Surgery

Which information should the nurse include when teaching a patient who has just received a prescription for ciprofloxacin (Cipro) to treat a urinary tract infection? a. Use a sunscreen with a high SPF when exposed to the sun. b. Sun exposure may decrease the effectiveness of the medication. c. Photosensitivity may result in an artificial-looking tan appearance. d. Wear sunglasses to avoid eye damage while taking this medication.

A

A patient's temperature has been 101° F (38.3° C) for several days. The patient's normal caloric intake to meet nutritional needs is 2000 calories per day. Knowing that the metabolic rate increases 7% for each Fahrenheit degree above 100° in body temperature, how many total calories should the patient receive each day?

2140 Calories

Which action should the perioperative nurse take to best protect the patient from burn injury during surgery? a. Ensure correct placement of the grounding pad. b. Check emergency sprinklers in the operating room. c. Verify that a fire extinguisher is available during surgery. d. Confirm that all electrosurgical equipment is working properly.

A

Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative-pressure wound therapy? a. Low serum albumin level b. Serosanguineous drainage c. Deep red and moist wound bed d. Cobblestone appearance of wound

A

Which information in the preoperative patient's medication history is most important to communicate to the health care provider? a. The patient takes garlic capsules every day. b. The patient quit using cocaine 10 years ago. c. The patient took a prescribed sedative the previous night. d. The patient uses acetaminophen (Tylenol) for aches and pains.

A

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient? a. Potential complication: hypovolemic shock b. Potential complication: venous thromboembolism c. Potential complication: fluid and electrolyte imbalance d. Potential complication: impaired surgical wound healing

B

During assessment of the patient's skin, the nurse observes a similar pattern of discrete, small, raised lesions on the left and right upper back areas. Which term should the nurse use to document the distribution of these lesions? a. Confluent c. Zosteriform b. Symmetric d. Generalized

B

The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which health screening should the nurse include in the teaching plan for this patient? a. Screening for allergies b. Screening for malignancies c. Screening for antibody deficiencies d. Screening for autoimmune disorders

B

Which statement, if made by a new circulating nurse, reflects understanding of the circulating nurse role? a. "I will assist in preparing the operating room for the patient." b. "I will don sterile gloves to obtain items from the unsterile field." c. "I will remain gloved while performing activities in the sterile field." d. "I will assist with suturing of incisions and maintaining hemostasis as needed."

A

A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Discontinue the antibiotic. b. Give diphenhydramine IV. c. Inject epinephrine IM or IV. d. Prepare an infusion of dopamine. e. Provide 100% oxygen using a nonrebreather mask

A,E,C,B,D

. Which nursing action should the operating room (OR) nurse manager delegate to the registered nurse first assistant (RNFA) when caring for a surgical patient? a. Adjust the doses of administered anesthetics. b. Make surgical incisions and suture as needed. c. Provide postoperative teaching about coughing. d. Coordinate transfer of the patient to the operating table.

B

A patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse expect to administer? a. Corticosteroids c. Hepatitis B vaccine b. Gamma globulin d. Fresh frozen plasma

B

Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help to transport a patient to the clinical unit? a. Clarify the postoperative orders with the surgeon. b. Help with the transfer of the patient onto a stretcher. c. Document the appearance of the patient's incision in the chart. d. Provide hand off communication to the surgical unit charge nurse.

B

Which action in the perioperative patient plan of care can the charge nurse delegate to a surgical technologist? a. Teach the patient about what to expect in the operating room (OR). b. Pass sterile instruments and supplies to the surgeon and scrub technician. c. Monitor and interpret the patient's echocardiogram (ECG) during surgery. d. Give the postoperative report to the postanesthesia care unit (PACU) nurse.

B

Which data identified during the preoperative assessment alerts the nurse that special protection techniques should be implemented during surgery? a. Stated allergy to cats and dogs b. History of spinal and hip arthritis c. Verbalization of anxiety by the patient d. Having a sip of water 3 hours previously

B

Which example should the nurse use to explain an infant's "passive immunity" to a new mother? a. Vaccinations b. Breastfeeding c. Stem cells in peripheral blood d. Exposure to communicable diseases

B

Which finding would indicate to the nurse that a postoperative patient is at increased risk for poor wound healing? a. Potassium 3.5 mEq/L c. Hemoglobin 10.2 g/dL b. Albumin level 2.2 g/dL d. White blood cells 11,900/µL

B

Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin? a. Use a sunscreen with an SPF of at least 10 for adequate protection. b. Try to stay out of the direct sun between the hours of 10 AM and 2 PM. c. Water resistant sunscreens will provide good protection when swimming. d. Increase sun exposure by no more than 10 minutes a day to avoid skin damage.

B

Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of concern to the nurse? a. Brown macules on extremities b. Reports a history of allergic rashes c. Skin wrinkled with tenting on both hands d. Longitudinal nail ridges and sparse scalp hair

B

Which patient should the nurse assess first? a. Patient with urticaria after receiving an IV antibiotic b. Patient who is sneezing after subcutaneous immunotherapy c. Patient who has graft-versus-host disease and severe diarrhea d. Patient with multiple chemical sensitivities who has muscle stiffness

B

Which statement by a patient scheduled for surgery is most important to report to the health care provider? a. "I have a strong family history of cancer." b. "I had a heart valve replacement last year." c. "I had bacterial pneumonia 3 months ago." d. "I have knee pain whenever I walk or jog."

