Adult Exam 1

Acetaminophen

-blocks peripheral pain receptors -tylenol -hepatotoxicity and nephrotoxicity -4,000mg in 24 hrs

Tolerance

-continued exposure to a medication leads to decreased effectiveness of the medication -different than physical dependence

pseudoaddiction

-due to under-treatment of pain -pt's ask for more pain meds, staff starts to avoid giving medications bc they think pt is addicted

physical dependence

-manifest w withdrawal symptoms d/t the cessation of the medication

NSAIDs

-works by inhibiting the synthesis of prostaglandins -aspirin, ibuprofen -side effects: GI bleeding, acute renal failure

A client has a one-time prescription for morphine 1 mg IV push. The drug is available as 5 mg/mL. The nurse administers _______ mL of morphine for one dose.

0.2

A patient needs morphine 2 mg IV push. The drug is available as 5 mg/mL. How many mL would the nurse administer? ______mL of morphine

0.4

what 3 things should an informed consent form have?

1. nature/reason for surgery that's understood by patient (side specificity) 2. Who is performing surgery 3. Risks of procedure/anesthesia documented

A blind patient is to have a surgical procedure. She asks the nurse whether she will be able to sign her own consent form. What is the nurse's best response? A. "yes, but your signature will need to have two witnesses" B. "no, but your next of kin can sign the consent form for you" C. "yes, but you will need to make an X instead of signing your name" D. "no, but you can give instructions to sign for you to any responsible adult"

A

A colostomy is scheduled to be done on a patient who has severe Crohn's disease. What is the correct classification for this surgery? A. palliative B. minor C. restorative D. curative

A

A nurse is assessing the pain level of a client who came to the ED reporting severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. The nurse is assessing which of the following components of a pain assessment? A. presence of associated manifestations B. location of pain C. pain quality D. aggravating and relieving factors

A

A nurse is assisting an anesthesiologist in the delivery of nitrous oxide by face mask to a client during the induction of anesthesia. Which of the following is the priority nursing action? A. assess O2 sat B. measure BP C. palpate HR D. check temp

A

A nurse is caring for a client who is scheduled for an exploratory laparotomy. The client's temp is 102.2F orally. Which of the following actions should the nurse take? A. inform the surgeon of the elevated temp B. transfer the client to the preoperative unit C. apply ice packs to the groin D. encourage the client to increase intake of clear liquids

A

A nurse is caring for a client who reports nausea and vomiting 2 days postoperative following a hysterectomy. Which of the following actions should the nurse perform first? A. assess bowel sounds B. administer antiemetic medication C. restart prescribed IV fluids D. insert a prescribed NG tube

A

A patient arrives in the PACU. Which action does the nurse perform first? A. Assess for a patient airway and adequate gas exchange B. assess the patient's pain level using the 0-10 pain assessment scale C. position the patient in a supine position to prevent aspiration D. calculate the PCA pump maximum dose per hour to avoid an overdose

A

A patient has an MH incident during surgery. To whom does the nurse report this incident? A. north american MH registry B. TJC C. CDC D. occupational safety and health administration

A

According to ethical principles, which patient has been provided social justice? A. patient with no health insurance receives the same care as all the other patients B. patient gets a bath and a back rub at the exact time that the nurse promised C. patient decides what will be included in the advanced directives D. patient agrees with the nurse's advice to eat healthy and balanced diet

A

Acetaminophen is the FIRST-LINE medication for which patient? A. Needs relief from pain related to a minor surgical procedure B. Has chronic pain and discomfort due to rheumatoid arthritis C. Experiences burning and tingling in legs due to diabetes D. Has intermittent abdominal cramping due to Crohn's disease

A

After a patient is prepared for surgery and before preoperative drugs are given and the patient is transported to surgery, which essential intervention can the nurse delegate to the UAP at this time? A. assist the patient to empty their bladder B. help the patient to remove all clothing C. ask the patient if they want to brush teeth D. recheck the patient's identity

A

An appendectomy is being performed on a patient with appendicitis. What is the correct classification for this surgery? A. curative B. diagnostic C. urgent D. radical

A

An older adult is scheduled for an elective surgical procedure. On assessment the nurse notes brittle nails, dry flaky skin, muscle wasting, and dry sparse hair. The patient's BP is 82/48 and HR is 112/ min. How does the nurse interpret this assessment data? A. poor fluid and nutrition status B. improper care in the home C. expected physiological changes of aging D. depression related to aging process

A

Based on evidence-based practice, what is the best choice for managing chronic pain for a 73-year-old woman with OA? A. acetaminophen is the primary drug of choice B. Tramadol is the first-line choice for this patient C. long-term use an oral NSAID, such as ibuprofen, is the best D. topical NSAIDs and nonpharmacologic measures should be tried first

A

Bedside computers are an example of informatics used in health care primarily for which purpose? A. Documenting interdisciplinary care B. Enhancing collaboration and coordination of care C. Offering clients access to e-mail and the Internet D. Retrieving data for evidence-based practice

A

Cataract surgery, Hernia surgery, Joint replacement A. Elective-non-acute B. Urgent-prompt attention C. Emergent-life threatening

A

During the preoperative screening, the nurse discovers that the patient is allergic to shellfish. What is the nurse's best first action? A. notifies the surgeon B. develops a plan to keep the patient safe C. obtains an order for a shellfish-free diet D. asks the patient if any other family members have the same allergy

A

The client is NPO for surgery scheduled to occur in 4 hours. It is now 9 AM, and the client's regularly prescribed oral drugs (digoxin 0.125 mg, docusate [Colace] 300 mg, and ferrous fumarate [Feostat] 325 mg) are due to be administered. The physician will not be available until the time of surgery. What is the nurse's best action? A. Administer digoxin with minimal water and hold the other drugs. B. Administer all medications parenterally. C. Administer all medications orally. D. Hold all medications.

A

The home health nurse is visiting a 73-year-old diabetic patient who was recently discharged after surgery. While reviewing a list of the patient's medications, the nurse sees that there are several different classes of analgesics listed. Which action is the nurse MOST LIKELY to take? A. Assesses patient's understanding of the multimodal treatment plan and ability to comply B. Contacts the health care provider to discontinue medications that contribute to poly pharmacy. C. Emphasizes that medications with more side effects are the last choice for pain. D. Advises the patient not to take any NSAIDS because of irritation of gastric mucosa

A

The nurse is caring for a patient who has had abdominal surgery. After a hard sneeze, the patient reports pain in the surgical area, and the nurse immediately sees that the patient has a wound evisceration. What priority action must the nurse do first? A. call for help and stay with the patient B. leave the patient and immediately call the surgeon C. cover the wound with a nonadherent dressing moistened with normal saline D. take the patient's vital signs

A

The nurse is interviewing a patient who frequently comes to the clinic to obtain medication for chronic back pain. The patient states, "I know you guys think I'm faking, but I hurt and I am really sick of your attitude." What is the best response? A. "sir tell me about your pain and how it is affecting your life" B. "sir, you can speak to a pain specialist if you would prefer" C. "sir, i see you are frustrated, but you are unfairly judging me" D. "sir, we are trying our best; lets just continue the interview"

A

The older overweight patient is being placed on the operating table for an appendectomy. What is the priority med-surg concept for this patient? A. safety B. tissue integrity C. immunity D. gas exchange

