the nurse that a client who is 3 days postop following an Abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP? A. Change the abdominal dressing. B. Obtain vital signs. C. Palpate for possible bladder distention. D. Observe the incision site.

Obtain vital signs. Obtaining vital signs is a skill within the scope of practice for an AP; therefore, the nurse can delegate this task to the AP.

A nurse is admitting a client to the surgical unit from the PACU following a cholecystectomy. Which of the following assessment is the nurse's priority? A. Bowel sounds B. Surgical dressing C. Temperature D. Oxygen saturation

Oxygen saturation The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to assess the client's oxygen saturation. The nurse should check the client's airway, listen to the client's breath sounds, and check the client's pulse oximetry to assess for respiratory depression.

A nurse is caring for a client who is postop following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postop period? A. Medicate the client for pain. B. Instruct the client on use of crutches. C. Perform neurovascular checks of the extremities. D. the client to perform exercises of the ankle and toes.

Perform neurovascular checks of the extremities. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is the performance of neurovascular checks. These are a vital aspect of care for the client who has a sustained a fracture and should be monitored every hour for the first 24 hr. Circulation can easily become impaired due to constriction, which develops as the extremity swells from edema. This may cause nerve damage and tissue anoxia.

A nurse overhears two AP from the medical-surgical unit discussing a hospitalized client while in the cafeteria. Which of the following is the priority nursing action? A. Quietly tell the APs that this is not appropriate. B. Ask the nurse manager to provide an inservice program about confidentiality to the staff on the unit. C. Complete an incident report. D. Document the occurrence in a personal log.

Quietly tell the APs that this is not appropriate. The nurse has a professional duty to protect the client's confidential information. When using the urgent vs. nonurgent approach to client care, the nurse determines the priority is to stop the APs before there is an additional breach of confidentiality.

A nurse on a medical-surgical unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the AP? A. Wound drainage for culture B. Urine from an indwelling catheter C. Blood for PaCO2 D. Random stool specimen

Random stool specimen The nurse should delegate collection of a random stool specimen to the AP because it does not require the skills of a licensed nurse. However, the nurse, not the AP, should collect a stool specimen if a culture using a sterile swab is required.

A nurse is assisting a provider with a sterile procedure and prepares to pour a solution onto a piece of gauze. Identify the sequence of steps the nurse should follow when pouring the solution.

Remove the bottle cap Place the bottle cap face up on clean a surface. Pick up the bottle with the label facing his palm. Pour 1 to 2 mL into a receptacle. Pour the solution onto the guaze.

A nurse is caring for a client who is postop following abdominal surgery and reports incisional pain. The surgeon has prescribed morphine 4 mg IV bolus every 6 hr as needed. Before administering this medication, the nurse should complete which priority assessment? A. Blood pressure B. Apical heart rate C. Respiratory rate D. Temperature

Respiratory rate The priority action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to evaluate the client's respirations. The respiratory rate is especially important because opioid analgesics like morphine can cause respiratory depression.

A nurse is changing the dressing of client who is 1 week postoperative following abdominal surgery and notes the presence of serisanguineous drainage. The nurse should recognize that this is an indication of which which of the following circumstances? A. Serosanguineous drainage at this time is expected after abdominal surgery. B. Serosanguineous drainage at this time is a manifestation of possible dehiscence. C. Serosanguineous drainage at this time is a manifestation of hemorrhage. D. Serosanguineous drainage at this time is a manifestation of infection.

Serosanguineous drainage at this time is a manifestation of possible dehiscence. Serosanguineous drainage beyond the fifth postoperative day is a manifestation of possible dehiscence and the provider should be notified.

A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? A. Nurse B. Anesthesiologist C. Surgeon D. Surgical suite nurse

Surgeon The health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client. The surgeon who is performing the surgical repair of the fracture would be responsible for obtaining informed consent.

A nurse is caring for a client who is postop. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pain? A. Vital sign measurement B. The client's self-report of pain severity C. Visual observation for nonverbal signs of pain D. The nature and invasiveness of the surgical procedure

The client's self-report of pain severity Because nurses cannot measure pain objectively, it is standard practice to accept that pain is what the client says it is and to intervene accordingly.

A nurse is preparing a client for a hip arthroplasty. For which of the following reasons should the nurse assess the client's vital signs? A. To prevent postoperative hypotension B. To determine how the client will tolerate the procedure C. To assess the client's pain level D. To establish a baseline for postoperative assessment

To establish a baseline for postoperative assessment Preoperative vital signs are assessed in order to establish a baseline for postoperative assessments.

A nurse is assessing a client who is 3 days postop following abdominal surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following should the nurse suspect? A. Ulcerative colitis B. Cholecystitis C. Paralytic ileus D. Wound dehiscence

Ulcerative colitis The nurse should identify ulcerative colitis as a chronic inflammatory condition that primarily affects the rectum. Cholecystitis The nurse should identify cholecystitis as an inflammation of the gallbladder. Paralytic ileus(correct) A paralytic ileus in a postoperative client is indicated by the absence of bowel sounds, abdominal distention, and the client passing no stool or flatus. It is often caused by bowel handling during surgery and opioid analgesic use. Wound dehiscenceThe nurse should identify wound dehiscence as when the edges of the client's wound are no longer intact.

A nurse is assessing a client who is postop following a vaginal hysterectomy. Which of the following findings is a manifestation of DVT? A. Coolness of the leg or legs B. Decreased pedal pulses C. Pain in the ankle and foot D. Unilateral leg edema

Unilateral leg edema Unilateral edema is a manifestation of DVT.

A nurse is preparing a teaching plan for a client who speaks limited English and is scheduled for a surgical procedure. Which of the following guidelines should the nurse plan to use when selecting written educational materials for the client? SATA A. Use culturally diverse materials. B. Use pictures. C. Use materials written at an eighth-grade level. D. Use materials written in the client's spoken language. E. Provide a variety of educational materials.

Use culturally diverse materials is correct. The nurse needs to have knowledge of the client's cultural background and beliefs to show respect to the client and promote understanding. Using culturally diverse materials facilitates learning and adherence. Use pictures is correct. Visual aids, such as pictures, can facilitate understanding and reinforce communication. Use materials written at the eighth-grade level is incorrect. Generally, for an adult learner, written materials should be written at a sixth-grade reading level or lower. Teaching materials should include short words and sentences, large type, and a simple format. Use materials written in the client's spoken language is correct. The nurse should provide materials to the client in her spoken language so that she can review and understand the information. Provide a variety of educational materials is correct. Using a variety of written materials and teaching techniques increases the client's attention to the information, reinforces learning, and offers a mixture of learning opportunities.