B

Which statement by a patient would alert the nurse to a risk for decreased immune function? a. "I had a chest x-ray 6 months ago." b. "I had my spleen removed after a car accident." c. "I take one baby aspirin every day to prevent stroke." d. "I usually eat eggs or meat for at least two meals a day."

B

Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for an open cholecystectomy? a. Care for the surgical incision b. Deep breathing and coughing c. Oral antibiotic therapy after discharge d. Medications to be used during surgery

B

A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first? a. Assess the patient's pain. c. Take the patient's vital signs. b. Orient the patient to the unit. d. Read the postoperative orders.

C

A patient undergoing an emergency appendectomy has been using St. John's wort to prevent depression. Which complication would the nurse expect in the postanesthesia care unit? a. Increased discomfort b. Increased blood pressure c. Increased anesthesia recovery time d. Increased postoperative wound bleeding

C

A patient who takes a diuretic and a β-blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the health care provider before surgery? a. Hematocrit 36% c. Serum potassium 3.2 mEq/L b. Blood pressure 144/82 d. Pulse rate 54-58 beats/minute

C

A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? a.Skin flushing c.Rising body temperature b.Muscle cramps d.Decreasing blood pressure

C

A patient's 4 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound? a. Dry gauze dressing c. Hydrocolloid dressing b. Nonadherent dressing d. Transparent film dressing

C

A patient's T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate? a. Notify the patient's surgeon. b. Place the patient on bed rest. c. Document the color and amount of drainage. d. Irrigate the T-tube with sterile normal saline.

C

A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed? a. Patient drinks 2 to 3 L of fluid in 24 hours. b. Patient uses the spirometer 10 times every hour. c. Patient's breath sounds are clear to auscultation. d. Patient's temperature is less than 100.2°F orally.

C

A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C) The patient reports having no discomfort. Which action by the nurse is appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Check the patient's temperature again in 4 hours. d. Give acetaminophen (Tylenol) prescribed PRN for pain.

C

The health care provider asks the nurse whether a patient's angioedema has responded to prescribed therapies. Which assessment should the nurse perform? a. Obtain the patient's blood pressure and heart rate. b. Question the patient about any clear nasal discharge. c. Observe for swelling of the patient's lips and tongue. d. Assess the patient's extremities for wheal and flare lesions.

C

The nasogastric (NG) tube is removed on the second postoperative day, and the patient is placed on a clear liquid diet. Four hours later, the patient complains of frequent, cramping gas pains. What action by the nurse is the most appropriate? a. Reinsert the NG tube. c. Assist the patient to ambulate. b. Give the PRN IV opioid. d. Place the patient on NPO status.

C

The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago. Which action should the nurse take first? a. Suction the patient's mouth. b. Increase the oxygen flow rate. c. Perform the jaw-thrust maneuver. d. Elevate the patient's head on two pillows.

C

Which action by the nurse will be most helpful to a patient who is expected to ambulate, deep breathe, and cough on the first postoperative day? a. Schedule the activity to begin after the patient has taken a nap. b. Administer prescribed analgesic medications before the activities. c. Ask the patient to state two possible complications of immobility. d. Encourage the patient to state the purpose of splinting the incision.

B

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon? a. Tympanic temperature 99.2° F (37.3° C) b. Fine crackles audible at both lung bases c. Redness and swelling along the suture line d. 200 mL sanguineous fluid in the wound drain

D

The nurse assesses a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately? a. The patient complains of incisional pain. b. The patient's heart rate is 110 beats/min. c. The patient is unable to detect when the eyelids are touched. d. The skin around the incision is pale and cold when palpated.

D

Which action will the perioperative nurse take after surgery is completed for a patient who received ketamine as an anesthetic agent? a. Question the order for giving a benzodiazepine. b. Ensure that atropine is available in case of bradycardia. c. Provide a quiet environment in the postanesthesia care unit. d. Anticipate the need for higher than usual doses of analgesic agents.

C

Which information about intradermal skin testing should the nurse teach to a patient with possible allergies? a. "Do not eat anything for about 6 hours before the testing." b. "Take an oral antihistamine about an hour before the testing." c. "Plan to wait in the clinic for 20 to 30 minutes after the testing." d. "Reaction to the testing will take about 48 to 72 hours to occur."

C

Which information should the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma (BCC)? a. Treatment plans include watchful waiting. b. Screening for metastasis will be important. c. Minimizing sun exposure reduces risk for future BCC. d. Low dose systemic chemotherapy is used to treat BCC.

C

Which information will the nurse include when teaching an older patient about skin care? a. Dry the skin thoroughly before applying lotions. b. Bathe and wash hair daily with soap and shampoo. c. Use warm water and a moisturizing soap when bathing. d. Use antibacterial soaps when bathing to avoid infection.