A

Which assessment is the MOST important for the nurse to perform for the client admitted to the PACU after the surgery under general anesthesia? A. Determining the client's level of consciousness B. Checking for pain on dorsi and plantar flexion of the foot C. Assessing the response to pin-prick stimulation from feet to mid-chest level D. Comparing blood pressure taken in the right arm to blood pressure taken in the left arm

A

Which important aspect of coordinating care within the interdisciplinary team is facilitated by use of the "SBAR" procedure? A. Communication B. Implementation C. Policymaking D. Protocol development

A

Which intervention by the nurse will help a postoperative patient with compliance in getting up to ambulate? A. offer the patient pain medication 30-45 min before ambulation B. assist the patient to turn from side to side every 2 hours C. remind the patient to perform extremity exercises every 4 hours D. teach the patient that activity helps prevent postoperative complications

A

Which members of the surgical team usually accompany a postoperative patient to the PACU? A. anesthesia provider and circulating nurse B. circulating nurse and surgeon C. surgeon and anesthesia provider D. surgical assistant and surgeon

A

Which nursing intervention is most appropriate for the patient in the operative setting? A. provide a climate of privacy, comfort, and confidentiality when caring for the patient B. instruct the patient that after the preoperative medication has taken effect, they will be drowsy C. avoid discussing the activities taking place around the patient while in the holding area D. assist members of the surgical team readying the operating room suite

A

Which nursing interventions will prevent the potential intraoperative complication of radial nerve complications (wrist drop)? A. support the wrist with padding; don't overtighten wrist straps B. place pillows or foam padding under bony prominences, maintain good body alignment, and slightly flex joints and support with pillows and pads C. pad the elbow, avoid excessive abduction, and secure the arm firmly on an arm board positioned at shoulder level D, place safety strap above or below the area. Place a pillow or padding under the knees

A

Which patient is most at risk for postoperative nausea and vomiting? A. the patient with a history of motion sickness B. the patient with a NG tube C. the patient who recently experienced a weight loss of 50 lbs D. the patient who had MIS

A

Which patient is most likely to experience inequality in health care? A. a 73-year-old transgender female who is asking for directions to the public restroom B. a 56-year-old woman who has liver failure and wants to be on the transplant list C. a 34-year-old man seeking treatment for a broken wrist sustained by falling from a motorcycle D. a 17-year-old female who wants a pregnancy test but is unaccompanied by a parent

A

Which patient is most likely to receive a prescription for gabapentin? A. a patient who has persistant burning and tingling sensation in the lower extremities B. a patient who reports a gnawing and burning discomfort in the epigastric area between meals C. a patient who expresses fear, anxiety, and uncertainty related to episodes of angina D. a patient who has intractable pain related to malignant spread of cancer

A

Which patient is most likely to report pain that would be considered acute? A. has a hx of peripheral vascular disease; foot is suddenly cold and blue B. has a hx of diabetic neuropathy; reports burning sensation in lower leg C. has a hx of old ankle fracture; reports recent diagnosis of OA D. has a hx of osteosarcoma in the femur with amputation above tumor site

A

Which statement is true regarding the patient who has given consent for a surgical procedure? A. information necessary to understand the nature of and reason for the surgery has been provided B. the length of stay in the hospital has been pre-approved by the managed care provider C. information about the surgeon's experience has been provided D. the nurse has provided detailed information about the surgical procedure

A

A nurse is caring for a female client who manifests indications of hypovolemia while in the PACU. which of the following requires action by the nurse? SATA A. urine output less than 25mL/hr B. hct 48% C. BUN 24 D. tenting of skin over the sternum E. apical pulse rate of 62

A, B, C, D

A nurse is reviewing the health records of several clients in the PACU to identify risk factors that can lead to postoperative complications. which of the following clients are at risk for complications? SATA A. a client who has a WBC of 22,500 B. a client who uses an insulin pump C. a client who takes warfarin daily D. a client who has HF E. a client who has a BMI of 26

A, B, C, D

A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care? SATA A. encourage use of incentive spirometer every 2 hours B. instruct the client to splint the incision when coughing and deep breathing C. reposition the client every 2 hours D. administer antibiotic therapy E. assist with early ambulation

A, B, C, E

Which clinical features are found in a MH crisis? SATA A. sinus tachycardia B. jaw muscle rigidity C. hypotension D. a decrease in end-tidal CO2 level E. skin mottling and cyanosis F. an extremely elevated temp at onset

A, B, C, E, F

The nurse has received a patient in the holding area who is scheduled for a left femoral-popliteal bypass. What are the priority safety measures for this patient before surgery? SATA A. the operative limb is marked by the surgeon B. the patient is positively identified by checking the name and date of birth C. the patient is asked to confirm the marked operative limb D. the patient is identified by checking the name and room number E. the patient is instructed to verify any family members waiting F. the patient is kept on NPO status

A, B, C, F

A client who had a total knee replacement 2 weeks ago reports severe pain at the surgical site. Which responses by the nurse are MOST appropriate for the client at this time? SELECT ALL THAT APPLY A. "Please rate your pain on a 0-10 scale, with 10 being the worst possible pain." B. "Could you describe the pain in your knee?" C. "By now your pain should be a lot less than it was 2 weeks ago." D. "Which positions make the pain feel worse or better?" E. "Having your joint replaced should have decreased your knee pain."

A, B, D

A nurse providing preoperative teaching to a client who is to have abdominal surgery. Which of the following statements should the nurse make? SATA A. "take your heart medication with a sip of water before surgery" B. "splint the abdominal incision with a pillow when coughing and deep breathing" C. bed rest is recommended for the first 48 hrs" D. "you may eat solid foods up to 4 hrs before surgery"

A, B, D

The 79-year-old patient with type 2 diabetes is scheduled for surgery to remove his left great toe. Which risk factors for complications of surgery does the nurse assess in this patient? SATA A. presence of chronic illnesses B. problems with healing C. absence of smoking history D. dehydration E. electrolyte imbalance F. daily exercise routine

A, B, D, E

The PACU nurse is assessing an older adult patient for postoperative pain. Which nonverbal manifestations by the patient suggest pain to the nurse? SATA A. restlessness B. profuse sweating C. difficult to arouse D. confusion E. increased BP F. decreased HR

A, B, D, E

The PACU nurse is receiving the "handoff" report for a patient transferred in from the OR. Which statements about this report are accurate? SATA A. a handoff report requires clear, concise language B. a handoff report is a two-way verbal interaction between the health care professional giving the report and the nurse receiving it C. the hand off report should be individualized based on the patient and their surgery D. the receiving nurse takes the time to restate the information to verify what was said E. the receiving nurse takes the time to ask questions, and the reporting professional must respond to the questions until a common understanding is established F. the receiving nurse continues assessing other patients while the handoff report is being given

A, B, D, E

What information should be included in the handoff report when a patient is transferred from the OR to the PACU staff? SATA A. type and extent of surgical procedure B. intraoperative complications and how they were handled C. list of usual daily medications D. type and amount of IV fluids and blood products given E. location and type of incisions, dressings, catheters, tubes, drains, or packing. F. name, address, and phone number of next of kin