A nurse is providing teaching for a client who is postop following below-the-knee amputation. The nurse should instruct the client that which of the following nutrients is necessary for wound healing? A. Vitamin B1 C. Vitamin C D. Folate E. Vitamin E

Vitamin C Vitamin C promotes collagen synthesis, which is essential for wound healing.

A nurse is providing teaching to a group of AP about hand hygiene. Which of the following statements by one of the APs indicates a need for further teaching? A. "As long as I change gloves between clients, it is not necessary to wash my hands." B. "I should wash my hands before I provide client care." C. "I will not wear artificial nails when providing client care." D. "It is acceptable to use alcohol-based hand products after most client contact."

"As long as I change gloves between clients, it is not necessary to wash my hands." While the use of gloves does reduce contamination, it is still necessary to perform hand hygiene between clients. This statement by one of the APs indicates a need for further teaching.

A nurse is preparing to witness informed consent for a client who is preoperative. The client asks the nurse, "Are there other options besides surgery?" Which of the following responses should the nurse make? A. "It is time to sign the consent so your treatment can begin." B. "I would not have this type of surgery if I were you." C. "Have you discussed other treatments with your provider?" D. "I can inform the surgeon you do not want the surgery."

"Have you discussed other treatments with your provider?" The nurse should seek clarification to determine what the client may or may not know about alternatives to the surgical procedure. The nurse should notify the provider about the need to discuss alternatives to surgery if necessary. Informed consent requires that the client is aware of the limitations and alternatives to the procedure.

A nurse is supervising a licensed practical nurse who is providing care to a client who is postop. Which of the following statements by the client requires the nurse to follow up with the PN? A. "I do not know how to make the remote control work." B. "Do you know when I will be going home?" C. "My dressing was changed earlier this morning." D. "I have not received any of my medications today."

"I have not received any of my medications today." Failure to receive prescribed medications in a timely manner can have a negative effect on client outcomes. The nurse should immediately follow up with the PN to determine if medications have been administered and, if not, to learn why. It is possible that the client does not remember receiving medications or that no medications were been prescribed as of this time. Effective supervision requires that any issue that can negatively impact client care is followed up on immediately.

A nurse is providing preop teaching to a client who is to undergo an open bowel resection at 1300 next week. Which of the following statements by the client indicates the need for further teaching? A. "I will be able to eat solid food when I wake up from anesthesia." B. "I will have a glass of juice the morning of my surgery." C. "I understand what risks I can expect with this surgery." D. "I will take time to relax if I get nervous the night before surgery."

"I will be able to eat solid food when I wake up from anesthesia." 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 the nurse removes the tube, the client can start to drink clear liquids and progress to more solid fluids as she is able to tolerate them.

A nurse is teaching a client who is preop how to deep breathing exercises and cough effectively after surgery. Which of the following statements by the client indicates an understanding of the teaching? A. "I'll splint my incision with a pillow to cough." B. "I'll ask for pain medication after I do the exercises." C. "I'll use the incentive spirometer when I can get out of bed." D. "I'll breathe deeply and cough every 4 hours."

"I'll splint my incision with a pillow to cough." The client should use a pillow to splint the incision to reduce the pain and discomfort of coughing.

A nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear anti-embolism stockings during and after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make? A. "They protect your legs and heels from skin breakdown." B. "They help keep you warm after your surgery." C. "They improve your circulation to keep blood from pooling in your legs." D. "They make it easier for you to do leg exercises after your surgery."

"They improve your circulation to keep blood from pooling in your legs." Antiembolism stockings promote venous return from the legs, thus helping to prevent venous thrombosis, also known as clot formation, and peripheral edema.

A nurse is caring for a client who is using a PCA pump for postop pain management. The nurse enters the room to find the client asleep on his partner pressing the button to dispense another dose. Which of following responses should the nurse make? A. "Next time you think he needs more medication, call me and I'll push the button." B. "It's a good idea to help make sure your husband can sleep comfortably." C. "Why do you think your husband needs more medication when he is asleep?" D. "Your husband should decide when more medication is needed."

"Your husband should decide when more medication is needed." The nurse should explain to the client's partner that the client is the only one who should operate the PCA pump. In situations where the client is not able to do so, the provider may authorize a nurse or a family member to operate the pump.

An older adult client is scheduled to have an elective surgical procedure and informs the nurse that she wants to be designated as a "DNR" case. Which of the following responses should the nurse provide? A. "This is a minor procedure; there is no need for this request." B. "You need to let your provider know your wishes after the procedure." C. "You need to discuss your request with the hospital chaplain." D. "Your provider needs to talk with you concerning your request."

"Your provider needs to talk with you concerning your request." The nurse should inform the client that the provider is responsible for consulting with the client and writing a DNR order.

A nurse is preparing to administer meperidine 75 mg IM to a client who reports postoperative pain. Available is meperidine 100mg/mL. How many mL should the nurse administer?

0.8

A nurse on a medical-surgical unit is caring for four clients. Which of the following clients should the nurse expect to experience anticipatory grieving? A. A client who discovers her pain is from appendicitis. B. A client who experiences traumatic amputation of an extremity. C. A client who is in a coma from a traumatic brain injury. D. A client who is diagnosed with metastatic liver cancer.

A client who is diagnosed with metastatic liver cancer. The client who is diagnosed with metastatic liver cancer is terminal and will experience anticipatory grief. Anticipatory grief is preparing and adjusting one's life changes through finalizing connections and taking care of business.

A nurse is admitting a client who has active TB to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client? A. A room with air exhaust directly to the outdoor environment B. A room with another nonsurgical client C. A room in the ICU D. A room that is within view of the nurses' station

A room with air exhaust directly to the outdoor environment A room with air exhaust directly to the outside environment eliminates contamination of other client-care areas. This type of ventilation system is referred to as an airborne infection isolation room.

A nurse is assessing a client who is 2 days postop and auscultates bilateral breath sounds, but absent breath sounds in the bases. The nurse should suspect which of the following postop complications? A. Atelectasis B. Pneumonia C. Pulmonary embolism D. Arterial thrombus

Atelectasis Atelectasis is an incomplete alveolar expansion or collapse. Breath sounds are dull or absent over areas of alveolar collapse.