C

The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)? a. The patient who reports increased tenderness and swelling around a leg wound b. The patient who was just admitted after suturing of a full-thickness arm wound c. The patient who needs teaching about home care for a draining abdominal wound d. The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer

D

The nurse is caring for a patient diagnosed with furunculosis. Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP)? a. Applying antibiotic cream to the groin b. Obtaining cultures from ruptured lesions c. Evaluating the patient's personal hygiene d. Cleaning the skin with antimicrobial soap

D

The nurse notes darker skin pigmentation in the skinfolds of a middle-aged patient who has a body mass index of 40 kg/m2. What is the nurse's appropriate action? a. Discuss the use of drying agents to minimize infection risk. b. Instruct the patient about the use of mild soap to clean skinfolds. c. Teach the patient about treating fungal infections in the skinfolds. d. Ask the patient about a personal or family history of type 2 diabetes.

D

The nurse notes that a patient's open abdominal wound widens as it extends deeper into the abdomen. How would the nurse document this characteristic? a. Eschar c. Maceration b. Slough d. Undermining

D

A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care? a. The new nurse cleans the ulcer with half-strength peroxide. b. The new nurse uses a hydrocolloid dressing (DuoDerm)on the ulcer. c. The new nurse irrigates the pressure ulcer with saline using a 30-mL syringe. d. The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer.

A

A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate? a. Elevate the ankle above heart level. b. Apply a warm moist pack to the ankle. c. Ask the patient to try bearing weight on the ankle. d. Assess the ankle's passive range of motion (ROM).

A

A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take? a. Prepare the patient for a skin biopsy. b. Teach the use of corticosteroid cream. c. Explain how to apply tretinoin (Retin-A) to the face. d. Discuss the need for topical application of antibiotics.

A

A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value? a.IgE b.IgA c.Basophils d.Neutrophils

A

A patient who had knee surgery received IV ketorolac 30 minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale). Which action is most effective for the nurse to take at this time? a. Administer the prescribed PRN IV morphine sulfate. b. Notify the health care provider about the ongoing pain. c. Reassure the patient that postoperative pain is expected after knee surgery. d. Teach the patient that the effects of ketorolac typically last about 6 to 8 hours.

A

A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse's highest priority? a. Maintaining the patient's blood glucose within a normal range b. Ensuring that the patient has an adequate dietary protein intake c. Giving antipyretics to keep the temperature less than 102° F (38.9° C) d. Redressing the surgical incision with a dry, sterile dressing twice daily

A

A patient who is scheduled for a therapeutic abortion tells the nurse, "Having an abortion is wrong." Which functional health pattern should the nurse further assess? a. Value-belief c. Sexuality-reproductive b. Cognitive-perceptual d. Coping-stress tolerance

A

A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/µL and a band count of 11%. What prescribed action should the nurse take first? a. Obtain cultures of the wound. b. Begin antibiotic administration. c. Continue to monitor the wound for drainage. d. Redress the wound with wet-to-dry dressings.

A

A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. The nurse should assess for which adverse effect? a. Thinning of the affected skin c. Dryness and scaling in the area b. Alopecia of the affected areas d. Reddish-brown skin discoloration

A

A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first? a. Perform a bladder scan. b. Insert a straight catheter. c. Encourage increased oral fluid intake. d. Assist the patient to ambulate to the bathroom.

A

After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first? a. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating b. Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery c. Patient who has bibasilar crackles and a temperature of 100° F (37.8 °C) on the first postoperative day after chest surgery d. Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) was given

A

An older adult patient who is having an annual check-up tells the nurse, "I feel fine, and I don't want to pay for all these unnecessary cancer screening tests!" Which information should the nurse plan to teach this patient? a. Consequences of aging on cell-mediated immunity b. Decrease in antibody production associated with aging c. Impact of poor nutrition on immune function in older people d. Incidence of cancer-associated infections in older individuals

A

Monitored anesthesia care (MAC) is going to be used for a closed, manual reduction of a dislocated shoulder. What action does the nurse anticipate? a. Starting an IV in the patient's unaffected arm b. Securing an airtight fit for the inhalation mask c. Preparing for placement of an epidural catheter d. Giving deep sedation under physician supervision.

A

Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of the rash? a. The donor T cells are attacking the patient's skin cells. b. The patient needs treatment to prevent hyperacute rejection. c. The patient's antibodies are rejecting the donor bone marrow. d. The patient is experiencing a delayed hypersensitivity reaction.

A

The health care provider diagnoses impetigo in a patient who has crusty vesicopustular lesions on the lower face. Which instructions should the nurse include in the teaching plan? a. Clean the infected areas with soap and water. b. Apply alcohol-based cleansers on the lesions. c. Avoid use of antibiotic ointments on the lesions. d. Use petroleum jelly (Vaseline) to soften crusty areas.

A

The nurse interviews a patient scheduled to undergo general anesthesia for a bilateral hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery? a. The patient's father died after general anesthesia for abdominal surgery. b. The patient drinks 3 cups of coffee every morning before going to work. c. The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago. d. The patient drank 4 ounces of apple juice 3 hours before coming to the hospital.

