Adult Health Prep U 8 and 14, 15, 16

heart

he leading cause of death in older adults in the United States is ______________ disease

reconstructive

A client is scheduled to have surgery to address a cleft palate. What type of surgery would the nurse be preparing this client for? reconstructive corrective diagnostic prophylactic

Lithotomy

A client is undergoing a perineal surgical procedure. The nurse should place the client in which position? Lithotomy Trendelenburg Sims Dorsal recumbent

Placing one food at a time in front of the client during meals

A client with moderate Alzheimer's disease has been eating poorly, losing weight, and playing with food at meals. The nurse best intervenes by Placing one food at a time in front of the client during meals Cutting the client's food into small pieces Serving hot foods at a warm temperature Converting liquid foods to a gelatin texture

Evisceration

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding? Hernia Dehiscence Erythema Evisceration

I should use laxative every other day

After teaching an older adult about measures to relieve constipation, which statement by the client indicates a need for additional teaching? "I should use a laxative every other day." "I'll make sure that I drink plenty of fluids each day." "I'm going to start walking every day for exercise." "I need to avoid foods that are high in fat."

disability

Chronic conditions, many of which are preventable or treatable, are the major cause of ___________ and pain among older adults.

Adrenal

Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency? Pituitary Adrenal Thyroid Parathyroid

open body wounds.

Hypothermia may occur as a result of the infusion of warm fluids. increased muscle activity. open body wounds. being young.

Side-lying, knees to chest

In which position would a client undergoing a lumbar puncture be placed? Supine Semi-Fowler's Side-lying, knees to chest Trendelenburg

false

T or F The actual percentage of long-term nursing home residents has doubled over the last 25 years due to increased longevity and management of chronic illnesses.

circulating nurse

The OR personnel responsible for maintaining the safety of the client and the surgical environment is the: Anesthesiologist Circulating nurse Scrub nurse Surgeon

Listening to music Watching television Changing position

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

depression

the most common affective or mood disorder of old age is ____________, often related to chronic illness or pain.

true

ture or flase Most Americans 75 years of age and older remain functionally independent regardless of how they perceive their health.

what picture

A patient is to undergo surgery on his kidney. The patient would be placed in which position for the surgery?

"I'll be sleepy but able to respond to your questions."

After teaching a patient scheduled for ambulatory surgery using moderate sedation, the nurse determines that the patient has understood the teaching based on which of the following statements? "I'm so glad that I will be unconscious during the surgery." "I won't feel it, but I'll have a tube to help me breathe." "Only the surgical area will be numb." "I'll be sleepy but able to respond to your questions."

keeping records

As a circulating nurse, what task are you solely responsible for? Keeping records. Estimating the client's blood loss. Handing instruments to the surgeon. Counting sponges and needles.

emergent surgery

Informed consent from the surgical client is essential in all of the following categories of surgery except: Elective surgery Emergent surgery Required surgery Urgent surgery

Circulating nurse

The OR personnel responsible for maintaining the safety of the client and the surgical environment is the: Anesthesiologist Circulating nurse Scrub nurse Surgeon

Administer morphine sulfate.

The client who had spinal anesthesia complains of a headache. Which of the following is an inappropriate action by the nurse? Increase fluid intake. Keep the head of the bed flat. Maintain a quiet environment. Administer morphine sulfate.

age physical condition gender health status

The nurse assesses a client to determine if there is increased risk for complications intraoperatively or postoperatively. Which are general risk factors? Select all that apply. nutritional status age physical condition gender health status ethnicity

false

True or False Significant declines in intelligence, learning, and memory are inversely proportional to increases in age.

true

True or false Age-related macular degeneration is the primary cause of vision loss and blindness in adults 65 years and older.

<30 mL

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

Dantrolene sodium

What medication should the nurse prepare to administer in the event the client has malignant hyperthermia? Dantrolene sodium Fentanyl citrate Naloxone Thiopental sodium

emergency

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as emergency. urgent. required. elective.

protective

if neglect or abuse of any kind—including physical, emotional, sexual, neglect or financial abuse—is suspected, the local adult __________________ services agency must be notified.

"It is because the anesthesia you will receive is cleared through the liver.

A client scheduled for surgery asks why blood tests are being done to evaluate liver function. Which response will the nurse make? "It is just a routine test done before every surgery." "It is done to determine if you need antibiotics prior to surgery." "It is to make sure that you haven't had any alcohol before the surgery." "It is because the anesthesia you will receive is cleared through the liver."