A, B, D, E

A patient with the type 1 DM is scheduled for surgery at 0700. Which actions must the nurse perform for this patient before he goes to the operating rooms? SATA A. modify the dose of insulin given based on the patient's blood glucose as ordered B. complete the preoperative checklist before transfer to the surgical suite C. teach the patient about foot care and properly fitted shoes D. delegate obtaining the patient's fingerstick blood glucose and vital signs to the UAP E. check if the patient is wearing any jewelry and call security to secure valuables if necessary F. place the patient on NPO status for the period ordered by the surgeon

A, B, D, E, F

The nurse has given the ordered preoperative medications to the patient. What actions must the nurse take after administering these drugs? SATA A. raise the siderails B. place the call light within the patient's reach C. as the patient to sign the consent form D. instruct the patient not to get out of bed E. place the bed in its lowest position F. tell the patient that they may become drowsy

A, B, D, E, F

Which health care workers are likely to be members of a RRT? SATA A. critical care nurse B. respiratory therapist C. phlebotomist D. social worker E. intensivist F. pastoral caregiver

A, B, E

The health care provider removed a patient's original surgical dressing 2 days after surgery and is discharging the patient home with daily dressing changes. Which actions will the nurse take for this patient's discharge teaching? SATA A. ask the patient's family or significant other to observe the dressing change B. ask the UAP to get dressing supplies for the patient C. instruct that the drainage will appear serosanguineous D. instruct the patient to go to the ED for problems related to dressing changes E. have the case manager arrange for a home health nurse to ensure that dressing changes are done and there are no complication sor infections F. teach the patient and family the signs and symptoms of infection

A, B, E, F

In addition to providing care with skill in techniques and procedures, what must the medical-surgical nurse also be prepared to utilize when caring for the patient? (Select all that apply) A. Teaching B. Patient Safety C. Spiritual counseling and support D. Rehabilitation strategies and methods E. Administrative scheduling and budgeting F. Coordination of care

A, B, F

An older client take ibuprofen 1600 mg daily for osteoarthritis. Which health teaching will the nurse provide for the client related to this medication? SELECT ALL THAT APPLY A. "Be sure and take your medication with food to prevent stomach ulcers." B. "Take your medication only when you need it for chronic pain." C. "Avoid any over-the-counter medications that may contain ibuprofen." D. "Take your blood pressure often because ibuprofen can cause it to go up." E. "You might want to take acetaminophen because it has fewer side effects than ibuprofen."

A, C

Which characteristics are appropriate to moderate sedation drugs? SATA A. reduce sensory perception B. require placement of an artificial airway C. amnesia action is short D. return to normal function is rapid E. increase LOC F. may be administered only by a physician

A, C, D

Which interventions must the OR nurses provide for patient physiological integrity during the intraoperative period? SATA A. apply padding to the OR bed to protect skin integrity B. communicate patient's fears about anesthesia to the nurse anesthetist C. monitor patient's airway, vital signs, ECG, and O2 sat. during and after sedation D. assess and document skin condition before transferring patient to the PACU E. ensure that patient's wished about advance directives are respected F. reposition every 2 hrs, especially for very long surgeries

A, C, D

Which tasks should the nurse delegate to an UAP? SATA A. turn patient every 2 hours B. evaluate patient's skin during bathing C. feed patient breakfast and lunch D. assist patient with morning care E. take and record patient's vital signs F. discontinue IV infusion

A, C, D, E

To reduce the incidence of patients with a known history or risk of MH, what best practices are put in place in the operating room? SATA A. list of medications available for emergency treatment of MH B. genetic counseling after each episode of MH C. dedicated MH cart with treatment medications D. treatment before, during, and after surgery if the patient has a known history or risk E. additional nursing support on call if MH develops F. available MH hotline number

A, C, D, E, F

Which nursing actions posses a high risk for contributing to error and patient harm? SATA A. caring for several unstable patients who require complex nursing and medical interventions B. requesting the assistance of another staff member to turn a patient C. administering cardiac medications before evaluating vital signs D. preparing medications while trying to answer a student's questions about laboratory results E. recognizing a patient's change in mental status but assuming that it is transitory F. taking a verbal order over the phone from a health care provider regarding a patient's code status

A, C, D, E, F

Which are implied with informed consent? SATA A. the patient understands the nature of and reason for surgery B. the patient is informed of what type of anesthesia drugs will be used C. the patient understands who will do the surgery and who will be present during the surgery D. the patient understands the risks associated with the surgical procedure and its potential outcomes E. the patient understands that blood and blood products must be available during surgery F. the patient is informed of all available options and the benefits and risks associated with each option

A, C, D, F

Which are interventions for the med-surg nurse to use in preventing hypoxemia for the postoperative patient? SATA A. monitor the patient's O2 sat B. position the patient supine C. encourage the patient to cough and breathe deeply D. get the patient ambulating as soon as possible E. instruct the patient to rest as much as possible F. remind the patient to use incentive spirometry every hour while awake

A, C, D, F

Which patient would be a candidate for moderate sedation? SATA A. endoscopy B. cesarean section delivery C. closed fracture reduction D. cardiac catheterization E. abdominal surgery F. cardioversion

A, C, D, F

What techniques are essential to performing a proper surgical scrub of the hands by the surgeon, assistants, and scrub nurse? SATA A. use a broad-spectrum, surgical antimicrobial solution B. scrub for 2 min, followed by a rinse with water C. use an alcohol-based antimicrobial solution D. hold hands and arms so that water runs off, not up or down the arms E. scrub for 3-5 min, followed by a rinse with water F. keep hands below the elbows during the scrub and rinse

A, D, E

Which postoperative interventions will the nurse typically teach a patient to prevent complications following surgery? SATA A. ROM exercises B. massaging of lower extremities C. taking pain medication only when experiencing severe pain D. incision splinting E. deep-breathing exercises F. use of incentive spirometry

A, D, E, F

What are physiologic responses that indicate a patient is experiencing acute pain? SATA A. diaphoresis B. somnolence C. bradypnea D. hypotension E. tachycardia F. dilated pupils

A, E, F

The nurse is caring for four clients who will undergo surgery today. Which client does the nurse recognize as at HIGHEST risk for surgical complication? A. 52-year old who takes aspirin daily B. 58-year old who has well controlled type II diabetes C. 64-year old who has just received presurgical prophylactic antibiotics D. 69-year old who will be discharged after surgery to an extended care facility

A.

-Impaired control over drug use -Compulsive use -Continued use despite harm -Craving

Addiction includes one or more of:

A 75-year-old patient is having an exploratory laparotomy tomorrow. The wife tells the nurse that at night the patient gets up and walks around his room. What priority action does the nurse take after hearing this information? A. notifies the provider B. develops a plan to keep the patient safe C. obtains an order for sleep medication D. tells the patient not to get out of bed at night

B

A nurse is caring for a client who develops a systemic toxic reaction following a regional block. Which of the following actions should the nurse take? A. monitor serum creatinine levels B. provide airway support C. turn the client to the right side D. administer 0.9% sodium chloride 500mL Iv bolus

B

A patient is requesting moderate sedation for repair of a torn meniscus and has no medical contraindications. How does the nurse respond to this patient's request? A. "your surgeon will decide if you will receive moderate sedation or general anesthesia" B. "you can discuss your request for moderate sedation with your surgeon and anesthesiologist" C. "most patients prefer general anesthesia. Can you tell me why you want moderate sedation" D. " it can be frightening to see surgery done on yourself. You need to think about that"

B

A patient who can barely ambulate with a walker at home is having a left total knee replacement. What is the most appropriate category for this surgery? A. urgent B. restorative C. simple D. palliative