A

The nurse notes the presence of white lesions that resemble milk curds in the back of a patient's throat. Which question by the nurse is appropriate at this time? a. "Are you taking any medications?" b. "Do you have a productive cough?" c. "How often do you brush your teeth?" d. "Have you had an oral herpes infection?"

A

The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer? a. Administer prescribed PRN hydrocodone 30 minutes before the change. b. Pour sterile saline onto the new dry dressings after the wound has been packed. c. Apply antimicrobial ointment before repacking the wound with moist dressings. d. Soak the old dressings with sterile saline 30 minutes before the dressing change

A

The nurse working in the dermatology clinic assesses a young adult female patient who has. severe cystic acne. Which assessment finding is of concern related to the patient's prescribed isotretinoin ? a. The patient recently had an intrauterine device removed. b. The patient already has some acne scarring on her forehead. c. The patient has also used topical antibiotics to treat the acne. d. The patient has a strong family history of rheumatoid arthritis.

A

The surgical unit nurse has just received a patient with a history of smoking from the postanesthesia care unit. Which action is most important at this time? a. Auscultate for adventitious breath sounds. b. Obtain the blood pressure and temperature. c. Remind the patient about harmful effects of smoking. d. Ask the health care provider to prescribe a nicotine patch.

A

A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan (select all that apply)? a. Cool, wet cloths or compresses can be used to reduce itching. b. Take cool or tepid baths several times daily to decrease itching. c. Add oil to your bath water to aid in moisturizing the affected skin. d. Rub yourself dry with a towel after bathing to prevent skin maceration. e. Use of an over-the-counter (OTC) antihistamine can reduce scratching.

A,B,E

Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)? a. Administer patch testing to a patient with allergic dermatitis. b. Interview a new patient about chronic health problems and allergies. c. Apply a sterile dressing after the health care provider excises a mole. d. Explain potassium hydroxide testing to a patient with a skin infection. e. Teach a patient about site care after a punch biopsy of an upper arm lesion

A,C

A patient's blood pressure in the postanesthesia care unit (PACU) has dropped from an admission blood pressure of 140/86 to 102/60 mm Hg with a pulse change of 70 to 96 beats/min. SpO2 is 92% on 3 L of oxygen. In which order should the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Increase the IV infusion rate. b. Assess the patient's dressing. c. Increase the oxygen flow rate. d. Check the patient's temperature.

A,C,B,D

While ambulating in the room, a patient complains of feeling dizzy. In what order will the nurse accomplish the following activities? (Put a comma and a space between each answer choice [A, B, C, D].) a. Have the patient sit down in a chair. b. Give the patient something to drink. c. Take the patient's blood pressure (BP). d. Inform the patient's health care provider.

A,C,B,D

A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions? (Put a comma and a space between each answer choice [A, B, C, D]). a. Administer IV antibiotics. b. Sponge patient with cool water. c. Perform wet-to-dry dressing change. d. Administer acetaminophen (Tylenol).

A,D,B,C

13. A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action should the nurse take? a. Withhold the usual scheduled insulin dose because the patient is NPO. b. Obtain a blood glucose measurement before any insulin administration. c. Give the patient the usual insulin dose because stress will increase the blood glucose. d. Give half the usual dose of insulin because there will be no oral intake before surgery.

B

A 35-yr-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face. Which additional assessment information will be most important for the nurse to obtain? a. History of sun exposure by the patient b. Method of contraception used by the patient c. Length of time the patient has used fluorouracil d. Appearance of the treated areas on the patient's face

B

A patient arrives at the outpatient surgical center for a scheduled laparoscopy under general anesthesia. Which information requires the nurse's preoperative intervention to maintain patient safety? a. The patient has never had general anesthesia. b. The patient is planning to drive home after surgery. c. The patient had a sip of water 4 hours before arriving. d. The patient's insurance does not c

B

A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching? a. The patient has multiple dysplastic nevi. b. The patient uses a tanning booth weekly. c. The patient is fair-skinned and has blue eyes. d. The patient's mother died of a malignant melanoma.

B

A patient in the health care provider's office for allergen testing using the cutaneous scratch method develops itching and swelling at the skin site. Which action should the nurse take first? a. Monitor the patient's edema. b. Administer a dose of epinephrine. c. Provide a prescription for oral antihistamines d. Ask the patient about the use of new skin products.

B

A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient? a. Testing for human leukocyte antigen (HLA) match b. Administration of immunosuppressant medications c. Insertion of an arteriovenous graft for hemodialysis d. Placement of the patient on the transplant waiting list

B

A patient reports chronic itching of the ankles and continuously scratches the area. Which assessment finding will the nurse expect? a. Hypertrophied scars on both ankles b. Thickening of the skin around the ankles c. Yellowish-brown skin around both ankles d. Complete absence of melanin in both ankles

B

A patient scheduled for an elective hysterectomy tells the nurse, "I am afraid that I will die in surgery like my mother did!" Which initial response by the nurse is appropriate? a. "Surgical techniques have improved in recent years." b. "Tell me more about what happened to your mother." c. "You will receive medication to reduce your anxiety." d. "You should talk to the doctor again about the surgery."