Report the infection to an immediate supervisor.

A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse? Report the infection to an immediate supervisor. Ensure the infection is covered with a dressing. Return to work after taking antibiotics for 24 hours. Request a role change to circulating nurse.

malignant hyperthermia

During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication? malignant hyperthermia hypothermia infection fluid volume excess

Halothane

Nursing students are reviewing information about agents used for anesthesia. The students demonstrate understanding when they identify which of the following as an inhalation anesthetic? Halothane Fentanyl Succinylcholine Propofol

Cosmetic Diagnostic Palliative

Several of the clients at the clinic are preparing to have surgery within the next 2 weeks. They are completing preoperative paperwork today with their visit. What are some of the reasons that people might need to have surgery? Select all that apply. Cosmetic Diagnostic Palliative Normative Causative

A gastrostomy tube

The nurse expects informed consent to be obtained for insertion of: An indwelling urinary catheter An intravenous catheter A gastrostomy tube A nasogastric tube

Allergies Surgical history Medical history Current medications History of present illness

The nurse is preparing the medical record for a client scheduled for surgery. Which item(s) will the nurse ensure are in the history and physical? Select all that apply. Allergies Surgical history Medical history Home care needs Current medications History of present illness

"Some possible negative effects include difficulty waking up and slow heart rate."

anesthesia. What is the best response by the nurse? "Some possible negative effects include difficulty waking up and slow heart rate." "Few negative effects occur with general anesthesia." "Amnesia and analgesia are some of the negative effects of anesthesia." "Clients can experience pain and loss of consciousness."

Decreased lean tissue mass

A 70-year-old patient who is to undergo surgery arrives at the operating room (OR). The nurse, when reviewing the patient's medical record, understands that this patient will require a lower dose of anesthetic agent because of which of the following? Increased anxiety level Increased tissue elasticity Decreased lean tissue mass Impaired thermoregulation

"What precipitates the outbursts?"

A client reports to the nurse that her grandmother with Alzheimer's disease recently moved in with her and her two school-aged children. The client states the grandmother becomes agitated and starts yelling and crying frequently. The woman asks, "What can I do?" The nurse first responds: "What precipitates the outbursts?" "You need to remain calm during the outbursts." "Play quiet music that your grandmother may like." "Start rubbing her shoulders and her back."

When the client is transferred onto the operating table

At what point does the preoperative period end? When the decision is made to proceed with surgery When the client is transferred onto the operating table When the client is admitted to the PACU When the client signs the consent form

Review the scheduled procedure, site, and client.

Once the operating team has assembled in the room, the circulating nurse calls for a "time out." What action should the nurse take during the time out? Ensure that sufficient surgical supplies are available. Check that all surgical personnel are properly attired. Review the scheduled procedure, site, and client. Confirm that informed consent has been obtained.

Risk for perioperative positioning injury related to positioning in the OR

The client is undergoing a surgical procedure that is expected to last several hours. Which nursing diagnosis is most related to the duration of the procedure? Risk for perioperative positioning injury related to positioning in the OR Risk of latex allergy response related to possible exposure in the OR environment Disturbed sensory perception related to the effects of general anesthesia Anxiety related to ineffective coping with surgical concerns

Urine retention

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

A client who has a history of arthritis

The nurse recognizes that which of the following clients is at the lowest risk for perioperative complications? A client who takes prednisone A client who takes clopidogrel A client who has a history of arthritis A client recently diagnosed with type 2 diabetes

bronchospasm, pneumonia, and atelectasis

The nurse will educate the client about the risk for developing ,_______ , ______ and _____________, if the client does not implement diaphragmatic breathing exercises in the postoperative period of care.

Wound infection

The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing? Hyperthermia Atelectasis Wound infection Uncontrolled pain

wound infection

The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing? Hyperthermia Atelectasis Wound infection Uncontrolled pain

maintaining pulmonary ventilation.