A nurse is caring for a client who is postop and has a prescription for antiembolic stockings. Which of the following actions should the nurse take? A. Apply the stockings while the client is sitting in a chair. B. Remove the stockings once each day. C. Check the stockings for wrinkles. D. Measure the size of the client's foot.

Check the stockings for wrinkles. The nurse should check the stockings for wrinkles or constriction that can increase the risk for skin breakdown or reduced circulation.

A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions? A. Talking to the client at the bedside B. Administering an intermittent IV bolus medication C. Completing a dressing change D. Administering an IM injection

Completing a dressing change Standard precautions require personal protective equipment when there is a risk of contact with body fluids. A dressing change does present a risk for coming into contact with body fluids.

A nurse is planning preop care for a client who will undergo surgery. Which of the following is the priority action by the nurse? A. Determine what the client knows about the surgery. B. Identify the client's usual coping mechanisms. C. Review the client's current home environment. D. Discuss if family members will assist with postoperative care.

Determine what the client knows about the surgery. The first step in planning preoperative care is to identify the client's learning needs. The nurse does this by determining the client's past experiences with surgery, his current knowledge about the scheduled procedure, and identifying his expectations and fears.

A nurse is planning care for a client who is postop. Which of the following statements about pain management should the nurse consider when implementing client care? SATA A. Use of analgesics will eventually lead to addiction. B. Each client's expression of pain may be different and individualized. C. Patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic range. D. Pain level and pain tolerance can be assessed using a scale from 0 to 10. E. The client will express the feeling of pain both verbally and nonverbally.

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 is caring for a client 8 hr postop following a total knee replacement. Which of the following actions should the nurse take? A. Place a pillow under the affected limb. B. Apply cool compresses to the affected limb every 6 hr. C. Promote bed rest for 5-7 days. D. Encourage increased fluid intake.

Encourage increased fluid intake. Increased fluid intake will prevent dehydration, which can contribute to the development of deep vein thrombophlebitis.

A nurse is planning care for a client who states he is anxious concerning abdominal surgery. Which of the following actions should the nurse take? A. Explain to the client that all patients feel that way prior to surgery. B. Suggest the client talk to the provider. C. Ask the client what to expect tomorrow. D. Encourage the client to express negative emotions.

Encourage the client to express negative emotions. The nurse is acknowledging the client's negative emotions, therefore providing open therapeutic communication.

A nurse is developing a plan of care for a client who os postop. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? A. Perform range-of-motion exercises B. Place suction equipment at the bedside C. Encourage the use of an incentive spirometer D. Administer an expectorant

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

A nurse is assessing a client who is postop and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect? A. Fatigue B. Hypertension C. Bradycardia D. Diarrhea

Fatigue The nurse should identify that the client who has anemia due to blood loss following surgery will experience fatigue. This is due to the body's decreased ability carry oxygen to vital tissues and organs

A nurse is preparing a sterile field prior to inserting a urinary catheter for a client. Identify the sequence of steps the nurse should plan to follow. perform hand hygiene place package on work surface open outermost flap away from self open side flap, pulling to the side open innermost flap toward self use inner surface of package as sterile field

First, the nurse should perform hand hygiene. Hand hygiene reduces the number of micro-organisms on the skin and prevents the spread of micro-organisms to the sterile field. Next, the nurse should place the package on a flat, clean, dry work surface above waist level. Next the nurse should open the outermost flap away from herself. The nurse should open the outermost flap by first grasping the tip of the flap. The nurse should keep her arms outstretched and away from her body. The nurse should then open the side flap, pulling it to the side. The nurse should grasp the outside surface of the edge of the first side flap and allow the flap to lie flat on the table surface. The nurse should keep her arms to the side and not over the sterile surface. Repeat these steps for the second side flap. The nurse should not allow flaps to spring back onto the sterile items. Next, the nurse should open the innermost flap toward herself. The nurse should grasp the outside border of the last innermost flap. It should fall flat and not spring back onto the sterile items. Finally, the nurse should use the inner surface of package as a sterile field. The sterile package will contain sterile items.

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? A. Mouth breathing B. Frequent swallowing C. Reports of thirst D. Reports of pain

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

A nurse is caring for a client 1 day postop who has developed atelectasis. Which of the following manifestations is an expected finding for this condition? A. Apnea B. Dysphagia C. Hypoxemia D. Pleural effusion

Hypoxemia The nurse can expect to find the client with hypoxemia, which is decreased oxygenation of the red blood cells and cyanosis due to poor oxygen exchange.

A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? A. Document what the nurse believes was the cause of ulcer development. B. Include any relevant statements the client made about the ulcer. C. Document in the client's medical record that she completed an incident report. D. Question the charge nurse about care deficits that might have contributed to the ulcer's development.

Include any relevant statements the client made about the ulcer. The nurse should document any relevant statements the client makes about the ulcer and use quotation marks to indicate that they are the client's words and not the nurse's.

A nurse is caring for a client who is postoperative and is at risk for developing VTE. The nurse should instruct the client to avoid which of the following unsafe actions? A. Elevating her feet B. Massaging her legs C. Flexing her ankles D. Ambulating soon after surgery

Massaging her legs Massaging an extremity that has a blood clot can cause it to detach and become an embolus. The use of sequential compression devices and antiembolic stockings and therapeutic anticoagulation can help prevent this postoperative complication.

A nurse on a medical-surgical unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer? A. Delivering meal trays to clients in their rooms B. Assisting a client who has difficulty seeing the foods on the tray while eating C. Delivering a routine urine specimen to the laboratory D. Observing a postoperative client who is confused

Observing a postoperative client who is confused A nurse who uses delegation is responsible for delegating tasks to the right person. A volunteer does not have the training to intervene if this client tries to get out of bed or starts pulling at tubes. The observation of this client should be assigned to a member of the nursing staff.

A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postop following a partial bowel resection, requires a dressing change, total parental nutrition administration and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first? A. Weigh the second client. B. Obtain vital signs for both clients. C. Administer pain medication to the first client. D. Change the dressings of both clients.

Obtain vital signs for both clients. = Using the nursing process as an organizing framework, the nurse should obtain vital signs on the two clients to determine if there are any emergent problems.

A nurse is caring for a client who is 1 day postoperative following hip open reduction with internal fixation. The client is scheduled to begin physical therapy in 30 min. Which of the following actions should the nurse take? A. Position the client's legs in an adducted position. B. Offer to administer analgesia. C. Tell the client to bend forward at the waist when getting out of bed. D. Bathe and dress the client

Offer to administer analgesia. The nurse should offer to premedicate the client prior to painful procedures, such as physical therapy, to help keep pain under control.