B

A patient with an abdominal aortic aneurysm is having surgical repair. What is the correct classification for this surgery? A. restorative B. emergent C. urgent D. minor

B

During the perioperative period a patient receives surgery on the wrong extremity. To which agency must this occurrence be reported? A. AORN B. CMS C. TJC D. ASA

B

For which circumstance would the nurse alert the RRT? A. patient is newly diagnosed with multiple organ failure B. patient has difficulty breathing and intense chest pain C. patient has severe pain and ordered medication is not available D. patient is threatening to leave the hospital against medical advice

B

In the PACU the nurse assesses that a patient is bleeding profusely from an abdominal incision. What is the nurse's best first action? A. notify the surgeon B. apply pressure to the wound dressing C. instruct the UAP to get additional dressing supplies D. request and draw a CBC

B

The acute, life-threatening complication of MH results from the use of which agents? A. hypnotics and neuromuscular blocking agents B. succinylcholine and inhalation agents C. nitrous oxide and pancuronium for muscle relaxation D. fentanyl and regional anesthesia for spinal block

B

The morning after a patient's lower leg surgery, the nurse notes that the dressing is wet from drainage. The surgeon has not yet been in to see the patient on rounds. What does the nurse do about the dressing? A. removes the dressing and puts on a dry, sterile dressing B. reinforces the dressing by adding dry, sterile dressing material on top of the existing dressing C. applies dry, sterile dressing material directly to the wound and the retapes the original dressing D. does nothing to the dressing but calls the surgeon to evaluate the patient immediately

B

The nurse is assessing a patient who is receiving opioid medication via a patient-controlled analgesia device. The patient is very drowsy and difficult to arouse. What should the nurse do FIRST? A. Wake the patient and tell the patient to stop pushing the button so frequently. B. Stay with the patient and discontinue the basal rate. C. Let the patient sleep but increase the frequency of assessment. D. Obtain an order for exclusive use of nonopioid medication

B

The nurse is assisting a surgical patient with pain management. Which outcome statement best demonstrates that the short-term goal is being met 45 min after receiving pain medication? A. patient reports that the pain level is 6/10 B. patient tolerates the dressing change without grimacing C. patient declines a prn anxiolytic medication D. patient asks for assistance to go to the bathroom

B

The nurse is caring for several patients who will receive medication. Which patient is most likely to receive around-the-clock oral opioids? A. patient with fibromyalgia B. patient with chronic cancer pain C. patient with crohn's disease D. patient who had a stroke

B

The nurse is performing an assessment on a client who has arrived in the preoperative holding area. Which client statement requires IMMEDIATE nursing intervention? A. "I'm a little bit anxious about my surgery." B. "When I eat shrimp, my tongue swells, and I have difficulty breathing." C. "This left knee replacement will help me walk much more comfortably again." D. "Before I get discharged home, I want to have my eyeglasses and hearing aids returned."

B

The nurse is teaching incisional care to a patient who is being discharged after abdominal surgery. Which priority instruction must the nurse include? A. do not rub or touch the incision site B. practice proper handwashing C. clean the incision site 2 times a day with soap and water D. splint the incision site as often as needed for comfort

B

The postoperative patient has a penrose drain in place. Which action does the nurse take to prevent skin irritation, wound contamination, and infection? A. keeps the sterile safety pin in place at the end of the drain B. place absorbent pads under and around the exposed drain C. uses minimal tape; when tape is needed, use hypoallergenic tape D. shortens the drain by pulling it out a short distance and trimming off the excess external portion

B

The preoperative patient tells the nurse that she is afraid that she may experience a reaction if she must receive blood during or after her surgery. What is the nurse's best response to the patient's concern? A. "the likelihood that you will need a blood transfusion for your surgery is minimal, so don't worry about this" B. "you could donate some of your own blood a few weeks before your surgery" C. "with today's technology and procedures, it is very unlikely that you would have a reaction to donated blood" D. "the nursing staff follows strict procedures to prevent such an event from ever happening"

B

What is the best type of pain scale to use for children or for adult patients who have language barriers or reading problems? A. 0-10 numeric rating scale B. FACES C. vertical presentation scale D. pasero opioid-induced sedation scale

B

What is the best way for the nurse to assess the patient's understanding after teaching? A. have the patient teach important points to the family B. ask the patient to repeat back the information C. quiz the patient on relevant points of the information D. repeat the important points to the patient

B

What is the primary purpose of a PACU? A. follow-through on the surgeon's postoperative orders B. ongoing critical evaluation and stabilization of the patient C. prevention of lengthened hospital stay D. arousal of patient following the use of conscious sedation

B

What is the purpose of the Rapid Response Team? A. Provide Code Blue teams in case of simultaneous emergencies. B. Enable the nurse to recognize changes in patient status before an acute emergency. C. Replace immediate consultation with the physician or medical resident. D. Provide teams of staff already familiar with the patient's medical diagnosis.

B

When changing the client's abdominal dressing on the second postoperative day, the nurse observes crusting on about half of the suture line and oozing of a small amount of serosanguineous drainage. What is the nurse's best action? A. Loosen the sutures or staples in the area where crusts have formed. B. Clean the suture line with sterile saline and apply new dressings. C. Gently remove the crusts and culture the material beneath. D. Apply pressure over the incision and notify the surgeon

B

Which intervention take priority when a patient is emerging and recovering from general anesthesia? A. check vital signs every 5 min B. be prepared to suction the patient C. increase the rate of IV fluid administration D. check the patient's pupil sizes

B

Which is the best way for the nurse to assess the patient's learning after teaching? A. Have the patient write a summary of the points covered. B. Ask the patient to repeat the information back. C. Quiz the patient on relevant points in the instruction. D. Repeat the important points to the patient.

B

Which nursing action best exemplifies the concept of patient-centered care? A. uses sterile technique to establish a peripheral intravenous catheter B. assesses the patients values and attitudes about advanced directives C. checks the patient's vital signs and compares them to baseline values D. administers breathing treatments according to the scheduled time

B

Which nursing action exemplifies the goal of case management in an acute care setting? A. making sure the patient's dietary choices meet prescribed nutritional needs B. coordinating inpatient and community-based care before discharge C. monitoring the patients vital signs and noting trends of change over time D. reviewing the patient's hospital bill for accuracy and any excessive charges

B

Which patient has the highest risk for inadequate pain management? A. 56-year-old man who had major abdominal surgery for a stab wound B. 78-year-old woman who was transferred to a nursing home after hip surgery C. 10-year-old child who had a tonsillectomy and whose parents can't speak english D. 24-year-old postpartum woman with a history of drug abuse

B

life threatening if past 24-48 hour period. There's time to prep the O.R. but maybe not time for NPO order (intestinal obstruction, closed fracture, kidney stones) A. Elective-non-acute B. Urgent-prompt attention C. Emergent-life threatening

B

A patient with breast cancer is scheduled for a left mastectomy. the patient has informed the surgeon and nurse that she is a Jehovah's witness and doesn't want any blood transfusions. In preparation for intraoperative care of this patient, what measures does the nurse take? SATA A. obtain 2 units of packed RBC, typed and cross-matched B. make provider aware of the patient's request for no blood transfusions C. ensure autotransfusion device is in place intraoperatively D. ensure the patient has a medical necessity order for emergency blood transfusion E. inform the patient of potential risks if blood transfusion is not given F. tell the patient that in case of emergency she may receive blood to save her life