B

A patient scheduled to undergo total knee replacement surgery under general anesthesia asks the nurse, "Will the doctor put me to sleep with a mask over my face?" Which response by the nurse is most appropriate? a. "Only your surgeon can tell you what method of anesthesia will be used." b. "I will check with the anesthesia care provider to find out what is planned." c. "General anesthesia is now given by injecting drugs into your veins, so you will not need a mask over your face." d. "Masks are no longer used for anesthesia. A tube will be inserted into your throat to deliver gas that will put you to sleep."

B

A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching? a. "I need to find a different way to earn extra money." b. "I will take oral antihistamines before going to work." c. "I will get a prescription for epinephrine and learn to self-inject it." d. "I should wear a Medic-Alert bracelet indicating my allergy to bee stings."

B

A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate? a. Increase the IV fluid rate. b. Assess for bladder distention. c. Notify the anesthesia care provider (ACP). d. Demonstrate the use of the nurse call bell button.

B

A patient who has not had any prior surgeries tells the nurse doing the preoperative assessment about allergies to avocados and bananas. Which action is most important for the nurse to take? a. Notify the dietitian about the specific food allergies. b. Alert the surgery center about a possible latex allergy. c. Reassure the patient that all allergies are noted on the health record. d. Ask whether the patient uses antihistamines to reduce allergic reactions.

B

A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first? a. Administer the prescribed opioid. b. Check the oxygen (O2) saturation. c. Take the blood pressure and pulse. d. Apply wrist restraints to secure IV lines.

B

A patient with atopic dermatitis has a new prescription for pimecrolimus (Elidel). After teaching the patient about the medication, which statement by the patient indicates that further teaching is needed? a. "After I apply the medication, I can get dressed as usual." b. "If the medication burns when I apply it, I will wipe it off." c. "I need to minimize time in the sun while using the Elidel." d. "I will rub the medication in gently every morning and night."

B

A teenaged male patient who is on a wrestling team is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis? a. Ringlike rashes with red, scaly borders over the entire scalp b. Papular, wheal-like lesions with white deposits on the hair shaft c. Patchy areas of alopecia with small vesicles and excoriated areas d. Red, hivelike papules and plaques with sharply circumscribed borders

B

After receiving a change-of-shift report, which patient should the nurse assess first? a. The patient who has multiple leg wounds with eschar to be debrided b. The patient receiving chemotherapy who has a temperature of 102° F c. The patient who requires analgesics before a scheduled dressing change d. The newly admitted patient with a stage IV pressure ulcer on the coccyx

B

Five minutes after receiving the ordered preoperative midazolam by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate? a. Assist the patient to the bathroom. b. Offer the patient a urinal or bedpan. c. Ask the patient to wait until the drug has been fully metabolized. d. Tell the patient that a bladder catheter will be placed in the operating room.

B

Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, the patient complains of itching at the site, weakness, and dizziness. What action should the nurse take first? a. Apply antiinflammatory cream. b. Place a tourniquet above the site. c. Administer subcutaneous epinephrine. d. Reschedule the patient's other allergen tests.

B

In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72 mm Hg, pulse 74 beats/min, respirations 12 breaths/min, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first? a. Place the patient in a side-lying position. b. Encourage the patient to take deep breaths. c. Prepare to transfer the patient to a clinical unit. d. Increase the rate of the postoperative IV fluids.

B

The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patient's ankle. How should the nurse determine if the lesion is related to intradermal bleeding? a. Elevate the patient's leg. b. Press firmly on the lesion. c. Check the temperature of the skin around the lesion. d. Palpate the dorsalis pedis and posterior tibial pulses.

B

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider? a. The patient's temperature is 100.3° F (37.9° C). b. The patient's calf is swollen, warm, and painful. c. The 24-hour oral intake is 600 mL greater than the total output. d. The patient reports abdominal pain at level 6 (0 to 10 scale) when ambulating.

B

The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate? a.Obtain wound cultures. c.Notify the health care provider. b.Document the assessment. d.Assess the wound every 2 hours.

B

The nurse facilitates student clinical experiences in the surgical suite. Which action, if performed by a student, would require the nurse to intervene? a. The student wears a mask in the semirestricted area. b. The student wears street clothes in the semirestricted area. c. The student wears surgical scrubs in the semirestricted area. d. The student covers head and facial hair in the semirestricted area.

B

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I don't understand what the doctor said about the surgery." Which action should the nurse take next? a. Provide a thorough explanation of the planned surgical procedure. b. Notify the surgeon that the informed consent process is not complete. c. Give the prescribed preoperative antibiotics and withhold sedative medications. d. Notify the operating room nurse to give a more complete explanation of the procedure.

B

The nurse taking a health history learns that the patient, who has worked in rubber tire manufacturing, has allergic rhinitis and multiple food allergies. Which action by the nurse is correct? a. Recommend that the patient use latex gloves in preventing blood-borne pathogen contact. b. Document the patient's history and teach about clinical manifestations of a type I latex allergy. c. Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops. d. Advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves.