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning? A. Hypoactive bowel sounds in two quadrants B. Request for a cup of tea and some toast C. Passage of flatus D. Abdominal distention

Passage of flatus Passing flatus and belching indicate the return of peristaltic activity.

A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take? A. Prevent aspiration. B. Ensure adequate nutrition. C. Promote oral hygiene D. Relieve the client's pain.

Prevent aspiration. When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority goal is to prevent the client from aspirating. Because the client's jaws are wired together, aspiration of emesis is a possibility. Therefore, the client should be given medication for nausea, and wire cutters should be kept at the bedside in case of vomiting.

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's O2 is 85%. Which of the following actions should the nurse take first? A. Administer oxygen at 2 L/min. B. Administer prescribed analgesic medication. C. Encourage coughing and deep breathing. D. Raise the head of the bed.

Raise the head of the bed. Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head and neck can be extended, which promotes a patent airway. This is the first action the nurse should take and is the least invasive.

A nurse is working with an AP while caring for a surgical client who is 1 day postop. Which tasks should the nurse take responsibility for completing? A. Measuring vital signs B. Removing the abdominal dressing C. Helping the client into the shower D. Ambulating the client in the hallway

Removing the abdominal dressing The nurse cannot delegate assessment, diagnosis, planning, or evaluation because these are steps of the nursing process that require nursing judgment. When removing an abdominal dressing, the nurse should assess the surgical wound and determine if any further action is needed. This could include notifying the provider and using sterile technique to complete a dressing change

A nurse is monitoring a client who is postop and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? SATA A. Restlessness B. Grimacing C. Moaning D. Clenching E. Drowsiness

Restlessness Grimacing Clenching

A nurse is assisting a provider with a sterile procedure and prepares to pour solution onto a piece of sterile gauze. In what order should the nurse perform the following steps when pouring sterile soutions?

The nurse should first perform hand hygiene before assisting with the procedure as part of medical asepsis to reduce the growth and transmission of infectious agents. The nurse should then remove the bottle cap carefully to avoid touching inside the cap and the bottle, because these areas are sterile. After removing the cap, the nurse should place it with the inside of the cap face-up on a clean surface, because it is sterile on the inside. The nurse should pick up with the label against the palm of the hand This prevents the solution from running down the side of the bottle, which may damage the label. The nurse should then pour 1 to 2 mL of solution into a receptacle to be discarded. This cleans the inside lip of the bottle. The final step is to pour the solution onto the sterile gauze. The nurse should not hold the bottle over the sterile field. Make sure the lip of the bottle does not come into contact with the sterile gauze. Hold the bottle high enough to avoid splashing of the solution.

A nurse is reviewing the diagnostic test results for an older adult female client who is preop for a knee arthroplasty. The nurse should notify the surgeon of which of the following results? A. WBC count 20,000/mm3 B. Hematocrit 40% C. Creatinine 0.9 mg/dL D. Potassium 3.8 mEq/L

WBC count 20,000/mm3 This result exceeds the expected reference range for WBC of 5,000 to 10,000/mm3. The client's elevated WBC count indicates infection. The nurse should notify the surgeon.

A nurse is teaching a client who is preop for colectomy. The client asks the nurse why he needs a large-bore NG tube. Which of the following statements should the nurse make? A. "The tube is a routine standard following this type of surgery." B. "The tube will allow us to provide you with nutrition." C. "The tube will remove gas and fluid from your stomach." D. "The tube can be explained to you once you are stable after surgery."

"The tube will remove gas and fluid from your stomach. "The nurse should inform the client that the NG tube will decompress the stomach of gas and fluid in order to allow the bowel to rest.

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? A. Increase ambulation. B. Decrease fluid intake. C. Increase protein intake. D. Offer the client the bedpan every 2 hr.

Increase ambulation. Decreased bowel motility is an adverse effect of anesthesia. The nurse should encourage the client to ambulate and increase fiber intake as prescribed to promote a return of bowel function and reduce the risk for paralytic ileus.

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 A. Poor nutritional state B. Altered mental status C. Obesity D. Pain medication administration E. Wound infection

Poor nutritional state is correct. A client who is in a poor nutritional state is at risk for dehiscence due to impaired healing. Altered mental status is incorrect. Altered mental status is not a risk factor for dehiscence. Obesity is correct. A client who is obese is at risk for dehiscence due to poor healing abilities of adipose tissue and the constant strain placed on the incision. Pain medication administration is incorrect. A client who is taking pain medication is not at risk for dehiscence. Wound infection is correct. A client who has a wound infection is at risk for dehiscence due to delayed healing.

A nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP). The nurse should plan to administer the client's PRN bethanechol when the client reports which of the following manifestations? A. Bladder spasms B. Severe pain. C. An inability to void D. Frequent episodes of painful urination

An inability to void Bethanechol is a cholinergic medication that stimulates the parasympathetic nervous system, thus improving the tone and motility of the smooth muscles of the urinary tract enough to initiate urination.

A nurse is caring for a client who is postop following abdominal surgery. The nurse discovers a loop of bowel through an opening in the surgical incision. Which of the following actions should the nurse take? A. Place the head of the client's bed in the flat position. B. Gently reinsert the bowel back into the client's wound. C. Apply moistened sterile gauze to the site. D. Position the client on his left side.

Apply moistened sterile gauze to the site. The nurse should apply moistened sterile gauze to the site to reduce the risk for further injury and infection.

A nurse is caring for a client who is postop following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the client? SATA A. Broth B. Grape juice C. Nonfat milk D. Custard E. Lemon gelatin

Broth is correct. Fat-free broth is an acceptable component of a clear liquid diet. Coffee and tea are also acceptable. Grape juice is correct. Grape juice is an acceptable component of a clear liquid diet, along with apple juice and cranberry juice. Nonfat milk is incorrect. Nonfat milk is an acceptable component of a full liquid diet, not a clear liquid diet. Custard is incorrect. Custard is an acceptable component of a full liquid diet, not a clear liquid diet. Lemon gelatin is correct. Lemon gelatin is an acceptable component of a clear liquid diet, along with sugar, honey, hard candy, and ice pops.