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

stage IV

The surgical client has been intubated and general anesthesia has been administered. The client exhibits cyanosis, shallow respirations, and a weak, thready pulse. The nurse recognizes that the client is in which stage of general anesthesia? Stage I Stage II Stage III Stage IV

maintain patient safety

A nurse is receiving a client to the postanesthesia unit. What initial nursing activity is most important in the postoperative recovery area? Maintain patient safety. Administer medications and fluids. Assess pain level. Inspect surgical site.

scrub role

A nurse who is part of the surgical team is involved in setting up the sterile tables. The nurse is functioning in which role? Registered nurse first assistant Scrub role Circulating nurse Anesthetist

A gastrostomy tube

The nurse expects informed consent to be obtained for insertion of: An indwelling urinary catheter An intravenous catheter A gastrostomy tube A nasogastric tube

Perineal surgery

The nurse positions the client in the lithotomy position in preparation for Renal surgery Pelvic surgery Perineal surgery Abdominal surgery

residual lung volume

When assessing an older adult, the nurse anticipates an increase in which component of respiratory status? Vital capacity Gas exchange and diffusing capacity Cough efficiency Residual lung volume

frequently monitor vital signs

A client has been administered ketamine for moderate sedation. What is the priority nursing intervention? Assessing for hallucinations Frequently monitoring vital signs Administering oxygen Providing a quiet dark room for recovery

Decreased acetylcholine level

A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes? Decreased acetylcholine level Increased acetylcholine level Increased norepinephrine level Decreased norepinephrine level

Etomidate

A patient is to receive general anesthesia. The nurse anticipates that which of the following would be used for induction? Isoflurane Etomidate Nitrous oxide Tetracaine

Position the client to maintain a patent airway.

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

Protect bony prominences with extra padding.

The nurse is preparing an older adult for a surgical procedure. Which action will the nurse take to protect the client from injury during the operative period? Apply a warm blanket after the procedure. Protect bony prominences with extra padding. Estimate amount of blood loss during the procedure. Provide antiembolic stockings to be applied postoperatively.

Reinforcing dressings or applying pressure if bleeding is frank

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? Elevating the head of the bed Reinforcing dressings or applying pressure if bleeding is frank Rubbing the back Encouraging the client to breathe deeply

A systolic blood pressure lower than 90 mm Hg

What measurement should the nurse report to the physician in the immediate postoperative period? A systolic blood pressure lower than 90 mm Hg A temperature reading between 97°F and 98°F Respirations between 20 and 25 breaths/min A hemoglobin of 13.6

e independent with toileting Ambulate a functional distance Get in and out of bed unassisted

A client recovering from surgery asks, "When can I go home?" The nurse responds by stating which of the following activities must be completed before discharging home? Select all that apply. Complete total self-care Be independent with toileting Ambulate a functional distance Get in and out of bed unassisted Perform instrumental activities of daily living

It is because the anesthesia you will receive is cleared through the liver."

A client scheduled for surgery asks why blood tests are being done to evaluate liver function. Which response will the nurse make? "It is just a routine test done before every surgery." "It is done to determine if you need antibiotics prior to surgery." "It is to make sure that you haven't had any alcohol before the surgery." "It is because the anesthesia you will receive is cleared through the liver."

circulating nurse

A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented? Circulating nurse Scrub nurse Surgeon Registered nurse first assistant

ingest 5 or 6 small meals a day

An elderly client exhibits blood pressure of 110/76 while prone, 100/72 sitting, and 92/64 standing. The nurse instructs the client to

Post a sign stating "You are in the hospital" at the client's eye level.

An elderly client recovering from a hip repair becomes disoriented and tries to get out of bed frequently. The client states, "I forget I am in the hospital." The best nursing intervention is to Post a sign stating "You are in the hospital" at the client's eye level. Raise the upper and lower side rails of the bed. Place the client in a Posey chest restraint with ties attached to the bed frame. Administer an oral dose of prescribed alprazolam (Xanax).

polyuria infection dehydration

An older adult reports urinary incontinence that has been occurring for years. On which areas will the nurse focus when assessing this client's concern? Select all that apply. Polyuria Infection Dizziness Dehydration Respiratory rate

asess cardiovascular function

An older adult seeks medical attention for a new onset of epigastric distress and bilateral arm pain. Which action will the nurse complete? Encourage the client to ambulate. Assess cardiovascular function. Recommend taking an over-the-counter antacid. Review the contents of the client's most recent meal.

Ask the client if there is someone who can help make decisions for treatment.