B

The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? a. "I need to be monitored closely for development of malignant tumors." b. "After a couple of years I will be able to stop taking the cyclosporine." c. "If I develop acute rejection episode, I will need additional types of drugs." d. "The drugs are combined to inhibit different ways the kidney can be rejected."

B

The nurse working in the postanesthesia care unit (PACU) notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5° F (35.8° C). Which action should the nurse take next? a. Notify the anesthesia care provider. b. Cover the patient with a warm blanket. c. Avoid giving opioid analgesics until the patient is warmer. d. Give acetaminophen (Tylenol) 650 mg suppository rectally.

B

There is one opening in the schedule at the dermatology clinic, and four patients are seeking appointments today. Which patient will the nurse schedule for the available opening? a. 50-yr-old with skin redness after having a chemical peel 3 days ago b. 38-year old with a 7-mm nevus on the face that has recently become darker c. 62-yr-old with multiple small, soft, pedunculated papules in both axillary areas d. 42-yr-old with complaints of itching after using topical fluorouracil on the nose

B

When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing? a. The patient has had the heel ulcers for 6 months. b. The patient takes oral hypoglycemic agents daily. c. The patient states that the ulcers are very painful. d. The patient has several incisions that formed keloids.

B

When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8° F (38.2° C). Which action should the nurse take next? a. Place ice packs in the patient's axillae. b. Have the patient use the incentive spirometer. c. Request an order for acetaminophen (Tylenol). d. Ask the health care provider to prescribe a different antibiotic.

B

When performing a skin assessment, the nurse notes angiomas on the chest of an older patient. Which action should the nurse take next? a. Suggest an appointment with a dermatologist. b. Assess the patient for evidence of liver disease. c. Teach the patient about skin changes with aging. d. Discuss the use of sunscreen to prevent skin cancers.

B

While in the holding area, a patient reveals to the nurse that his father had a high fever after surgery. What action by the nurse is a priority? a. Place a medical alert sticker on the front of the patient's chart. b. Alert the anesthesia care provider of the family member's reaction to surgery. c. Give 650 mg of acetaminophen (Tylenol) per rectum as a preventive measure. d. Reassure the patient that his temperature will be closely monitored after surgery.

B

. The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery. The results are white blood cell (WBC) count 10.2 × 103/µL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 × 103/µL. Which action should the nurse take? a. Notify the surgeon and anesthesiologist immediately. b. Ask the patient about any symptoms of a recent infection. c. Continue to prepare the patient for the surgical procedure. d. Discuss the possibility of blood transfusion with the patient.

C

A 38-yr-old woman is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to communicate to the anesthesiologist and surgeon before surgery? a. The patient's lack of knowledge about postoperative pain control b. The patient's history of an infection following a cholecystectomy c. The patient's report that her last menstrual period was 8 weeks ago d. The patient's concern about being able to resume lifting heavy items

C

A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse assess this patient for cyanosis? a. Assess the skin color of the earlobes. b. Apply pressure to the palms of the hands. c. Check the lips and oral mucous membranes. d. Examine capillary refill time of the nail beds.

C

A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon? a. Patient is Rh positive and donor is Rh negative b. Six antigen matches are present in HLA typing c. Results of patient-donor crossmatching are positive d. Panel of reactive antibodies (PRA) percentage is low

C

A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure ulcer? a. Stage I c. Stage III b. Stage II d. Stage IV

C

A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole from the upper back. The nurse should prepare the patient for which type of biopsy? a. Shave biopsy c. Incisional biopsy b. Punch biopsy d. Excisional biopsy

C

A patient in the surgical holding area is being prepared for a spinal fusion. Which action by a member of the surgical team requires immediate intervention by the charge nurse? a. Wearing street clothes into the nursing station b. Wearing a surgical mask into the holding room c. Walking into the hallway outside the operating room with hair uncovered d. Putting on a surgical mask, cap, and scrubs before entering the operating room

C

A patient is anxious and reports difficulty breathing after being stung by a wasp. What is the nurse's priority action? a. Provide high-flow oxygen. c. Assess the patient's airway. b. Administer antihistamines. d. Remove the stinger from the sit

C

A young male patient with paraplegia has a stage II sacral pressure ulcer and is being cared for at home by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and family? a. Change the patient's bedding frequently. b. Apply a hydrocolloid dressing over the ulcer. c. Change the patient's position every 1 to 2 hours. d. Record the size and appearance of the ulcer weekly.

C

After the home health nurse teaches a patient's family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed? a. The family member uses a lift sheet to reposition the patient. b. The family member uses clean tap water to clean the wound. c. The family member dries the wound using a hair dryer on a low setting. d. The family member places contaminated dressings in a plastic grocery bag.

C

An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful? a. The new nurse assists a nauseated patient to a supine position. b. The new nurse positions an unconscious patient supine with the head elevated. c. The new nurse positions an unconscious patient on the side upon arrival in the PACU. d. The new nurse places a patient in the Trendelenburg position for a low blood pressure.

