PrepU ML Quiz Ch 19

A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse? A. Position the client in the side-lying position. B. Administer an anti-emetic. C. Ask the client for more clarification. D. Obtain an emesis basin.

A

A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem? A. Pink color B. Copious red blood in the sputum C. Foul smell D. Pieces of vomitus

A

A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first? A. Moisten sterile gauze with normal saline and place on the protruding organ. B. Place a dry, sterile dressing over the protruding organs. C. Place a pressure dressing over the opening and secure. D. Have the client lay quietly on back and call the physician.

A

A significant mortality rate exists for patients with alcoholism who experience delirium tremens postoperatively. When caring for the patient with alcoholism, the nurse should assess for symptoms of alcoholic withdrawal: A. On the second or third day. B. 4 days after surgery. C. Within the first 12 hours. D. About 24 hours postoperatively.

A

Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis? A. Decreased cardiac output B. Urinary retention C. Ineffective airway clearance D. Acute pain

A

On postoperative day 2, a client requires care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing? A. Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing B. Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive C. Covering the well-approximated wound edges with a dry dressing D. Cleaning the wound with soap and water, then leaving it open to the air

A

The nurse is concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus? A. Absence of peristalsis B. Abdominal distention C. Abdominal tightness D. Increased abdominal girth

A

The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by: A. First intention B. Granulation C. Third intention D. Second intention

A

A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client? A. experiences pain within tolerable limits. B. maintains adequate fluid status. C. exhibits wound healing without complications. D. resumes usual urinary elimination pattern.

A

A client develops a hemorrhage one hour post surgery. The nurse knows this is most likely an intermediary hemorrhage from a vein because it occurred: A. within the first few hours, and has darkly colored blood that flows quickly. B. during surgery, and has bright red blood that flows freely. C. at a suture site, and the blood appears intermittently in spurts. D. a few hours after surgery, and the bright red blood appears with each heartbeat.

A

The nurse recognizes which symptom as a clinical manifestation of shock? A. Rapid, weak, thready pulse B. Flushed face C. Increased urine output D. Warm, dry skin

A

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients? A. Pneumonia B. Hypoxemia C. Pulmonary edema D. Pleurisy

A

What is the highest priority nursing intervention for a client in the immediate postoperative phase? A. Maintaining a patent airway B. Assessing urinary output every hour C. Monitoring vital signs at least every 15 minutes D. Assessing for hemorrhage

A

You are caring for a client who needs to ambulate. What considerations should be included when planning the postoperative ambulatory activities for the older adult? A. Tolerance B. Convalescent period C. Respiratory depressive effects D. Detailed medication history

A

The client asks the nurse about ways to control pain other than taking pain medication. Which strategy should the nurse include when responding to the client? Select all that apply. A. Changing position B. Listening to music C. An epidural infusion D. An On-Q pump E. Watching television

A, B, E

When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation via the O2 saturation monitor despite the client's breathing appearing normal, what action should the nurse take first? A. Apply oxygen. B. Assess the client's heart rhythm and nail beds. C. Document the findings. D. Notify the physician.

B

Which action should be incorporated into the client teaching plan to prevent deep vein thrombosis? A. Use of blanket rolls to elevate the lower extremities B. Hourly leg exercises C. Fluid restriction D. Prolonged dangling of the legs over the edge of the bed

B

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation? A. Third-intention healing B. Second-intention healing C. First-intention healing D. Primary-intention healing

B

A nurse is caring for a client with a chest tube connected to a dry suction water seal drainage system. The nurse notes 2cm of water and intermittent bubbling in the water seal chamber. Which action will the nurse take? A. Check for an air leak. B. Add water to the water seal chamber. C. Document the findings. D. Notify the health care provider.

C

A patient who underwent abdominal surgery 3 hours ago has started to hemorrhage. The nurse would classify this type of hemorrhage has which of the following? A. Primary B. Tertiary C. Intermediary D. Secondary

C

Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dL, and a blood pressure lying in bed of 110/70 mm Hg. The nurse suspects abnormal orthostatic changes when the client gets out of bed and reports vertigo. What vital sign value most supports the client's orthostatic changes? A. Blood pressure of 120/90 mm Hg B. Blood pressure of 150/100 mm Hg C. Blood pressure of 90/50 mm Hg D. Blood pressure of 110/80 mm Hg

C

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? A. Pale yet able to blanch with digital pressure B. Necrotic and hard C. Pink to red and soft, bleeding easily D. White with long, thin areas of scar tissue

C

The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what? A. Calculus formation B. Requirement of intermittent catheterization C. Urine retention D. Urinary infection

C

Which is a classic sign of hypovolemic shock? A. Dilute urine B. High blood pressure C. Pallor D. Bradypnea

C

A client asks why a drain is in place to pull fluid from the surgical wound. What is the bestresponse by the nurse? A. "It will cut down on the number of dressing changes needed." B. "Most surgeons use wound drains now." C. "The drain will remove necrotic tissue." D. "It assists in preventing infection."

D

A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the mostlikely cause of the client's change in condition? A. The client is showing signs of an anesthesia reaction. B. The client is displaying late signs of shock. C. The client is showing signs of a medication reaction. D. The client is displaying early signs of shock.