An older adult with mild dementia is diagnosed with a terminal illness. Which action will the nurse take to support this client's right to self-determination? Tell the client what treatment is needed. Provide care based upon the specific condition. Petition the court to appoint a guardian to make decisions for the client. Ask the client if there is someone who can help make decisions for treatment.

the vaginal tissues are dryer with aging

An older female client is concerned because of experiencing vaginal bleeding after having intercourse. Which response will the nurse make to this client? "The vaginal tissues are dryer with aging." "Intercourse should be avoided at your age." "Bleeding after intercourse results from a thickening of the vaginal walls." "Testing for a sexually transmitted infection is needed."

Pink to red and soft, bleeding easily

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

Increased residual lung volume (The older adult experiences an increase in residual lung volume, decreased vital capacity, decreased diffusing capacity, and decreased cough efficiency.)

The nurse identifies which of the following as an age-related change in the respiratory system? Increased residual lung volume Increased vital capacity Increased diffusion capacity Increased cough efficiency

Notify the physician.

The nurse is caring for a client 24 hours post surgery who is having persistent hiccups. What action is most appropriate for the nurse to take? Position the client on his or her side. Assist the client to intake ample amounts of water. Notify the physician. Instruct the client to take deep breaths.

Temperature of 102.5°F (39°C)

The nurse is caring for a client during an intraoperative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately? Pulse rate of 110 beats/min Respiratory rate of 18 breaths/min Blood pressure of 104/62 mm Hg Temperature of 102.5°F (39°C)

Blood pressure 80/50 mm Hg

The nurse is caring for a client who has just arrived for surgery. Which assessment finding indicates to the nurse that the client may be experiencing dehydration because of taking nothing by mouth after midnight for the surgery? Urine output 60 mL/hr Pulse 88 beats per minute Blood pressure 80/50 mm Hg Respiratory rate 20 breaths per minute

back pain stiff joints Loss of gluteus maximus mass Difficulty with activities of daily living

The nurse is caring for an older adult who has a sedentary lifestyle. Which changes to the client's musculoskeletal system will the nurse expect to assess? Select all that apply. Back pain Stiff joints Loss of gluteus maximus mass Hypertrophy of deltoid muscle Difficulty with activities of daily living

"Aspiration is a concern and can be a complication if food or fluid is taken close to the surgery time."

The patient asks the nurse why food is withheld before surgery. What is the best response by the nurse? "Aspiration is a concern and can be a complication if food or fluid is taken close to the surgery time." "Distention is a severe complication if food or fluid is taken close to the surgery time." "Infection may occur if food or fluid is taken prior to surgery." "Obstruction will occur if food or fluid is taken prior to surgery."

Educating clients on signs and symptoms of infection

What action by the nurse best encompasses the preoperative phase? Educating clients on signs and symptoms of infection Documenting the application of sequential compression devices (SCDs) Monitoring vital signs every 15 minutes Shaving the client using a straight razor

Pneumonia

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

Reinforce the need to perform leg exercises every hour when awake

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

continuously monitors the sedated client.

A 17-year-old client is having same-day surgery. Solely during the intraoperative phase of perioperative care, the nurse: continuously monitors the sedated client. performs a complete assessment of the client. obtains a surgical consent from the client's mother. assesses how well the client is recovering from anesthesia.

tumor excision

An example of a curative surgical procedure is a biopsy. a face-lift. tumor excision. placement of gastrostomy tube.

Roll the client onto his or her side.

A client receiving moderate sedation for a minor surgical procedure begins to vomit. What should the nurse do first? Roll the client onto his or her side. Suction the mouth. Provide a basin. Administer an antiemetic medication.

independence

Nursing interventions for Alzheimer's disease are aimed at promoting patient function and _____________ for as long as possible.

Risk for perioperative positioning injury related to positioning in the OR

The client is undergoing a surgical procedure that is expected to last several hours. Which nursing diagnosis is most related to the duration of the procedure? Risk for perioperative positioning injury related to positioning in the OR Risk of latex allergy response related to possible exposure in the OR environment Disturbed sensory perception related to the effects of general anesthesia Anxiety related to ineffective coping with surgical concerns

"Let me explain to you what will happen next."

Which nursing statement would best ease a client's anxiety before an emergency operative procedure? "You will be just fine; the operating room nurses will take good care of you." "It is best to take deep breaths and relax before the procedure." "Let me explain to you what will happen next." "We will keep your family informed of your progress."