C

An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient's health history has implications for planning patient teaching about the medication at this time? a. The patient restricts salt to 2 grams per day. b. The patient eats green leafy vegetables daily. c. The patient drinks grapefruit juice every day. d. The patient drinks 3 to 4 quarts of fluid each day.

C

An older patient is being discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, "I don't know if I can take care of myself once I'm home." Which action by the nurse is most appropriate? a. Provide written instructions for the care. b. Assess the patient's home support system. c. Discuss specific concerns regarding self-care. d. Refer the patient for home health care services.

C

On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate? a. Increase the IV fluid rate. b. Notify the anesthesia care provider (ACP). c. Continue to take vital signs every 15 minutes. d. Administer oxygen therapy at 100% per mask.

C

The charge nurse is assigning semiprivate rooms for new admissions. Which patient could safely be assigned as a roommate for a patient who has acute rejection of an organ transplant? a. A patient who has viral pneumonia b. A patient with second-degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant

C

The nurse instructs a patient about application of corticosteroid cream to an area of contact dermatitis on the right leg. Which patient action indicates that further teaching is needed? a. The patient takes a tepid bath before applying the cream. b. The patient spreads the cream using a downward motion. c. The patient applies a thick layer of the cream to the affected skin. d. The patient covers the area with a dressing after applying the cream.

C

The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first? a. Reinforce the dressing. c. Take the patient's vital signs. b. Apply an abdominal binder. d. Recheck the dressing in 1 hour.

C

The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider? a. Blood glucose of 136 mg/dL b. Oral temperature of 101° F (38.3° C) c. Separation of the proximal wound edges d. Patient complaint of increased incisional pain

C

The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching? a. The patient applies corticosteroid cream to pruritic areas. b. The patient adds oilated oatmeal to the bath water every day. c. The patient uses bacitracin-neomycin-polymyxin on minor abrasions. d. The patient takes diphenhydramine at night if persistent itching occurs.

C

The nurse is preparing a patient on the morning of surgery. The patient refuses to remove a wedding ring, saying, "I've never taken it off since the day I was married." Which response by the nurse is best? a. Have the patient sign a release form and leave the ring on. b. Tell the patient that the hospital is not liable for loss of the ring. c. Suggest that the patient give the ring to a family member to keep. d. Inform the operating room personnel that the patient is wearing a ring.

C

The nurse obtains a health history from a patient who is scheduled for elective hip surgery in 1 week. The patient reports use of garlic and ginkgo biloba. Which action by the nurse is most appropriate? a. Teach the patient that these products may be continued preoperatively. b. Advise the patient to stop the use of herbs and supplements at this time. c. Discuss the herb and supplement use with the patient's health care provider. d. Reassure the patient that there will be no interactions with anesthetic agents.

C

The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision deficits. His wife answers most questions that are directed to the patient. Which action should the nurse take when doing the teaching? a. Use printed materials for instruction so that the patient will have more time to review the material. b. Direct all the teaching toward the wife because she is the obvious support and caregiver for the patient. c. Provide additional time for the patient to understand preoperative instructions and carry out procedures. d. Ask the patient's wife to wait in the hall in order to focus preoperative teaching with the patient himself.

C

The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which items should the nurse gather for this procedure? a. Sterile gloves c. Cotton-tipped applicators b. Patch test instruments d. Syringe and intradermal needle

C

The nurse reviewing a clinic patient's medical record notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is appropriate? a. Schedule an additional dose the following week. b. Administer the scheduled dosage of the allergen. c. Consult with the health care provider about giving a lower allergen dose. d. Re-evaluate the patient's sensitivity to the allergen with a repeat skin test.

C

The operating room nurse is providing orientation to a student nurse. Which action would the nurse list as a major responsibility of a scrub nurse? a. Document all patient care accurately. b. Label all specimens to send to the laboratory. c. Keep both hands above the operating table level. d. Take the patient to the postanesthesia recovery area

C

W hich action describes how the scrub nurse protects the patient with aseptic technique during surgery? a. Uses waterproof shoe covers b. Wears personal protective equipment c. Changes gloves after touching the upper arm of the surgeon's gown d. Requires that all operating room (OR) staff perform a surgical scrub

C

What instructions about plasmapheresis should the nurse include in the teaching plan for a patient diagnosed with systemic lupus erythematosus (SLE)? a. Plasmapheresis eliminates eosinophils and basophils from blood. b. Plasmapheresis decreases the damage to organs from T lymphocytes. c. Plasmapheresis removes antibody-antigen complexes from circulation. d. Plasmapheresis prevents foreign antibodies from damaging various body tissues.

C

What is the best method to prevent the spread of infection to others when the nurse is changing the dressing over a wound infected with Staphylococcus aureus? a. Change the dressing using sterile gloves. b. Apply antibiotic ointment over the wound. c. Wash hands and properly dispose of soiled dressings. d. Soak the dressing in sterile normal saline before removal.

C

When assessing a new patient at the outpatient clinic, the nurse notes dry, scaly skin; thin hair; and thick, brittle nails. What is the nurse's most important action? a. Instruct the patient about the importance of nutrition for skin health. b. Make a referral to a podiatrist so that the nails can be safely trimmed. c. Consult with the health care provider about the need for further diagnostic testing. d. Teach the patient about using moisturizing creams and lotions to decrease dry skin.