A nurse is caring for a client who is preoperative. The nurse signs as a witness on the client's consent form. The nurse's signature on the consent form indicates which of the following? A. Determines the client does not have a mental illness B. Confirms the client appears competent to provide consent C. Asserts the nurse has explained the risks and benefits of the procedure D. Records that the client's spouse agrees the procedure is necessary

Confirms the client appears competent to provide consent By signing as a witness on a procedural consent form, the nurse is confirming the client was the one who signed the consent form and that he seems to be competent to give consent

A nurse is caring for an older adult client who has had surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following interventions should the nurse include in the client's postop plan of care? SATA A. Discontinue suction when assessing for peristalsis B. Irrigate the NG tube with 0.9% sodium chloride irrigation solution. C. Place sequential compression devices on the bilateral lower extremities. D. Reposition the client from side to side every 2 hr. E. Encourage the use of an incentive spirometer every 2 hr while the client is awake.

Discontinue suction when assessing for peristalsis is correct. The nurse should turn off suction while auscultating the abdomen to determine the return of peristalsis because the suction masks any present bowel sounds. Irrigate the NG tube with 0.9% sodium chloride irrigation solution is correct. The client requires the NG tube for gastric decompression, so the nurse must make sure it remains patent. Irrigating the NG tube with normal saline irrigation solution every 4 hr will ensure patency. Place sequential compression devices on the bilateral lower extremities is correct. Sequential compression devices improve blood flow for clients who have mobility limitations and help prevent venous thromboembolism in the lower extremities. Reposition the client from side to side every 2 hr is correct. The nurse should reposition the client from side to side at least every 2 hr but should also assist with early ambulation to improve ventilation and help mobilize secretions. Encourage the use of an incentive spirometer every 2 hr while the client is awake is incorrect. Use of the incentive spirometer helps prevent atelectasis. The client should use the device each hour while awake

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? A. Aspirin PO B. Enoxaparin subcutaneous C. Heparin infusion D. Warfarin PO

Enoxaparin subcutaneous

A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. During transport to the facility, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the client's family. Which of the following actions should the nurse anticipate the neurosurgeon taking? A. Invoking implied consent B. Delaying the surgery until a member of the client's family is reached C. Asking the client to sign the surgical consent form D. Prescribing naloxone to reverse the effects of the morphine

Invoking implied consent The client is unable to sign the consent form because he is sedated from the morphine. The neurosurgeon has the legal right to invoke implied consent and proceed with the surgery if it is determined an emergency and surgery is in the client's best interest. The neurosurgeon should document the specifics of the situation in the client's medical record.

A nurse is caring for a client who is postop following a cholecystectomy and reports pain. Which of the following actions should the nurse take? SATA A. Offer the client a back rub. B. Remind the client to use incisional splinting. C. Identify the client's pain level. D. Assist the client to ambulate. E. Change the client's position.

Offer the client a back rub is correct. Nonpharmacological comfort measures can improve pain management. Remind the client to use incisional splinting is correct. Holding a pillow against the incision when moving, turning, or coughing can help the client with self-management of pain. Identify the client's pain level is correct. The nurse should use a standard scale to determine and document the severity of the client's pain. Assist the client to ambulate is incorrect. If the client reports pain, the nurse should implement interventions to manage the pain, such as administering analgesia and giving it time to take effect, before assisting the client to ambulate. Change the client's position is correct. Nonpharmacological measures for managing pain include repositioning, imagery, and distraction.

A nurse is providing care for a client who is 2 days postop following abdominal surgery and is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray? A. Cranberry juice B. Flavored gelatin C. Skim milk D. Chicken broth

Skim milk Full liquids include milk and milk products, so the client may now ask for skim milk.

A nurse is developing a plan of care for a client who is 12 hr postop following colon resection. Which of the following interventions should the nurse include in the plan to reduce respiratory complications? A. Use incentive spirometer every 4 hr while awake. B. Initiate ambulation after discontinuing the NG tube. C. Maintain supine position with abdominal binder. D. Splint the incision to support coughing every 2 hr.

Splint the incision to support coughing every 2 hr. Breathing exercises include deep or diaphragmatic breathing to enlarge the chest cavity and expand the lungs. Coughing and splinting may be performed also with deep breathing every 1 to 2 hr after surgery. The purposes of coughing are to expel secretions, keep the lungs clear, allow full aeration, and prevent pneumonia and atelectasis.

A nurse is planning to perform a sterile dressing change for a client. Which of the following actions should the nurse plan to take? A. Hold gauze packages 7.6 cm (3 in) above the sterile field. B. Place sterile supplies within the 2.54 cm (1 in) border of the sterile field. C. Use sterile forceps to move the sterile items on the sterile field. D. Position the wrapped package on the bedside table so the outer flap opens towards her

Use sterile forceps to move the sterile items on the sterile field. A sterile object remains sterile only if the nurse touches it with another sterile object. This principle guides the nurse in placement of sterile objects and how she should handle them such as using sterile forceps or wearing sterile gloves to handle objects on a sterile field.

A nurse is caring for four clients on a medical-surgical unit. Which of the following clients should the nurse assess first? A. A client who has a nasogastric tube for decompression and the gastric aspirate is green with a pH of 5.3 B. A client who had an indwelling urinary catheter removed 5 hr ago and has not voided C. A client who has COPD and the capillary refill time on both hands is 4 seconds D. A client who has late-stage cirrhosis and whose breath has a fruity odor

A client who had an indwelling urinary catheter removed 5 hr ago and has not voided After removal of an indwelling urinary catheter, the client should void within 4 hr. If the client has not voided in 4 hr, the nurse may need to reinsert the catheter; therefore, when using the priority-setting framework of urgent vs. nonurgent, this client should be assessed first because he has not voided for 5 hr.

A nurse is assessing four clients on a surgical unit. Which of the following clients should the nurse care for first? A. A client who has diarrhea and requests clear liquids for breakfast B. A client who has a cast on the left leg and reports numbness and paresthesia C. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150 D. A client who has pneumonia and has an axillary temperature of 38° C (101° F)

A client who has a cast on the left leg and reports numbness and paresthesia The client who has a cast is at risk for acute compartment syndrome (ACS). Numbness and paresthesia are manifestations of ACS; therefore, when using the airway, breathing, circulation (ABC) approach to client care, the nurse should care for this client first.