Risk for perioperative positioning injury related to positioning in the OR

Which of the following is an inappropriate nursing action by the surgical nurse? Covering the hair with a surgical cap Wearing a surgical jacket with knitted cuffs on the sleeves Wearing sterile gloves over artificial nails Changing shoe covers that become torn

Wearing sterile gloves over artificial nails

Which of the following is an inappropriate nursing action by the surgical nurse? Covering the hair with a surgical cap Wearing a surgical jacket with knitted cuffs on the sleeves Wearing sterile gloves over artificial nails Changing shoe covers that become torn

Wearing sterile gloves over artificial nails

Which of the following is an inappropriate nursing action by the surgical nurse? Covering the hair with a surgical cap Wearing a surgical jacket with knitted cuffs on the sleeves Wearing sterile gloves over artificial nails Changing shoe covers that become torn

Splint the incision site using a pillow during deep breathing and coughing exercises.

A client is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications? Splint the incision site using a pillow during deep breathing and coughing exercises. Pain medication should be taken before completing deep breathing and coughing exercises. Deep breathing and coughing exercises should be completed every 8 hours. Deep breathing and coughing exercises may be used as relaxation techniques.

"I will become unconscious."

Which statement by the client indicates further teaching about epidural anesthesia is necessary? "I will become unconscious." "I will lose the ability to move my legs." "I will be able to hear the surgeon during the surgery." "A needle will deliver the anesthetic into the area around my spinal cord."

The client can develop malignant hyperthermia up to 24 hours after surgery.

A client at risk for malignant hyperthermia returns to the surgical unit. For what time period will the nurse monitor the client for development of malignant hyperthermia? Malignant hyperthermia occurs in the operating room only. A client can develop malignant hyperthermia only with intravenous anesthesia after surgery. The client can develop malignant hyperthermia up to 24 hours after surgery. The client will need to be discharged with special instructions.

continue to walk at his current level

An elderly client reports fatigue without shortness of breath with walking 30 minutes five times each week. The nurse assesses the resting heart rate as 72 beats per minute; 10 minutes after walking, the client's heart rate is 92 beats per minute. What should the nurse instruct the client to do next? Continue to walk at his current level. Refrain from any form of exercise. Increase walking at a faster pace. Decrease walking frequency to three times each week.

loss of bone density

An elderly female client has been taking prednisone for breathing problems for many years. The nurse notes that the client's current height is 64 inches. Two years ago, her height was 66 inches. The nurse assesses this loss in height is most likely the result of Degeneration in the efficiency of bone joints The client's failure to exercise Loss of bone density Decreased muscle mass and joint cartilage

add mire leafy greens to your diet

An older adult asks what can be done to prevent the deterioration of the bones and muscles that often occurs with aging. Which response will the nurse make? "Add more leafy greens to your diet." "Eat small, frequent, high-protein meals." "Limit the intake of alcoholic beverages." "Limit weight-bearing exercises to once a week."

Ensure that the mother does not have access to car keys or drive an automobile.

A client has recently brought her elderly mother home to live with her family. The client states that her mother has moderate Alzheimer's disease and asks about appropriate activities for her mother. The nurse tells the client to Encourage the mother to take responsibility for cooking and cleaning the house. Ensure that the mother does not have access to car keys or drive an automobile. Allow the mother to smoke cigarettes outside on the porch without supervision. Turn off lights at night so that the mother differentiates night and day

Notify the surgical team.

A client is administered succinylcholine and propofol for induction of anesthesia. One hour after administration, the client demonstrates muscle rigidity with a heart rate of 180. What should the nurse do first? Notify the surgical team. Document the assessment findings. Administer dantrolene sodium. Obtain cooling blankets.

call the health care provider

A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action? Re-attempt to auscultate bowel sounds. Prepare to insert a nasogastric tube. Call the health care provider. Prepare to administer a stool softener.

The client can be discharged from the PACU.

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

pink color

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

Notify the health care provider that the consent form has not been signed.

The nurse notes that the consent form for surgery needs to be signed; however, the client just received preoperative medication. Which action will the nurse take? Ask the client to sign the consent form now. Ask a family member to sign the consent form. Notify the health care provider that the consent form has not been signed. Document that the client provided verbal consent to the surgery.

Absorption may be affected by changes in gastric pH.