D

A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention? A. Take off the pneumatic compression devices for sleeping. B. Rely on the IV fluids for hydration. C. Dangle at the bedside. D. Report early calf pain.

D

Corticosteroids have which effect on wound healing? A. Cause hemorrhage B. Mask the presence of infection C. Reduce blood supply D. May cause protein-calorie depletion

B

A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first? A. Place a dry, sterile dressing over the protruding organs. B. Moisten sterile gauze with normal saline and place on the protruding organ. C. Place a pressure dressing over the opening and secure. D. Have the client lay quietly on back and call the physician.

B

The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan? A. Family members can be involved in the administration of pain medications with patient-controlled analgesia. B. Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. C. There are no advantages of patient-controlled analgesia over a PRN dosing schedule. D. The client can self-administer oral pain medication as needed with patient-controlled analgesia.

B

When should the nurse encourage the postoperative patient to get out of bed? A. Within 6 to 8 hours after surgery B. As soon as it is indicated C. Between 10 and 12 hours after surgery D. On the second postoperative day

B

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? A. Second intention B. First intention C. Third intention D. Fourth intention

B

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: A. insert a rectal tube. B. auscultate bowel sounds. C. change the client's position. D. palpate the abdomen.

B

A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate? A. Document the findings and reassess in 24 hours. B. Assess for signs and symptoms of fluid volume deficit. C. Assess for edema. D. Discontinue the nasogastric tube suctioning.

B

A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse? A. Obtain an emesis basin. B. Position the client in the side-lying position. C. Administer an anti-emetic. D. Ask the client for more clarification.

B

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: A. third intention. B. first intention. C. fourth intention. D. second intention.

B

A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage? A. The client has a nasogastric (NG) tube in place that drained 400 ml. B. The Hemovac drain isn't compressed; instead it's fully expanded. C. The client has been lying on his side for 2 hours with the drain positioned upward. D. There is a moderate amount of dry drainage on the outside of the dressing.

B

A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client? A. The client should be transferred to an intensive care area. B. The client can be discharged from the PACU. C. The client must remain in the PACU. D. The client must be put on immediate life support.

B

The client is experiencing intractable hiccups following surgery. What would the nurse expect the surgeon to order? A. nizatidine B. metoclopramide C. chlorpromazine D. omeprazole

C

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action? A. Monitor vital signs for early detection of shock. B. Assess the incisional dressing to detect hemorrhage. C. Position the client to maintain a patent airway. D. Administer antiemetics to prevent nausea and vomiting.

C

The primary objective in the immediate postoperative period is A. controlling nausea and vomiting. B. relieving pain. C. maintaining pulmonary ventilation. D. monitoring for hypotension.

C

To prevent thromboembolism in the postoperative client, the nurse should include which of the following in the plan of care? A. Splint the incision when ambulating. B. Assist the client with deep breathing. C. Assist with oral fluid intake. D. Place a pillow under the knees.

C

Which action should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical client? A. Instruct the client to cross the legs or prop a pillow under the knees B. Maintain bed rest C. Reinforce the need to perform leg exercises every hour when awake D. Massage the calves or thighs

C

Which of the following clinical manifestations increase the risk for evisceration in the postoperative client? A. Edema B. Hypovolemia C. Valsalva maneuver D. Hypoxia

C

A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the mostlikely cause of the client's change in condition? A. The client is showing signs of an anesthesia reaction. B. The client is showing signs of a medication reaction. C. The client is displaying late signs of shock. D. The client is displaying early signs of shock.

D

A postoperative client with an open abdominal wound is currently taking corticosteroids. The physician orders a culture of the abdominal wound even though no signs or symptoms of infection are seen. What action by the nurse is appropriate? A. Hold the order until purulent drainage is noted. B. Request the order be discontinued without obtaining the specimen. C. Use an antibiotic cleaning agent before obtaining the specimen. D. Obtain the wound culture specimen.

D

The nurse cares for a client who is three hours post op abdominal hysterectomy and begins to develop hiccups. What nursing assessment will the nurse monitor more closely with the client's new symptoms? A. Temperature B. Respiratory rate C. Wound drainage D. Wound approximation

D

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? A. Pale yet able to blanch with digital pressure B. White with long, thin areas of scar tissue C. Necrotic and hard D. Pink to red and soft, bleeding easily

D

The nurse is caring for a postoperative client with an indwelling urinary catheter. The hourly urinary output is 80 mL at 9 am. At 10 am, the nurse assesses the hourly urinary output as 20 mL. What is the priority action by the nurse? A. Document the findings. B. Reassess the output at 11 am. C. Irrigate the catheter with sterile normal saline. D. Notify the primary care provider immediately.

D

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes: A. Assisting with incentive spirometry every 6 hours B. Positioning the client in a supine position C. Assessing breath sounds at least every 2 hours D. Ambulating the client as soon as possible

D

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? A. >200 mL B. Between 75 and 100 mL C. Between 100 and 200 mL D. <30 mL

D

Which action should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical client? A. Administer prophylactic high-dose heparin. B. Instruct the client to prop a pillow under the knees. C. Maintain bed rest. D. Reinforce the need to perform leg exercises every hour when awake.

D

Which term refers to the protrusion of abdominal organs through the surgical incision? A. Hernia B. Dehiscence C. Erythema D. Evisceration

D