UNRS 107 Quiz_Prep_Surgical pt_Rational - ATI Quiz #3 Prep (The surgical client)

16. A nurse is teaching a client how to use an incentive spirometer. Which of the following statements should the nurse make? A. "Inhale through the incentive spirometer 10 times with each use." B. "Use the incentive spirometer once every 4 hours." C. "Hold your breath for 7 seconds when using the incentive spirometer." D. "Sit up at a 30-degree angle when using the incentive spirometer."

A. "Inhale through the incentive spirometer 10 times with each use." Rationale: The client should use the incentive spirometer 10 times with each use to promote lung expansion and reduce the risk for atelectasis.

21. A nurse is teaching a client about reducing the risk for falls. Which of the following statements should the nurse make? A. "Install handrails in your bathroom." B. "Wear backless shoes." C. "Cover extension cords with a throw rug." D. "Use a standard height toilet seat."

A. "Install handrails in your bathroom." Rationale: The client should install handrails in their bathroom to reduce the risk for falls.

17. A nurse is admitting a client to the post-anesthesia care unit. Which of the following actions should the nurse take first? A. Check the client's airway. B. Check the client's blood pressure. C. Check the client's level of consciousness. D. Check the client's level of pain.

A. Check the client's airway. Rationale: The first action the nurse should take using the airway, breathing, circulation approach to client care is to check the client's airway. Anesthesia places the client at risk for hypoxia. The nurse should check the client's airway, reposition the airway if needed, and apply supplemental oxygen.

20. A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take? A. Cut the client's food into small pieces. B. Turn on the television when the client is eating. C. Place the head of the client's bed flat after meals. D. Instruct the client to tip their head back when eating.

A. Cut the client's food into small pieces. Rationale: The nurse should cut the client's food into small pieces and instruct the client to chew food completely before swallowing to reduce the risk of aspiration.

9. A nurse is caring for a client who is experiencing postoperative nausea and vomiting. The nurse should monitor the client for which of the following complications of vomiting? A. Dehydration B. Diarrhea C. Urinary frequency D. Peripheral edema

A. Dehydration Rationale: The client is at risk for dehydration and electrolyte imbalance. Therefore, the nurse should monitor the client for hypotension, tachycardia, and reduced urine output.

11. A nurse is teaching a newly licensed nurse about anesthesia. The nurse should include that the client is not arousable during which of the following types of anesthesia? A. General anesthesia B. Moderate sedation C. Local anesthesia D. Regional anesthesia

A. General anesthesia Rationale: General anesthesia involves the use of medications to depress the central nervous system. During this type of anesthesia, clients experience a loss of consciousness, reflexes, and sensation

12. A nurse is assessing a client who received lidocaine for local anesthesia. Which of the following findings should the nurse identify as a manifestation of lidocaine toxicity? A. Numbness around mouth B. Hypertension C. Diarrhea D. Elevated temperature

A. Numbness around mouth Rationale: Manifestations of lidocaine toxicity include numbness around mouth, tachycardia, tachypnea, and tinnitus.

5. A nurse is reviewing the medical history on a client who is preoperative for surgery. Which of the following findings places the client at risk for a postoperative complication? A. Obstructive sleep apnea B. Fractured ankle C. BMI 24 D. Glucose level 75 mg/dL

A. Obstructive sleep apnea Rationale: Obstructive sleep apnea places the client at risk for postoperative airway obstruction.

24. A nurse is caring for a client who had a stroke and has dysphagia. The nurse should monitor the client for which of the following complications? A. Gastroesophageal reflux disease B. Aspiration C. Peptic ulcer disease D. Dumping syndrome

B. Aspiration Rationale: Client who have dysphagia are at risk for aspiration pneumonia. The nurse should monitor the client for fever and adventitious breath sounds.

6. A nurse is caring for a client who is scheduled for surgery and who reports they smoke cigarettes. The nurse should identify that tobacco use increases the client's risk for which of the following postoperative complications? A. Malignant hyperthermia B. Blood clots C. Nausea D. Bleeding

B. Blood clots Rationale: Smoking tobacco increases the risk for blood clots, myocardial infarction, pneumonia, tissue necrosis, and delayed wound healing.

13. A nurse is planning care for a client who is scheduled for a colonoscopy. The nurse should expect the client to receive which of the following types of anesthesia? A. General anesthesia B. Moderate sedation C. Local anesthesia D. Regional anesthesia

B. Moderate sedation Rationale: Moderate sedation is used for short procedures, such as cataract removal or a colonoscopy. This type of anesthesia involves the use of short-acting IV sedatives.

23. A nurse is caring for a client who has dysphagia. The nurse should monitor the client for which of the following complications? A. Diarrhea B. Pneumonia C. Pulmonary embolism D. Pressure injury

B. Pneumonia Rationale: Clients who have dysphagia are at risk for aspiration pneumonia. The nurse should monitor the client for fever and adventitious breath sounds.

4. A nurse is teaching a newly licensed nurse about informed consent. Which of the following should be included as a responsibility of the nurse in this process? A. Discuss the risks of the procedure with the client. B. Explain alternatives to the procedure to the client. C. Confirm that the client is competent to sign for the procedure. D. Inform the client about what will occur during the procedure.