C

When examining an older patient in the home, the home health nurse notices irregular patterns of bruising at different stages of healing on the patient's body. Which action should the nurse take first? a. Ensure the patient wears shoes with nonslip soles. b. Discourage using throw rugs throughout the house. c. Talk with the patient alone and ask about the bruising. d. Notify the health care provider so that radiographs can be ordered.

C

Which abnormality on the skin of an older patient is the priority to discuss immediately with the health care provider? a. Dry, scaly patches on the face b. Numerous varicosities on both legs c. Petechiae on the chest and abdomen d. Small dilated blood vessels on the face

C

Which action best describes the role of the certified registered nurse anesthetist (CRNA) on the surgical care team? a. Performs the same responsibilities as the anesthesiologist. b. Gives intraoperative anesthetics ordered by the anesthesiologist. c. Releases or discharges patients from the postanesthesia care area. d. Manages a patient's airway under the direct supervision of the anesthesiologist.

C

When caring for a preoperative patient on the day of surgery, which actions included in the plan of care can the nurse delegate to unlicensed assistive personnel (UAP) (select all that apply)? a. Teach incentive spirometer use. b. Explain routine preoperative care. c. Obtain and document baseline vital signs. d. Remove nail polish and apply pulse oximeter. e. Transport the patient by stretcher to the operating room.

C,D,E

Which actions will the nurse include in the surgical time-out procedure before surgery (select all that apply)? a. Check for patency of IV lines. b. Have the surgeon identify the patient. c. Have the patient state name and date of birth. d. Verify the patient identification band number. e. Ask the patient to state the surgical procedure.

C,D,E

A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Perform a focused physical assessment. b. Obtain the health history from the patient. c. Teach the patient about the various diagnostic studies. d. Administer a skin test by the cutaneous scratch method.

D

A patient has received atropine before surgery and complains of dry mouth. Which action by the nurse is most appropriate? a. Check for skin tenting. b. Notify the health care provider. c. Ask the patient about any weakness or dizziness. d. Explain that dry mouth is an expected side effect

D

A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. While in the postanesthesia care unit (PACU), what assessment finding is most important for the nurse to report? a. Lethargy c. Disorientation to time b. Complaint of nausea d. Weak chest movement

D

A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure? a. Shield any unaffected areas with lead-lined drapes. b. Apply petroleum jelly to the areas around the lesions. c. Cleanse the skin carefully with antiseptic soap prior to PUVA. d. Have the patient use protective eyewear while receiving PUVA.

D

A patient who has severe refractory psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which action should the nurse take first? a. Discuss the possibility of participating in an online support group. b. Encourage the patient to volunteer to work on community projects. c. Suggest that the patient use cosmetics to cover the psoriatic lesions. d. Ask the patient to describe the impact of psoriasis on quality of life.

D

A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider? a. The patient's IgG level is increased. b. The injection site is red and swollen. c. The patient's symptoms did not improve in 2 months. d. There is a 2-cm wheal at the site of the allergen injection.

D

A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure? a. Curettage c. Punch biopsy b. Cryosurgery d. Surgical excision

D

A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient? a. Monitor white blood cell counts. b. Check the skin for areas of redness. c. Measure the temperature every 2 hours. d. Ask about feelings of fatigue or malaise.

D

An older adult patient with a squamous cell carcinoma (SCC) on the lower arm has a Mohs procedure in the dermatology clinic. Which nursing action will be included in the postoperative plan of care? a. Schedule daily appointments for dressing changes. b. Describe the use of topical fluorouracil on the incision. c. Teach how to use sterile technique to clean the suture line. d. Teach the use of cold packs to reduce bruising and swelling.

D

Postoperatively, the nurse should monitor the patient who received inhalation anesthesia for which complication? a. Tachypnea c. Hypertension b. Myoclonus d. Laryngospasm

D

The nurse should assess the patient undergoing plasmapheresis for which clinical manifestation? a. Shortness of breath c. Transfusion reaction b. High blood pressure d. Extremity numbness

D

The nurse should plan to use a wet-to-dry dressing for which patient? a. A patient who has a pressure ulcer with pink granulation tissue b. A patient who has a surgical incision with pink, approximated edges c. A patient who has a full-thickness burn filled with dry, black material d. A patient who has a wound with purulent drainage and dry brown areas

D

When caring for a patient who has received a general anesthetic, the circulating nurse notes red, raised wheals on the patient's arms. Which action should the nurse take? a. Apply lotion to the affected areas. b. Cover the arms with sterile drapes. c. Recheck the patient's arms during surgery. d. Notify the anesthesia care practitioner (ACP).

D

The nurse is developing a health promotion plan for an older adult who worked in the landscaping business for 40 years. The nurse will plan to teach the patient about how to self-assess for which clinical manifestations (select all that apply)? a. Vitiligo b. Alopecia c. Intertrigo d. Erythema e. Actinic keratosis

D,E