B, C

In which situation is regional anesthesia used instead of general anesthesia? SATA A. for an endoscopy or cardiac catheterization B. in patients who have had adverse reaction to general anesthesia C. in some cases when pain management after surgery is enhanced by regional anesthesia D. in patients with serious medical problems E. when the patients has a preference and a choice is possible F. when the patient is having surgery of the head, neck, upper torsos, and abdomen

B, C, D, E

Which emergency care does the nurse recognize that will be implemented for a client with malignant hyperthermia? SELECT ALL THAT APPLY A. Removal of the endotracheal tube B. Cessation (stopping) of surgery when possible C. Insertion of Foley catheter to monitor urine output D. Transfer of patient to intensive care unit when stabilized E. Assessment of arterial blood gases for respiratory alkalosis F. Use of active cooling techniques such as a cooling blanket and ice packs around the axillae and groin

B, C, D, F

The nurse on the med-surg unit is caring for a postoperative patient. Which assessment criteria indicate to the nurse that the patient is experiencing respiratory difficulty? SATA A. the patient's O2 sat drops from 98% to 94% B. the patient is using accessory muscles to breathe C. the patient makes a high-pitched crowing sound when breathing D. the patient's blood pressure drops from 120/80 to 110/78 mmHg E. the patient's respiratory rate is 29/min F. the patient's urine output drops from 50mL/hr to 30mL/hr

B, C, E

A patient is prescribed morphine sulfate. Which nursing interventions decrease the risk of constipation? SELECT ALL THAT APPLY A. Give foods that are soft, such as white bread or white rice B. Encourage an increase in water and fluid intake C. Administer a stool softener ever morning D. Obtain an order for a bulk laxative E. Encourage movement, activity, and walking F. Teach to keep a record of bowel movements

B, C, E, F

A patient who is 2 days postoperative for abdominal surgery states, "I coughed and heard something pop." The nurse's immediate assessment reveals an opened incision with a portion of large intestine protruding. Which statements apply to this clinical situation? SATA A. incision dehiscence has occurred B. this is an emergency C. the wound must be kept moist with normal saline-soaked sterile dressings D. this is urgent situation E. incision evisceration has occurred F. a NG tube may be ordered to decompress the stomach

B, C, E, F

The nurse is preparing the patient for surgery. Which common laboratory tests does the nurse anticipate being ordered? SATA A. total cholesterol B. urinalysis C. electrolyte levels D. uric acid E. clotting studies F. serum creatinine

B, C, E, F

The nurse screens a preoperative patient for conditions that may increase the risk for complications during the perioperative period. Which conditions are possible risk factors? SATA A. emotionally stable B. age 67 C. obesity D. marathon runner E. pulmonary disease F. hypertension

B, C, E, F

Which assessment data finding for a client scheduled for total knee replacement surgery is MOST important for the nurse to communicate to the surgeon and the anesthesia provider before the procedure? SELECT ALL THAT APPLY A. The oxygen saturation is 97% B. The serum potassium level is 3.0 mEq/L C. The client took a total of 1300 mg of aspirin yesterday D. The client requests to talk with a registered dietician about weight loss E. The client took a regularly scheduled antihypertensive drug with a sip of water 2 hours ago F. After receiving the preoperative medications, the client tells the nurse that he lied on the assessment form and that he really is a current smoker.

B, C, F

When assessing the hydration status of an older postoperative patient, where must the nurse assess for tenting of the skin? SATA A. on the back of the hand B. on the forehead C. on the forearm D. on the sternum E. on the abdomen F. on the thigh

B, D

Which statements best describe the preoperative period? SATA A. it begins when the patient makes the appointment with the surgeon to discuss the need for surgery B. it ends at the time of transfer to the surgical suite C. it is a time during which the patient's need for surgery is established D. it begins when the patient is scheduled for surgery E. it is a time during which the patient receives testing and education related to impending surgery F. it is a tie when patients and families receive discharge instructions

B, D, E

Which criteria used by the health care team to determine when a patient is ready to be discharged form the PACU? SATA A. recovery score of 7 to 10 on rating scale B. stable vital signs with normal body temp C. ability to swallow but remains NPO for at least 4 hours D. intact cough and swallow reflexes E. adequate urine output F. return of gag reflex

B, D, E, F

The PACU nurse is assessing a patient transferred in from the OR. Which assessment findings apply to assessment findings apply to assessment of the cardiovascular system? SATA A. opens eyes on command B. absent dorsalis pedis pulse on the left foot C. foley catheter in place with clear yellow drainage D. monitor shows normal sinus rhythm E. states name correctly when asked F. apical pulse 85 beats/min

B, D, F

A 76-year-old patient is having a bilateral cataract removal. What is the correct classification for this surgery? A. major B. cosmetic C. elective D. emergent

C

A male patient is having revision of a scar on his forehead from a third-degree burn. What is the correct classification for this surgery? A. major B. restorative C. cosmetic D. curative

C

A nurse administered midazolam IV bolus to a client before a procedure. his BP is 86/40 and HR is 134. Which of the following IV medications should the nurse administer? A. naloxone B. morphine C. flumazenil D. atropine

C

A nurse is assessing a client who is reporting pain despite analgesia. Which of the following actions should the nurse take to assess the intensity of the client's pain? A. ask the client what precipitates his pain B. question the client about the location of his pain C. offer the client a pain scale to measure his pain D. use open-ended questions to identify the sensation of his pain

C

A nurse is assessing a patient with severe dementia who resides in a long-term care facility. A score of 9 is obtained using the pain assessment in advanced dementia scale. Based on assessment findings, which action will the nurse take? A. Speak calmly to the patient and explain that repositioning will make him more comfortable. B. Gently reassure the patient and continue routine observation for discomfort or pain. C. Assess the patient for the source of the pain and immediately inform the health care provider. D. Contact the family and ask how the patient would typically respond to discomfort.

C

A nurse is caring for a client who is receiving morphine via a PCA infusion device after abdominal surgery. Which of the following client understands how to use the device? A. "i'll wait to use the device until it's absolutely necessary" B. "i'll be careful about pushing the button so I don't get an overdose" C. "i should tell the nurse if the pain doesn't stop after I use this device" D. "i will ask my son to push the dose button when I am sleeping"

C

A nurse is caring for a client who reports a headache following an epidural regional nerve block. Which of the following actions should the nurse take? A. decrease the client's fluid intake B. apply pressure to the puncture site C. place the head of the bed flat D. instruct the client to lie prone

C

A nursing technician reports that a client who is receiving IV PCA morphine is very drowsy, unable to complete a sentence without falling asleep, and has a respiratory rate of 10 breaths per minute. What is the nurse's PRIORITY action at this time? A. Wake the client and raise the head of the bed to a 90-degree angle B. Promptly call the primary health care provider to reduce the opioid dose C. Document the assessment findings and take vital signs in an hour. D. Give naloxone according to agency protocol

C

A patient with RA reports having chronic pain for years with an exacerbation that started in the morning. Which observation indicates the patient has a physiologic adaption to pain? A. pupils are dilated B. breathing is shallow C. pulse rate is 70/min D. temp is 98.6F