C. Confirm that the client is competent to sign for the procedure. Rationale: The nurse should confirm the client is competent, of legal age, voluntarily giving consent, and has been given adequate information about the procedure.

8. A nurse is assessing a client who is experiencing hypovolemia. Which of the following findings should the nurse expect? A. Bradycardia B. Hypertension C. Oliguria D. Peripheral edema

C. Oliguria Rationale: The nurse should expect the client who has hypovolemia to have decreased urine output, decreased capillary refill, and confusion.

3. A nurse is caring for a client who is scheduled for surgery and has a history of alcohol abuse. The nurse should identify that alcohol abuse increases the client's risk for which of the following postoperative complications? A. Malignant hyperthermia B. Blood clots C. Nausea D. Bleeding

D. Bleeding Rationale: Alcohol abuse increases the risk for liver disease, portal hypertension, and esophageal varices, which can result in bleeding.

22. A nurse is caring for a client who is postoperative, has a peripheral IV, and is requesting ice chips. Which of the following actions should the nurse take? A. Remove the client's peripheral IV. B. Check the client for bladder distention. C. Lower the head of the client's bed. D. Check the client's gag reflex.

D. Check the client's gag reflex. Rationale: The nurse should check the client's gag reflex before administering ice chips to reduce the risk of aspiration.

25. A nurse is teaching a client about performing leg exercises to reduce the risk for deep vein thrombosis. Which of the following instructions should the nurse include? A. Perform leg exercises every 4 hr. B. Repeat each leg exercise 2 times per session. C. Point the toes toward the foot of the bed. D. Rotate the feet in a circular motion. E. Point the toes toward the head.

C. Point the toes toward the foot of the bed. D. Rotate the feet in a circular motion. E. Point the toes toward the head. Rationale: Perform leg exercises every 4 hr is incorrect. The client should use perform leg exercises every 1 to 2 hr to reduce the risk for deep vein thrombosis.Repeat each leg exercise 2 times per session is incorrect. The client should repeat each exercise 5 times per session to reduce the risk for deep vein thrombosis.Point the toes toward the foot of the bed is correct.The client should alternate dorsiflexion and plantar flexion of the feet to promote venous return and reduce the risk for deep vein thrombosis.Rotate the feet in a circular motion is correct.The client should rotate the feet in a circular motion to promote venous return and reduce the risk for deep vein thrombosis.Point the toes toward the head is correct. The client should alternate dorsiflexion and plantar flexion of the feet to promote venous return and reduce the risk for deep vein thrombosis.

10. A nurse is caring for an older adult client who experienced temporary disorientation following surgery. The nurse should identify that this finding as a manifestation of which of the following complications? A. Postoperative cognitive dysfunction B. Alzheimer's disease C. Postoperative delirium D. Dementia

C. Postoperative delirium Rationale: Postoperative delirium is a temporary condition in which clients become disoriented and confused following anesthesia. This condition can last up to a few weeks.

19. A nurse is teaching a client who is scheduled for abdominal surgery about coughing and deep breathing. Which of the following statements should the nurse make? A. "Lie supine to cough and deep breath." B. "Cough and deep breath every 4 hours." C. "Inhale through your mouth when deep breathing." D. "Splint your incision with a pillow when coughing."

D. "Splint your incision with a pillow when coughing." Rationale: The client should splint the incision with a pillow when coughing to decrease pain and support the incision.

18. A nurse is teaching a client about using a PCA device for postoperative pain management. Which of the following statements should the nurse make? A. "A large dose of pain medication is administered with each injection." B. "The pain medication is delivered into your muscle." C. "Your partner can push the PCA button for you if you are asleep." D. "You will have control of administering your own pain medication."

D. "You will have control of administering your own pain medication." Rationale: PCA devices allow the client to control administration of their own pain medication.

7. A nurse is assessing a client who is experiencing hypervolemia. Which of the following findings should the nurse expect? A. Bradycardia B. Hypotension C. Oliguria D. Peripheral edema

D. Peripheral edema Rationale: The nurse should expect the client who has hypervolemia to have peripheral edema, crackles in lungs, and increased central venous pressure.

14. A nurse is teaching a newly licensed nurse about anesthesia. The nurse should include that an epidural is an example of which of the following types of anesthesia? A. General anesthesia B. Moderate sedation C. Local anesthesia D. Regional anesthesia

D. Regional anesthesia Rationale: Regional anesthesia involves the use of an anesthetic agent injected into a sensory nerve pathway, such as during a spinal or epidural block. An epidural is an example of regional anesthesia.

15. A nurse is performing a skin preparation for a client who is scheduled for surgery. Which of the following actions should the nurse take? A. Shave the client's hair near the surgical site. B. Scrub the surgical site starting at the outer edge and moving inward. C. Cleanse the surgical site with a povidone-iodine solution. D. Use a new sponge each time the surgical site is scrubbed.

D. Use a new sponge each time the surgical site is scrubbed. Rationale: The nurse should use a new sponge each time the surgical site is scrubbed to reduce the risk of infection.