A nurse is caring for four postop clients. The nurse can delegate obtaining vital signs to an AP for which of the following clients? A. A client who is 1 hr postoperative following a thyroidectomy B. A client who is 2 hr postoperative following an abdominal hysterectomy C. A client who is 3 days postoperative following gastric bypass surgery D. A client who is 3 days postoperative following a craniotomy

A client who is 3 days postoperative following gastric bypass surgery The client's physiologic status and stability of vital signs are considerations when assigning vital signs to an AP. This client is 3 days postoperative and his condition would have stabilized by this time.

A nurse is providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? A. A client who is ambulatory following a cardiac catheterization 4 hr ago B. A client who has type1 diabetes mellitus and is hyperglycemic C. A client who has protein calorie malnutrition D. A client who has right-sided heart failure and 4+ edema to the lower extremities E. A client who has postoperative delirium

A client who is ambulatory following a cardiac catheterization 4 hr ago is incorrect. Because this client is ambulatory, there is no identified risk for the development of a pressure ulcer. A client who has type1 diabetes mellitus and is hyperglycemic is incorrect. The nurse should identify the client who has hyperglycemia as being at risk for long-term complications such as renal failure. However, this client has no identified risk for the development of a pressure ulcer. A client who has protein calorie malnutrition is correct. A client who has poor nutritional status is at risk for the development of pressure ulcers. A client who has right-sided heart failure and 4+ edema to the lower extremities is correct. A client who has poor skin perfusion resulting from a condition such as peripheral edema is at risk for the development of pressure ulcers. A client who has postoperative delirium is correct. A client who has a decreased level of consciousness, such as delirium, is at risk for the development of pressure ulcers.

A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients? A. A client who is postoperative following a lobectomy and has a chest tube B. A client who is being discharged to a long-term care facility C. A client who needs teaching about insulin self-administration D. A client who needs teaching prior to initiating cardiac rehabilitation activities

A client who is postoperative following a lobectomy and has a chest tube According to evidenced-based practice, the nurse from the PACU is most qualified to care for the postoperative client. Nurses in the PACU care for clients with chest tubes after surgery. This is the right client, the right task, and the right circumstances for this nurse.

A nurse is caring for four clients who are postop from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority? A. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous C. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg

A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg A client who is postoperative is at risk for hemorrhage. A blood pressure decrease of 15 to 20 points is significant. This client is unstable; therefore, this client is the nurse's priority.

A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall? A. An older adult client who is confused and has urinary frequency B. A client with diabetes mellitus who has a leg ulcer C. A client who is 1 day postoperative and has a nursing assistant helping him out of bed D. An adolescent client who has a leg fracture and has been using crutches for the past 2 days

An older adult client who is confused and has urinary frequency An older adult client who is confused and has urinary frequency is at the greatest risk for a fall because this client might attempt to go to the bathroom without assistance. The nurse should implement interventions to prevent a fall, such as using a bed alarm, and placing the client close to the nurses' station.

A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first? A. Determine the time the client last received pain medication. B. Measure the client's vital signs, including temperature. C. Ask the client to rate her pain on a scale from 0 to 10. D. Reposition the client and offer her a back rub.

Ask the client to rate her pain on a scale from 0 to 10. Using evidence-based practice, the nurse should first determine the severity of the client's pain by using a standard pain scale. Then the nurse can plan the appropriate interventions.

A nurse on a surgical unit is caring for a group of clients. Which of the following is the priority action of the nurse? A. Assessing a client who experiences unilateral calf pain when ambulating B. Reinforcing a client's dressing for the surgical site of an above-the-knee amputation C. Reassuring the partner of a client who sustained a closed head injury D. Taking a telephone prescription about a client who is to be transferred from PACU

Assessing a client who experiences unilateral calf pain when ambulating When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority action is assessing a client who has manifestations of a deep vein thrombosis, which can lead to pulmonary embolus. The nurse should assess this client and report the findings immediately to the provider.

A nurse on a medical-surgical unit is preparing to contact a provider about a client's condition. The client is 6 hr postop from a total hysterectomy. The nurse notes the client's postop oxygen saturation is 94% and her apical heart rate is 110. The nurse should include information about the client's oxygen saturation level and heart rate in which component of the SBAR report? A. Situation B. Background C. Assessment D. Recommendation

Assessment The nurse should include his assessments in this level of the report. For example, the client's oxygen saturation level and the client's apical heart rate. The nurse can also include the amount of vaginal bleeding and the appearance of the wound dressing.

A nurse is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care? SATA A. Assist the client to cough and deep breathe every hour. B. Administer PRN analgesics as needed. C. Encourage the client to turn every 4 hr. D. Give the client a back massage. E. Teach the client relaxation techniques

Assist the client to cough and deep breathe every hour is correct. Hourly coughing and deep breathing increases lung expansion and clears mucus to reduce the risk for pneumonia and atelectasis. Administer PRN analgesics as needed is correct. The nurse should assess and monitor the client for pain and administer PRN analgesics as needed. Encourage the client to turn every 4 hr is incorrect. The nurse should encourage the client to turn side to side every 2 hr to increase lung expansion and to reduce the risk for atelectasis and pneumonia. Give the client a back massage is correct. Massage is effective for producing physical and mental relaxation, reducing pain, and enhancing the effectiveness of pain medication. A back massage will promote sleep and comfort. Teach the client relaxation techniques is correct. Relaxation techniques, such as meditation, yoga, guided imagery, and deep breathing, alter cognitive pain perception. Relaxation techniques promote a sense of well-being and diminish stress.

A nurse is preparing to remove staples from a client's surgical incision. Which of the following actions should the nurse take? SATA A. Assure the client there will be no discomfort during the procedure. B. Clean the surgical site. C. Lift the staple remover when squeezing the handle. D. Examine the incision. E. Verify the prescription for staple removal.

Assure the client there will be no discomfort during the procedure is incorrect. The nurse should inform the client that removal of the staples cab cause stinging or a burning sensation as the staples are being removed. Clean the surgical site is correct. The nurse should clean the surgical site prior to removing the staples in order to effectively examine the site for redness, drainage, and approximation. Cleaning the incision also assists in removing dried drainage from the staples and incision that can cause increased discomfort when the staples are removed. Lift the staple remover when squeezing the handle is incorrect. When removing the staples, the nurse should press the handles together so they are completely closed. This causes the staple to bend in the middle, pulling the edge of the staple out of the skin. Lifting the staple remover when squeezing the handle could cause increased pain and skin trauma. Examine the incision is correct. The nurse should examine the skin edges for approximation, or closed edges, which are clean and intact prior to removing the staples. If the nurse notes the wound is not healing well, meaning edges are not approximated or intact, the nurse should notify the provider before removing any staples. Verify the prescription for staple removal is correct. The nurse should review the prescription for staple removal prior to initiating this procedure. In some instances, the prescription will indicate to remove every other staple, with the remaining staples to be removed a day or two later.