C

A patient with chronic leg pain reports pain level at 7/10, so the nurse administers a prn mediation. Which observation best suggests that the functional goal of therapy is being met? A. patient appears relaxed while talking with family members B. pulse, BP, and respirations are not eleveated C. patient ambulates independently down the hall without distress D. patient asks for additional food between lunch and dinner

C

A preoperative patient is scheduled for surgery at 0730. At 0600, the patient's vital signs are BP 90/60, HR 110 and irregular, RR 22 and oral temp is 100.9F. The patient's SaO2 is 92% and he has a productive cough. What is the nurse's priority action at this time? A. administer acetaminophen (Tylenol) with just a sip of water B. recheck the vital signs at 0700 C. call and notify the surgeon immediately D. have the patient cough and take some deep breaths

C

For which client pre-admission testing laboratory result does the nurse take immediate action? A. International normalized ratio 0.9 B. White blood cell count 8500/mm3 C. Serum potassium level 2.8 mEq/L D. Serum sodium level 132 mEq/L

C

For which client readmission testing laboratory result does the nurse take immediate action? A. INR 0.9 B. WBC count 8500 C. Potassium 2.8 D. Sodium 132

C

G.S.W, stab wound, MVC, subdural hematoma, open fracture A. Elective-non-acute B. Urgent-prompt attention C. Emergent-life threatening

C

If a patient experiences wound dehiscence, which description best characterizes what is happening to the wound? A. purulent drainage is present at incision site because of infection B. extreme pain is present at incision site C. a partial or complete separation of outer layers is present at incision site D. the inner and outer layers of the incision are separated

C

The PACU nurse is caring for a postoperative patient. The patient's O2 sat drops from 98% to 88%. What is the nurse's priority action? A. call the anesthesia provider B. call the surgeon C. call the RRT D. call the respiratory therapist

C

The health care provider informs the nurse that a young patient should receive morphine for severe pain but that caution is needed because the patient is opioid naive. Which consideration is the MOST IMPORTANT in caring for and observing this patient? A. Decreased analgesia may occur because the patient is opioid naive. B. Respiratory depression is a problem only for elderly adults with repspiratory disorders. C. Excessive sedation can progress to clinically significant respiratory depression D. A standing order for a PRN one-time dose of naloxone is needed for adverse effects

C

The med-surg nurse is caring for a postoperative patient whose lab values reveal an increase in band cells. What is the nurse's best interpretation of this value? A. the patient may need a transfusion B. the patient is using up clotting factors C. the patient is developing an infection D. the patient's result is expected postoperatively

C

The nurse is assessing a postoperative patient's GI system. What is the best indicator that peristaltic activity has resumed? A. presence of bowel sounds B. patient states they are hungry C. passing of flatus or stool D. presence of abdominal cramping

C

The nurse is assessing the patient's use of transdermal fentanyl and discovers that the patient is making several errors. What behavior is mOST LIKELY to result in fentanyl-induced respiratory distress? A. Pt is folding the patch in half B. Patient is saving the old used patches C. Pt is placing a heating pad over the patch D. Pt is using adhesive tape over the patch

C

The nurse is caring for a patient on the first postoperative day. The patient denies pain, but his BP and HR are elevated and he is diaphoretic and anxious. What should the nurse do first? A. believe and document the patient's self-report of "denies pain" B. call the health care provider and report the vital signs, diaphoresis, and anxiety C. assess the patient for postoperative complications or barriers to reporting pain D. ask a family member id the patient would typically be stoic during pain or discomfort.

C

The nurse is performing a pain assessment on a patient who had abdominal surgery. He was just transferred from the ICU to the med-surg unit. Which question would the nurse ask? A. "you are probably having pain at the incision site. Right?" B. "how bad is your pain? Is it better compared to before?" C. "can you tell me about any pain or discomfort you are having?" D. "do you think you can walk, or would you like pain medication first?"

C

The nurse sees that during the night the patient received lorazepam for anxiety, promethazine for nausea, and hydropmorphone for pain. Which assessment is the MOST IMPORTANT to conduct? A. Closely monitor liver enzymes to identify early indicators of adverse effects. B. Watch for symptoms of cardiotoxicity, such as tingling and cardiac dysrhythmias. C. Use the Pasero Opioid-Induced Sedation Scale and check respiratory status D. Watch for G.I. distress, decreased platelet count, and bleeding.

C

The older patient tells the home health nurse that he took 2 tablets of arthritis-strength ER acetaminophen at 0600 and 2 tablets of hydrocodone at 1400 and that he plans to take one dose of an OTC product that contains acetaminophen, doxylamine succinate, and dextromethorphan to sleep at night. What would the nurse do first? A. call the poison control, because the patient has exceeded the recommended dose of acetaminophen B. tell the patient to call the health care provider and report all medications that he takes C. educate the patient about the acetaminophen in each product and the max dosage/ day D. record the medications, frequency, and dosage in the medication reconciliation record

C

The patient has a history of rheumatoid arthritis and is also being treated for acute pain from a wrist fracture. Which medication is MOST LIKELY to be prescribed to reduce the pain and discomfort caused by inflammation? A. Morphine B. Acetaminophen C. Ibuprofen D. Bupivacaine

C

The patient is recovering in a PACU environment that advances the patient quickly from phase I care level to phase III care level, preparing for discharge top home. What type of surgery is this patient most likely having? A. elective surgery B. emergency surgery C. same-day surgery D. urgent surgery

C

The patient is scheduled to have MIS for a laparoscopic cholecystectomy. Part of the surgery is the injection of air into the abdomen to separate and better see the organs. What patient teaching must the nurse do about the insufflation? A. "your surgeon will make several small incisions instead of a large one" B. "you will be able to go home once your surgery is completed and you are awake" C. "you may experience some abdominal discomfort from the air injected with the surgery" D. "you will have a tube for drainage for a few days after your surgery is completed"

C

The patient is to receive regional anesthesia for injured knee repair surgery. Which type of regional anesthesia is this patient likely to receive? A. field block B. nerve block C. spinal anesthesia D. epidural anesthesia

C

The patient is transferred to the OR for right foot surgery. How does the nurse safely assure the patient's identification? A. ask the patient what type of surgery is scheduled B. state the patient's name and ask the patient if that is them C. check the patient's armband and ask the patient to state their name and birth date D. check the patient's chart and armband to assure that these match

C

The patient received moderate sedation IV prior to a bronchoscopy procedure. Before allowing the patient to have oral liquids, what must the nurse assess in this patient? A. the patient is arousable B. the patient is able to speak C. the patient's gag reflex is working D. the patient is able to rotate his head

C

The patient who received moderate sedation with midazolam appears to be overly sedated and has respiratory depression. Which drug does the nurse prepare to administer to this patient? A. lorazepam B. naloxone C. flumazenil D. butorphanol tartrate

C

The postanesthesia care unit reports to the nurse in the medical-surgical unit that the patient received 2 mg of IV morphine with relief. When is the patient likely to be transitioned to oral analgesics? A. Upon arrival to the med-surg unit B. When the health care provider writes postoperative orders C. When the pt is able to tolerate oral intake D. When the IV access is discontinued

C

To avoid electrical safety problems during surgery, what does the nurse do? A. observes for breaks in sterile technique B. continuously assists the anesthesia provider C. ensures proper placement of the grounding pads D. monitors the OR with available cameras

C

What client teaching will the nurse provide regarding postoperative leg exercises to minimize the risk for development of deep vein thrombosis after surgery? A. Only perform each exercise one time to prevent overuse B. Begin exercises by sitting at a 90 degree angle on the side of the bed. C. Point toes of one foot toward bottom of bed; then point toes of same leg toward his or her face. Repeat several times; then switch legs. D. Bend knee, and push heel of foot into the bed until the calf and thigh muscles contract. Repeat several times; then switch legs.