Which is a true statement regarding pharmacologic aspects of aging? Elderly have a decreased percentage of body fat. Potential for drug-drug reactions decreases with the number of drugs prescribed. Absorption may be affected by changes in gastric pH. Aged population tends to be compliant with their medication regimen.

"When is the last time you ate or drank?"

Which question is most important for the nurse to ask the client when obtaining the preoperative admission history? "Who is here with you?" "Did you bring a copy of your health care power of attorney?" "When is the last time you ate or drank?" "Did you bring any valuables with you?"

"Many people have diagnostic or short therapeutic surgical procedures."

You are the nurse working in an ambulatory surgery center. A teenage son of your clients ask you why so many people have surgery. What would be your best reply? "Many people have diagnostic or short therapeutic surgical procedures." "Lots of people have cancer and need tumors removed." "You know, we have a lot of sick people in the world." "Not everyone has to go to the hospital to have surgery anymore."

Encouraging clients to avoid cigarette smoking

A nurse is teaching nursing assistants in an extended-care facility measures to protect the skin of elderly clients. Which of the following measures is the nurse likely to recommend? Taking the clients outside for sun exposure daily Assisting clients to soak in the bathtub several times each week Encouraging clients to avoid cigarette smoking Instructing clients to use perfumed skin creams

"Older adults in long-term care facilities are at low risk for elder abuse."

The nurse caring for residents of a long-term care facility is explaining the occurrence of elder abuse in such facilities. Which statement from the nurse indicates the need for more education? "Older adults in long-term care facilities are at low risk for elder abuse." "Older adults with disabilities are at increased risk for elder abuse." "Most states requires nurses to report elder abuse." "Limitations to activities of daily living contribute to risk of elder abuse."

Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia

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

headache

The nurse is teaching the client about usual side effects associated with spinal anesthesia. Which of the following should the nurse include when teaching? Sore throat Itching Seizures Headache

decreased renal function

The nurse recognizes that the older adult is at risk for surgical complications due to: decreased renal function increased cardiac output increased skeletal mass decreased adipose tissue

Plan interventions to address consequences of age-related changes.

a department of nursing within a health care organization is adopting the Functional Consequences Theory when caring for older adults. Which action would the nurse take to faciliate using this theory when caring for a client? Identify reasons for changes in musculoskeletal function. Recognize that immune system changes cannot be altered. Plan interventions to address consequences of age-related changes. Establish improvement of cognitive function as the overall goal of care.

Suctioning the nasopharyngeal cavity of a client

hich of the following techniques least exhibits surgical asepsis? Adding only sterile items to a sterile field Keeping sterile gloved hands above the waist Suctioning the nasopharyngeal cavity of a client Placing the sterile field at least one foot away from personnel

During the postoperative phase

he nurse is assigned a client scheduled for an outpatient colonoscopy in an ambulatory care setting. During which phase of perioperative care would the nurse document the admission vital signs in the recovery room? During the preoperative phase During the intraoperative phase During the transfer phase During the postoperative phase

elective surgery

means that the client should have the surgery even though failure to have the surgery is not catastrophic

Ineffective thermoregulation

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis? Acute incisional pain Ineffective thermoregulation Decreased cardiac output Ineffective airway clearance

Review the scheduled procedure, site, and client.

Once the operating team has assembled in the room, the circulating nurse calls for a "time out." What action should the nurse take during the time out? Ensure that sufficient surgical supplies are available. Check that all surgical personnel are properly attired. Review the scheduled procedure, site, and client. Confirm that informed consent has been obtained.

experiences pain within tolerable limits.

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

It prevents aspiration and respiratory complications.

A client asks about the purpose of withholding food and fluid before surgery. Which response by the nurse is appropriate? It prevents overhydration and hypertension. It decreases urine output so that a catheter will not be needed. It prevents aspiration and respiratory complications. It decreases the risk of elevated blood sugar and slow wound healing.

II (Stage II is the excitement stage, which is characterized by struggling, shouting, and laughing. Stage I is the beginning of anesthesia, during which the client breathes in the anesthetic mixture and feelings of warmth, dizziness, and detachment occur. Stage III is surgical anesthesia characterized by unconsciousness and quietness. Surgical anesthesia is achieved by continued administration of anesthetic vapor and gas. Stage IV is medullary depression.)

