Test1: Med/surg

A patient is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? Ensure that informed consent is on the chart Administer prescribed anxiolytic medication Start the preoperative antibiotic infusion Reinforce any teaching done previously

Ensure that informed consent is on the chart

A new nurse is working with a preceptor on an inpatient medical-surgical unit. The preceptor advises the student that which is the priority when working as a professional nurse? Providing patient-focused care Ensuring patient safety Attending to holistic patient needs Not making medication errors

Ensuring patient safety

While monitoring a patient who had surgery under general anesthesia 2 hours ago, the nurse notes a sudden elevation in body temperature. This finding may be an indication of which problem? Malignant hyperthermia Malignant hypertension Tachyphylaxis Postoperative infection

Malignant hyperthermia A sudden elevation in body temperature during the postoperative period may indicate the occurrence of malignant hyperthermia, a life-threatening emergency. The elevated temperature does not reflect the other problems listed.

A nurse is giving a patient instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate? "Be sure to wash the area where you will have surgery very thoroughly." "Wash the surgical site first, then shampoo and wash the rest of your body." "After you wash the surgical site, shave that area with your own razor." "Use a washcloth to wash the surgical site; do not take a full shower or bath."

"Be sure to wash the area where you will have surgery very thoroughly."

A newly graduated nurse in the hospital states that, since she is so new, she cannot participate in quality improvement (QI) projects. What response by the precepting nurse is best? "Even being new, you can implement activities designed to improve care." "All staff nurses are required to participate in quality improvement here." "It's easy to identify what indicators should be used to measure quality." "You should ask to be assigned to the research and quality committee."

"Even being new, you can implement activities designed to improve care." The preceptor should try to reassure the nurse that implementing QI measures is not out of line for a newly licensed nurse. Simply stating that all nurses are required to participate does not help the nurse understand how that is possible and is dismissive. Identifying indicators of quality is not an easy, quick process and would not be the best place to suggest a new nurse to start. Asking to be assigned to the QI committee does not give the nurse information about how to implement QI in daily practice.

The nurse is preparing to bring a young female patient to the operating room for a total abdominal hysterectomy (TAH). The patient says to the nurse, "I am so glad that I will still be able to have children after this surgery." What is the nurse's best response? "You must have misunderstood your surgeon." "Weren't you taught about your surgery earlier?" "I will call the surgeon to speak with you before surgery." "That is very good news. How many children do you want?"

"I will call the surgeon to speak with you before surgery." TAH includes removal of the uterus, which will leave the client unable to have children. The surgeon should be called to speak with the patient and explain the surgery before the patient is moved to the operating room.

The nurse is caring for a patient who has had surgery the previous day. The patient tells the nurse, "Breathing in using this thing (incentive spirometer) is a ridiculous waste of time." What is the nurse's best response? "The spirometer will help your lungs expand." "The spirometer will improve blood flow in your lungs." "The spirometer will help prevent blood clots." "The spirometer will help you cough effectively."

"The spirometer will help prevent blood clots." "The spirometer will help you cough effectively." The primary purpose of using an incentive spirometer is to promote lung expansion. The incentive spirometer assists the patient in seeing how much air he or she can inhale. The nurse can encourage the patient by setting a volume and encouraging the patient to reach it. Although many patients may cough while using this, it does not help them cough. Patients begin to cough after taking deep breaths. The spirometer will help with airflow into the lungs, not with blood flow.

A patient will be undergoing palliative surgery. The patient's daughter asks what this means. What is the nurse's best response? "The surgery will relieve the symptoms but will not cure your father." "I won't have to worry about putting my makeup on tomorrow morning." "There are fewer risks with this type of surgery." "There is no guarantee of the outcome of the surgery."

"The surgery will relieve the symptoms but will not cure your father." The purpose of palliative surgery is to improve the patient's quality of life by reducing or eliminating distressing symptoms. It does not cure a health problem and often does not prolong life.

Ten hours after surgery, a postoperative patient reports that the antiembolism stockings and sequential compression devices itch and are too hot. The patient asks the nurse to remove them. What response by the nurse is best? "To prevent blood clots, you need them a few more hours." "Let me call the surgeon to see if you really need them." "No, you have to use those for 24 hours after surgery." "OK, we can remove them since you are stable now."

"To prevent blood clots, you need them a few more hours."

A nurse is preparing a patient for discharge after surgery. The patient needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important? "Wash your hands before touching the drain or dressing." "Be sure you keep all your postoperative appointments." "Call your surgeon if you have any questions at home." "Eat a diet high in protein, iron, zinc, and vitamin C."

"Wash your hands before touching the drain or dressing."