A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority? A. Request a prescription for a medication to ease the client's anxiety. B. Irrigate the NG tube with 100 mL of sterile water. C. Check to see if the suction equipment is working. D. Remove and reinsert the NG tube.

Check to see if the suction equipment is working. The first action the nurse should take using the nursing process is to assess the situation. The nurse should check for the most obvious reason why the client's symptoms have returned. If the suction equipment has malfunctioned, the nurse should adjust it or replace it with working equipment.

A nurse is assessing a client who has had staples removed from an abdominal wound postop. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? A. Check the client's vital signs. B. Assess the client's pain level. C. Cover the wound with a moist, sterile gauze dressing. D. Obtain a culture and sensitivity of the wound drainage.

Cover the wound with a moist, sterile gauze dressing. The client's wound has dehisced, or opened along the suture line, and is now draining. The primary clinical objective in managing a dehisced wound is to keep it clean and moist, and manage any exudate. The nurse's priority action therefore is to cover the wound with a moist, sterile, saline-soaked gauze dressing.

A nurse is assessing a client who is postop and finds the client's abdominal incision has eviscerated. Which of the following actions should the nurse take? A. Cover the wound with a sterile saline-soaked dressing. B. Place the client in high-Fowler's position. C. Auscultate all quadrants of the abdomen for bowel sounds. D. Gently reinsert the protruding tissue.

Cover the wound with a sterile saline-soaked dressing. The nurse should cover an eviscerated wound with sterile saline-soaked gauze to prevent damage and infection.

A nurse is caring for a client who is postop following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray? A. Lemon sherbet B. Plain yogurt C. Cranberry juice D. Carrot juice

Cranberry juice Cranberry juice is an acceptable component of a clear liquid diet, along with apple juice and grape juice

A nurse is caring for a client who requires removal of surgical sutures. Which of the following actions should the nurse take? A. Remove sutures by starting in the middle of the wound and working outward. B. Cut the suture as close to the skin as possible. C. Remove the sutures using clean bandage scissors. D. Apply clean gloves prior to beginning the suture removal.

Cut the suture as close to the skin as possible. The nurse should grasp the surgical knot with tweezers and gently lift while cutting below the suture knot. To avoid contamination, the nurse should never pull the visible portion of a suture through underlying tissue. The part of the sutures that is exposed on the skin surface harbors micro-organisms and debris and pulling the contaminated portion of the suture through the tissue can lead to infection.

A nurse is caring for a client who has a postop ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for? A. Elevated sodium level B. Decreased potassium level C. Elevated magnesium level D. Decreased calcium level

Decreased potassium level Hypokalemia is an electrolyte imbalance in which the serum potassium level is less than 3.5 mEq/L. Hypokalemia may be the result of diuretic use, diarrhea, vomiting, and prolonged nasogastric suctioning.

A nurse is caring for a group of clients on a medical-surgical unit. Which of the situations requires that the nurse wear gloves? SATA A. Emptying urine from an indwelling urine collection bag B. Providing oral care C. Changing an ostomy pouch D. Delivering a food tray to a client who has AIDS E. Placing oral medication tablets into a client's hand

Emptying urine from an indwelling urine collection bag is correct. Standard precautions indicate that the nurse should wear gloves when in direct contact with bodily fluids. Providing oral care is correct. Standard precautions indicate that the nurse should wear gloves when in direct contact with bodily fluids or mucous membranes. Changing an ostomy pouch is correct. Standard precautions indicate that the nurse should wear gloves when in direct contact with bodily fluids or excretions. Delivering a food tray to a client who has AIDS is incorrect. Standard precautions indicate that the nurse does not have to wear gloves unless in direct contact with bodily fluids, nonintact skin, mucous membranes or contaminated items. Delivering food trays to clients is not included in standard precautions. Placing oral medication tablets into a client's hand is incorrect. Standard precautions indicate that the nurse does not have to wear gloves unless in direct contact with bodily fluids, nonintact skin, mucous membranes or contaminated items. Administering medications to a client is not included in standard precautions.

A nurse is obtaining informed consent from a client who is preop. Which of the following actions should the nurse take? SATA A. Establish that the client is able to pay for the surgical procedure. B. Explain the surgical procedure to the client. C. Validate the signature is authentic. D. Verify the client understands the surgical procedure. E. Confirm that the consent is voluntary.

Establish that the client is able to pay for the surgical procedure is incorrect. The client's ability to pay for the procedure is not required prior to obtaining an informed consent. Explain the surgical procedure to the client is incorrect. It is the surgeon's responsibility to explain the procedure to the client. Validate the signature is authentic is correct. The nurse must validate the signature on the consent is made by the client or the client's legal guardian. Verify that the client understands the surgical procedure is correct. The nurse should verify the client understands the procedure and the risks. Confirm that the consent is voluntary is correct. The nurse should confirm the client is giving voluntary consent without coercion.

A nurse is caring for a client on the medical-surgical unit. The client has been taking warfarin at home and her lab values reveal her INR is 3.5. The client states she is checking her self out of the hospital and refuses to wait until her provider can discuss the situation with her. Which of the following actions should the nurse take? A. Tell the client she will not be permitted to leave the facility until she has signed the against medical advice (AMA) form. B. Tell the client if she leaves without a written prescription for discharge, her insurance will not pay for the facility visit. C. Explain the risk the client faces if she leaves the facility. D. Ask the security department to guard the room to the client's door.

Explain the risk the client faces if she leaves the facility. The expected reference range for INR while a client is taking warfarin is 2 to 3.The nurse has an obligation to explain to the client that her INR is very high and she is at risk for bleeding.

A nurse is caring for a client who is two days postop following creation of an ileal conduit. Which of the following is an unexpected finding associated with this procedure? A. Edema of the stoma B. Urine in the drainage appliance C. Redness of the stoma D. Feces in the drainage appliance

Feces in the drainage appliance Feces in the drainage appliance is an unexpected finding associated with this procedure. The ileal conduit procedure incorporates implantation of the ureters into a portion of the ileum that has been resected from its anatomical position and now functions as a reservoir or conduit for urine. Feces should not be draining from the conduit.