C

When using the SBAR method of communication, the nurse would include which information in the B section? A. recommend fingerstick glucose monitoring B. patient states he feels dizzy and light-headed C. admission diagnosis is new-onset type 2 diabetes D. bp is 130/90 mmHg; HR is 89 beats/min

C

Which client statement regarding appropriate pain control requires nursing intervention? A. "I'll listen to music when I feel pain." B. "Before exercise or physical therapy, I'll be sure I've taken my medication." C. "If the prescribed dose of medication doesn't help my pain, I'll take an extra dose." D. "I plan to keep a pain diary so I can see trends about when my pain worsens."

C

Which definition is appropriate for local anesthesia? A. injection of anesthetic agent into or around a nerve or group of nerves, resulting in blocked sensation and motor impulse transmission B. injection of the anesthetic agent into the epidural space; the spinal cord areas are never entered C. injection of an anesthetic agent directly into the tissue around an incision, wound, or lesion D. injection of anesthetic agent that blocks multiple peripheral nerves and reduces sensation in a specific body region

C

Which drug can cause adverse effects, particularly in an older adult, because of an accumulation of toxic metabolism? A. ibuprofen B. Morphine C. Meperidine D. Acetaminophen

C

Which drug may the surgeon allow the patient to take prior to surgery? A. daily vitamin B. stool softener C. antiseizure drug D. daily baby aspirin

C

Which indicator of return to consciousness occurs first as a patient recovers from general anesthesia? A. muscular irritability B. restlessness and delirium C. recognition of pain D. ability to reason and control behavior

C

Which is the top priority for nurses during the perioperative period? a. Patient teaching b. Patient diagnostic testing c. Patient safety d. Patient care documentation

C

Which medical condition increases the patient's risk for surgical wound infection? A. anxiety B. hiatal hernia C. DM D. amnesia

C

Which occurrence does the joint commission's national patient safety goals designate as a high-risk issue? A. being exposed to infectious diseases in the workplace B. violating privacy of patients confidential information C. administering medication that is not familiar to the nurse D. failing to review patients food allergies before serving meals

C

Which patient has chronic noncancer pain? A. a 17-year-old male after an appendectomy B. a 64-year-old male with back pain related to tumor growth C. a 48-year-old female who has persistent pain related to interstitial cystitis D. a 5-year-old female with stomach cramps related to food poisoning

C

Which situation is an example of a nursing intervention that addresses the IOM/ QSEN health care disparities competency? A. nurse recognizes that the patient's mannerisms are sexually offensive B. nurse administers pain medication as scheduled, before the patient requests it C. nurse listens with sensitivity while the lesbian patient talks about discrimination D. nurse advises an abused woman about legal protection, such as a restraining order

C

Which statement best describes the collaborative roles of the nurse and surgeon when obtaining the informed consent? A. the nurse is responsible for having the informed consent form on the chart for the HCP to witness B. the nurse may serve as a witness that the patient has been informed by the HCP before the surgery is performed C. the nurse may serve as a witness to the patient's signature after the HCP has the consent form signed before preoperative sedation is given and before surgery is performed D. the nurse has no duties regarding the consent form if the patient has signed the informed consent form for the HCP, even if the patient then asks additional questions about the surgery

C

The nurse is caring for an older-adult client who reports being "afraid to get hooked" on opioid pain medication after surgery. What is the appropriate nursing response? SELECT ALL THAT APPLY A. "Why do you think you're going to get hooked?" B. "Don't worry, I won't give you any opioid medications." C. "Have you had concerns with drug dependence in the past?" D. "Tell me what makes you most fearful about taking opioid medication." E. "There are ways we can keep you from becoming dependent on these drugs." F. "Older adults are much less likely to rely on pain medications that younger people."

C, D

A nurse is assessing a client's lab values before surgery. Which of the following results should the nurse report to the provider? SATA A. potassium 3.9 B. sodium 145 C. creatinine 2.8 D. blood glucose 235 E. WBC 17,850

C, D, E

A nurse is monitoring a client who is receiving opioid analgesia. Which of the following findings should the nurse identify as adverse effects of opioid analgesics? SATA A. urinary incontinence B. diarrhea C. bradypnea D. orthostatic hypotension E. nausea

C, D, E

A nurse is verifying informed consent for a client who is having paracentesis. Which of the following actions should the nurse take? SATA A. explain to the client the purpose of having the procedure B. inform the clients of risks to having the procedure C. ensure the client understands information about the procedure D. witness the client signing the informed consent form E. determine if the client is capable of understanding the s\reason for the procedure

C, D, E

Which signs/symptoms are considered post-operative complications? SATA A. sedation B. pain at the surgical site C. PE D. hypothermia E. wound evisceration F. postoperative ileus

C, D, E, F

A client was originally scheduled for surgery at noon. The surgeon is delayed, and the surgery has been rescheduled for 3:00 p.m. How will the nurse plan to administer the preoperative prophylactic antibiotic? A. Give at noon as originally prescribed B. Cancel orders; preoperative prophylactic antibiotics are given optionally C. Adjust the administration time to be given within 1 hour before surgery D. Hold the preoperative antibiotic so it can be administered immediately following surgery

C.

Category of surgical procedure that's performed to resolve health problem (cholecystectomy, hysterectomy, appendectomy)

Curative

A 47-year-old patient is having surgery to remove kidney stones. What is the correct classification for this surgery? A. restorative B. emergent C. palliative D. urgent

D

A female patient is having a biopsy of a nodule found in the right breast. Which classification identifies this surgery? A. urgent B. minor C. cosmetic D. diagnostic

D

A new, inexperienced nurse sees that the patient is receiving around-the-clock medication but also has orders for PRN analgesic every 4-6 hours as needed. How will the new nurse determine when a PRN dose is given? A. Administer a dose every 6 hours to ensure adequate relief. B. Call the health care provider and ask for specific parameters for PRN dosing C. Look at the med administration record to see what the previous nurse gave D. Assess the patient for breakthrough pain and anticipate painful procedures

D

A nurse is caring for a client who arrived at the PACU following a total hip arthroplasty. The client is not responding to verbal stimuli. Which of the following actions should the nurse perform first? A. compare and contrast the peripheral pulses B. apply a warm blanket C. assess dressings D. place the client in a lateral position

D

A nurse is discussing pain assessment with a newly licensed nurse. Which of the following information should the nurse include? A. most clients exaggerate their level of pain B. pain must have an identifiable source to justify the use of opioids C. objective data are essential in assessing pain D. pain is whatever the client says it is

D

A patient arrives at the PACU, and the nurse notes a respiratory rate of 10 with sternal retractions. The report from the anesthesia provider indicates that the patient received fentanyl during surgery. What is the nurse's best action? A. monitor the patient for effects of anesthetic for at least 1 hour B. closely monitor vital signs and pulse ox readings until the patient is responsive C. administer oxygen as ordered, monitoring pulse ox. D. maintain an open airway through positioning and suction if needed