A 78-year-old patient is in the recovery room after having a lengthy surgery on his hip. As he is gradually awakening, he requests pain medication. Within 10 minutes after receiving a dose of morphine sulfate, he is very lethargic and his respirations are shallow, with a rate of 7 per minute. The nurse prepares for which priority action at this time? Assessment of the patient's pain level Administration of naloxone (Narcan) Immediate intubation and artificial ventilation Close observation of signs of opioid tolerance

Administration of naloxone (Narcan) Naloxone, an opioid-reversal agent, is used to reverse the effects of acute opioid overdose and is the drug of choice for reversal of opioid-induced respiratory depression. This situation is describing an opioid overdose, not opioid tolerance. Intubation and artificial ventilation are not appropriate because the patient is still breathing at 7 breaths per minute. It would be inappropriate to assess the patient's level of pain.

A postoperative patient has just been admitted to the post-anesthesia care unit (PACU). What assessment by the PACU nurse takes priority? ! Airway Breathing Bleeding Cardiac rhythm

Airway

Bronchial obstruction by retained secretions has contributed to a postoperative patient's recent pulse oximetry reading of 87%. Which health problem is the patient probably experiencing? Atelectasis Pulmonary embolism Bronchospasm Hypoventilation

Atelectasis The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.

An inpatient nurse brings an informed consent form to a patient for an operation scheduled for tomorrow. The patient asks about possible complications from the operation. What response by the nurse is best? Do not have the patient sign the consent and call the surgeon Have the patient sign the consent, and then call the surgeon Answer the questions and document that teaching was done Remind the patient of what teaching the surgeon has done

Do not have the patient sign the consent and call the surgeon

A patient in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best? Insert a urinary catheter now instead of waiting Allow the patient to walk to the bathroom Give the patient a bedpan or urinal to use Delegate assisting the patient to the nurse's aide

Give the patient a bedpan or urinal to use

The surgical team in the operating room performs a surgical time-out just before starting hip replacement surgery for a 62-year-old woman. Which action would be part of the surgical time-out? Determine if the patient has any questions about the procedure Have the patient verify the procedure and the location of the surgery Check the chart for a signed consent form for the procedure Assess the patient's vital signs and oxygen saturation level

Have the patient verify the procedure and the location of the surgery During a surgical time-out, the surgery team will stop all activities right before the procedure to verify the patient identification, surgical procedure, and surgical site. Proper identification will be accomplished by asking the patient to state name, birth date, and operative procedure and location. In addition, the surgical team will compare the hospital ID number with the patient's own ID band and chart.

A patient has arrived in the postoperative unit. What action by the circulating nurse takes priority? Assessing fluid and blood output Checking the surgical dressings Ensuring the patient is warm Participating in hand-off report

Participating in hand-off report

The post-anesthesia care unit (PACU) charge nurse notes vital signs on four postoperative patients. Which patient would the nurse assess first? Patient with a respiratory rate of 6 breaths/min Patient with a pulse of 118 beats/min mm Hg Patient with a blood pressure of 100/50 Patient with a temperature of 96° F (35.6° C)

Patient with a respiratory rate of 6 breaths/min

A patient has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important when the patient arrives in the PACU? Prevent the patient from experiencing postoperative shivering Place the patient on a cardiac monitor and pulse oximeter Prepare to administer intravenous antiemetics to the patient Assist with administering muscle relaxants to the patient

Place the patient on a cardiac monitor and pulse oximeter

Which drug is used in the treatment of heparin toxicity? Phytonadione Protamine Cefazolin Naloxone

Protamine

The nurse is assessing patients for postoperative complications. What is the most commonly assessed postanesthesia recovery emergency? Cardiac Distress Respiratory Obstruction Dehydration Wound Infection

Respiratory Obstruction

When preparing a patient who has diabetes mellitus for surgery, the nurse should be aware of what surgical risk associated with this disease? Altered metabolism and excretion of drugs Fluid and electrolyte imbalance Slow wound healing Respiratory depression from anesthesia

Slow wound healing

Which of the following nursing interventions is most likely to prevent respiratory complications such as pneumonia and atelectasis in a post surgical patient? Control of anxiety and agitation Adequate nutrition and fluids Adequate pain control Use of incentive spirometry

Use of incentive spirometry

The nurse cares for a patient who is 5'7" tall, weighs 350 pounds, and is recuperating from an exploratory laparotomy. The patient cooperates with coughing and deep breathing, exercises and ambulates a distance of 25 feet in the hallway. For which postoperative complication should the nurse most vigiliantly assess the patient? Pneumonia Pulmonary emboli Wound dehiscense Fat emboli

Wound dehiscense Wound dehiscence is related to stress on surgical site; patient weight has the potential to place great stress on the incision, putting the patient at high risk for the complication of wound dehiscence is a separation of wound edges; experienced 5 to 6 days postoperatively; nursing care includes placing patient in low Fowler's position, no coughing, NPO, and notify health care provider if dehiscence occurs,