A nurse is providing discharge instructions to a client who developed DVT postop and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include? A. Applying cool compresses to her legs B. Wearing loose, non-constricting stockings C. Flexing her knees and feet frequently D. Taking an NSAID tablet daily

Flexing her knees and feet frequently = Leg, ankle, and foot exercises can help improve circulation and prevent venous stasis while the client is resting.

A nurse on a medical-surgical uni is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is SOB. The nurse should anticipate which of the following assessment findings for this client? A. Respiratory alkalosis B. Increased anteroposterior diameter of the chest C. Oxygen saturation level 96% D. Petechiae on chest

Increased anteroposterior diameter of the chest The nurse should anticipate an increased anteroposterior diameter of the chest (barrel chest) because of chronic hyperinflation of the lungs.

A nurse is reviewing the lab results of a client who is postoperative. Which of the following lab findings should the nurse identify as an indication of postoperative infection? SATA A. Increased band neutrophils B. Elevated erythrocyte sedimentation rate C. Absence of ketones in urine D. Negative leukocyte esterase in urine E. Increased hemoglobin

Increased band neutrophils is correct. Neutrophils, a type of white blood cell, protect the body from bacterial invasion through phagocytosis. The expected reference range for mature neutrophils is 2,500 to 8,000/mm3. In cases of infection, however, neutrophils are unable to keep up the body's defenses and the bone marrow releases immature neutrophils, called band cells or band neutrophils. This imbalance of immature neutrophils outnumbering mature neutrophils is termed bandemia. Elevated erythrocyte sedimentation rate is correct. The erythrocyte sedimentation rate measures the rate at which red blood cells settle in plasma over a specific time period. An increased rate, which means the red blood cells are settling faster than expected, can indicate an acute or chronic infection. Absence of ketones in urine is incorrect. Ketones are the end product of the breakdown of fatty acids and are present in urine when a client has poorly controlled diabetes in conjunction with hyperglycemia. Negative leukocyte esterase in urine is incorrect. Leukocyte esterase is an enzyme found in white blood cells. Their presence in a urinalysis indicates an infection in the urinary tract. Increased hemoglobin is incorrect. Hemoglobin is a molecule produced by the red blood cells for the purpose of carrying oxygen to the cells of the body. An increase in hemoglobin level in a client who is postoperative mostly likely indicates dehydration. Typically, a client who is postoperative will have a decreased hemoglobin level due to blood loss that occurred during surgery.

A nurse working on a surgical unit receives a phone call from a client's neighbor who requests a postop update of the client's condition. Which of the following actions by the nurse is appropriate? A. Provide the neighbor with a brief statement about the client's condition. B. Inform the neighbor that you do not have information about the client. C. Suggest that the neighbor call the client's health care provider for the information. D. Transfer the neighbor's call to the telephone in the client's hospital room.

Inform the neighbor that you do not have information about the client. Informing the neighbor that you do not have any information about the client upholds the client's rights under the federal legislation known as the Health Insurance Portability and Accountability Act (HIPAA), which mandates the protection of personal health information. The nurse should avoid making a statement verifies that the neighbor is a client in the facility.

A nurse is providing preop teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration? A. Place her hands on the sides of her rib cage. B. Inhale slowly and evenly through her nose. C. Hold her breath for at least 10 seconds. D. Exhale forcefully through the nose.

Inhale slowly and evenly through her nose. The nurse should inhale slowly and evenly through her nose until chest expansion is maximized

A nurse is planning postop care for a client who is scheduled for an ileal conduit procedure. The nurse should include which of the following in the client's plan of care? SATA A. Notify the provider immediately if mucus is present in the urine. B. Maintain the client on a fluid restriction. C. Apply skin barrier around the stoma site. D. Educate the client that hematuria is expected following the procedure. E. Monitor hourly urine output.

Notify the provider immediately if mucus is present in the urine is incorrect. Mucus in the urine is an expected finding following an ileal conduit procedure. Maintain the client on a fluid restriction is incorrect. Fluids should be encouraged following an ileal conduit procedure to flush the ileal conduit. Apply skin barrier around the stoma site is correct. Applying skin barrier around the stoma site is appropriate following an ileal conduit procedure to help prevent skin breakdown. Educate the client that hematuria is expected following the procedure is correct. Hematuria is an expected finding during the first 48 hr following an ileal conduit procedure. Monitor hourly urine output is correct. Monitoring hourly urine output is appropriate following an ileal conduit procedure ensure adequate urine output and provide for early detection of a blockage

A nurse is teaching a newly hired group of AP about infection-control measures on the unit. It is crucial for the nurse to remind the APs that which of the following is the most effective way to prevent the spread of pathogens during client care? A. Properly disposing of contaminated equipment B. Discarding used syringes in appropriate containers C. Changing soiled linens daily for clients who have draining wounds D. Performing hand hygiene frequently and consistently

Performing hand hygiene frequently and consistently The greatest risk to all clients and staff on the unit is infection from cross contamination; therefore, the priority action is hand hygiene. It is one of the most important and effective ways to prevent pathogen transmission. It applies to every health care setting and is a consistent imperative during client care.

A nurse in a long-term care facility is observing an AP changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control? A. Shakes the soiled linen to remove any toilet paper remnants B. Places the soiled linen on the floor before bagging it C. Holds the soiled linen against her body while carrying it to the linen bag D. Places clean linen that touched the floor in the soiled linen bag

Places clean linen that touched the floor in the soiled linen bag Linen that touches the floor or the AP drops requires laundering.

A nurse in a PACU is admitting a client who is postoperative following a tonsillectomy. Which of the following actions should the nurse plan to take to prevent aspiration? A. Place a bedside humidifier at the head of the client's bed. B. Suction the nasopharynx as needed. C. Withhold fluids until the client demonstrates a gag reflex. D. Perform chest physiotherapy.

Withhold fluids until the client demonstrates a gag reflex. Following a tonsillectomy, the client's gag reflex can be suppressed by local anesthetics or edema. To prevent aspiration, the gag reflex must be present before the client is allowed have fluids.

A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take 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. Explain the procedure to the client if they do not understand.

Witness the client's signature. 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.

A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider? A. Blood pressure 102/66 mm Hg B. Straw-colored urine from an indwelling urinary catheter C. Yellow-green drainage on the surgical incision D. Respiratory rate 18/min

Yellow-green drainage on the surgical incision Thick yellow-green drainage is indicative of an infection and should be reported immediately.