D

A patient develops develops respiratory distress after having a left total hip replacement. The patient develops labored breathing, and a pulse ox reading is 83% on 2 L O2 via nasal cannula. Which intervention is appropriate for the nurse to delegate to UAP? A. assess change in patient's respiratory status B. order necessary medications to be administered C. insert oral airway to maintain open airway D. check the patient's vital signs

D

A patient experiences MH immediately after induction of anesthesia. What is the nurse anesthetist's priority action? A. administer IV dantrolene sodium 2-3 mg/kg B. apply a cooling blanket over the torso C. assess the arterial blood gases and serum chemistries D. stop all inhalation anesthetic agents and succinylcholine

D

A preoperative nurse is caring for a client who is having a colon resection. Which of the following actions should the nurse take? A. encourage the client to void after preoperative medication administration B. administer antibiotics 2 hr prior to surgical incision C. remove hair using a manual razor D. remove nail polish on finger and toes

D

A scrub person is discussing artificial nail use with the nurse. The scrub person states, "I do not use artificial nails; I'm wearing gel polish to strengthen my nails." What is the appropriate nursing response? A. "I understand. That is my nail treatment of choice also." B. "Hand hygiene is enhanced by covering natural nails." C. "Wear double gloves to prevent puncture or contamination." D. "Gel polish is a type of artificial nail that alters skin flora and impedes hand hygiene."

D

An older patient, who was treated for a hip fracture, is being discharged from the hospital and transferred to a long-term care facility. What would be included in managing the transition of this patient? A. a list of the patient's valuables and property that were at the hospital B. available balance of Medicare benefits after hospital costs are covered C. family's preferences regarding advanced directives and living will D. discharge care instructions related to the hip fracture and surgical site

D

The PACU nurse caring for a client with a nasogastric tube notes that 300 mL of bright red blood has collected. What is the appropriate nursing action? A. Document as a normal finding B. Immediately remove the NG tube C. Place the client in trendelenburg position D. Call the client's surgeon to report the drainage

D

The Pt reports that he has been taking hydrocodone as prescribed by his provider uses over-the-counter acetaminophen whenever he needs additional pain relief. Which laboratory test indicates the adverse and additive effects of these two medications? A. Decreased clotting times B. Decreased hematocrit C. Elevated wbc D. Elevated liver enzymes

D

The home health nurse is reviewing the older adult's medication and sees that naproxen is prescribed. Which question is the nurse most likely to ask in order to assess for adverse effects? A. "have you noticed unusual fatigue, restlessness, or feelings of depression?" B. "do you notice dry mouth, dizziness, mental clouding, or weight gain?" C. "are you experiencing constipation, itching, or excessive sleepiness?" D. "have you had any gastric discomfort, vomiting, bleeding, or bruising?"

D

The nurse is assessing the patient for chronic pain or discomfort. Which is the best question to use elicit the quality of the pain? A. "am I correct in assuming that you are having pain?" B. "would you describe the pain as sharp?" C. "is the pain really bad right now?" D. "how would you describe your pain?"

D

The nurse is giving discharge instructions about multimodal analgesia to a daughter who will care for her elderly father at home while he recovers from surgery. The daughter suggests that the single best medication should be recommended for convenience and to save money. What is the BEST response? A. "The doctor always prescribes this combination of medications as the best therapy." B. "Elderly people frequently do better with fewer medications; let me call the doctor." C. "Just see how it goes for your dad. It is likely that you can gradually decrease the medication." D. "Combining different analgesics gives greater relief with lower doses and fewer side effects."

D

The patient in the OR holding area tells the nurse that his surgery is for the right foot. The patient's chart states that the surgery is for his left foot. What is the nurse's best action? A. do nothing because the patient is confused after receiving premedications B. make a note about this in the nursing notes of the patient's chart C. call the nurse anesthetist to check whether the chart or patient is correct D. notify the surgeon immediately before the patient goes into the OR about this discrepancy

D

The surgical team understands that time is crucial in recognizing and treating a MH crisis. Once recognized, what is the treatment of choice? A. danazol gluconate B. phenytoin sodium C. diazepam sulfate D. dantrolene sodium

D

Which description illustrates the beginning of the postoperative period? A. completion of the surgical procedure and arousal of the patient from anesthesia in the OR B. providing care before, during, and after surgery C. closure of the patient's surgical incision with sutures D. completion of the surgical procedure and transfer of the patient to the PACU

D

Which duties are within the scope of practice of the circulating nurse in the operative setting? A. manages the patient's care while the patient is in this area and initiates documentation on a perioperative nursing record B. sets up the sterile field; assists with the draping of the patient; and hands sterile supplies, equipment, and instruments to the surgeon C. assumes responsibility for the surgical procedure and any surgical judgements about the patient D. coordinates, oversees, and participates in the patient's nursing care while the patient is in the operating room

D

Which intervention for postsurgical care of a patient is correct? A. when positioning the patient, use the knee gatch of the bed to bend the knees and relieve pressure B. gently message the lower legs and calves to promote venous blood return to the heart C. encourage bedrest for 3 days after surgery to prevent complications D. teach the patient to splint the surgical wound for support and comfort when getting out of bed

D

Which member of the operating room team is responsible for setting up the sterile field? A. CRNA B. surgical assistant C. circulating nurse D. scrub nurse

D

Which patient is LEAST LIKELY to be a good candidate for patient-controlled analgesia? A. A 32-year-old male with severe burns and a hx of drug abuse B. 16-year-old male with multiple injuries sustained during an accident C. 34-year-old female with functional blindness who had abdominal surgery D. 25-year-old female with intermittent lucidity after a severe head injury

D

Category of surgical procedure where origin or cause is determined (breast biopsy, colonoscopy, exploratory laparotomy)

Diagnostic

What type of anesthesia? -reversible loss of consciousness induced by inhibiting neuronal impulses in the CNS -inhalation or I.V. -minor complications

General anesthesia

.7-1.8 5,000-10,000 3.5-5.0 135-145 .6-1.2 10-20 14-18 12-16 45-52% 37-48%

INR WBC Potassium Sodium Creatinine BUN hemoglobin men hemoglobin women hematocrit men hematocrit women

What type of anesthesia? -injected into the tissue -BREAST TISSUE, CARPAL TUNNEL -specific to area with procedure

Local anesthesia

What type of anesthesia? -reduce consciousness but not totally under -cholenoscopy -need to be able to maintain airway

Moderate sedation

symptoms of withdrawal

N/V, abdominal cramping, diaphoresis, muscle twitching, seizures, delirium, headaches, hallucinations, tachycardia

Serosanguineous

Pale, pink, watery; mixture of clear and red fluid

Category of surgery that does not cure, but relieves symptoms (debulking tumors, metastatic cancers, expands functioning but doesn't cure)

Palliative

What type of anesthesia? -block nerve of specific body region -knee surgery -puts at risk for post-op falls

Regional "blocks"

What type of Anesthesia? -preferable for older adults who can't tolerate general anesthesia -total knee/total hip -contraindicated with blood thinners, lovenox, anti-coagulants -no endotracheal tube

Spinal/Epidural anesthesia

Sanguineous

bloody

Category of surgery that enhances personal appearance (rhinoplasty, liposuction, burns)

cosmetic

Category of surgical procedure used to improve functional ability (replacing knee joint...restores previous ability to function)

restorative

Serous

yellowish/ clear