A client is receiving general anesthesia. The nurse anesthetist starts to administer the anesthesia. The client begins giggling and kicking her legs. What stage of anesthesia would the nurse document related to the findings? I II III IV

To prevent cerebrospinal fluid (CSF) leakage (The client receiving a subarachnoid block requires special positioning to prevent CSF leakage and headache and to ensure proper anesthetic distribution. Proper positioning doesn't help prevent confusion, seizures, or cardiac arrhythmias.)

A client is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist's instructions. Why does the client require special positioning for this type of anesthesia? To prevent confusion To prevent seizures To prevent cerebrospinal fluid (CSF) leakage To prevent cardiac arrhythmias

Side-lying bicycle riding

A client is scheduled for surgery that will require bed rest and arrives for preoperative teaching. Which exercise will the nurse instruct the client to perform to decrease likelihood of venous thrombosis? Early ambulation Deep knee bends Straight leg raises Side-lying bicycle riding

"You will be lying on your side with your knees to your chest."

A client is undergoing a lumbar puncture. The nurse educates the client about surgical positioning. Which statement by the nurse is appropriate? "You will be placed flat on the table, face down." "You will be on your back with the head of the bed at 30 degrees." "You will be lying on your side with your knees to your chest." "You will be flat on your back with the table slanted so your head is below your feet."

allow the client to wear the ring and cover it with tape

A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take? Discuss the risk for infection caused by wearing the ring. Allow the client to wear the ring and cover it with tape. Notify the surgeon to cancel surgery. Remove the ring once the client is sedated

Nasogastric tube

A client who sustained traumatic injuries caused by intoxication needs emergency surgery. Which device will be inserted before general anesthesia is given to prevent the development of a postoperative complication? Nasogastric tube Nasopharyngeal airway Indwelling urinary catheter Balloon catheter

distract the client with a familiar object or music

A client with Alzheimer disease becomes agitated while the nurse is attempting to take vital signs. What action by the nurse is most appropriate? Continue taking the vital signs. Place the client in a secluded room until calm. Distract the client with a familiar object or music. Document the inability to assess vital signs due to client's agitation.

emergent

A fractured skull would be classified under which category of surgery based on urgency? Elective Required Urgent Emergent

Pink to red and soft, noting that it bleeds easily

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue? Necrotic and hard Pale yet able to blanch with digital pressure Pink to red and soft, noting that it bleeds easily White with long, thin areas of scar tissue

Position the client in the side-lying position.

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

the most common cause of dementia in the elderly Is Alzheimers disease

A nurse is caring for a client with dementia. A family member of the client asks what the most common cause of dementia is. Which response by the nurse is most appropriate? "Dementia is a terrible disease of the elderly." "The most common cause of dementia in the elderly is Alzheimer's disease." "Drug interactions are the most common cause of dementia in the elderly." "Depression may manifest as dementia in elderly clients."

Use diaphragmatic breathing.

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching? Make inhalation longer than exhalation. Exhale through an open mouth. Use diaphragmatic breathing. Use chest breathing.

use diaphragmatic breathing (n chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion.)

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching? Make inhalation longer than exhalation. Exhale through an open mouth. Use diaphragmatic breathing. Use chest breathing.

The edges of a sterile package, once opened, are considered unsterile.

A perioperative nurse is conducting an in-service education program about maintaining surgical asepsis during the intraoperative period. Which of the following would the nurse emphasize? The edges of a sterile package, once opened, are considered unsterile. A distance of 3 feet must be maintained when moving around a sterile field. If a tear occurs in a sterile drape, a new sterile drape is applied on top of it. Circulating nurses may come in contact with the sterile field without contaminating it.

the edges of a sterile package, once opened, are considered unsterile.

A perioperative nurse is conducting an in-service education program about maintaining surgical asepsis during the intraoperative period. Which of the following would the nurse emphasize? The edges of a sterile package, once opened, are considered unsterile. A distance of 3 feet must be maintained when moving around a sterile field. If a tear occurs in a sterile drape, a new sterile drape is applied on top of it. Circulating nurses may come in contact with the sterile field without contaminating it.

"Several possible underlying factors could be causing the confusion. Alzheimer's usually does not present with sudden confusion."

An older adult develops sudden onset of confusion and is hospitalized. The family expresses concern that their loved one is developing Alzheimer disease. What response by the nurse is most appropriate? "What concerns you most about Alzheimer disease?" "Alzheimer disease can be a great burden on the family. What community resources do you know about?" "Once the underlying cause of the confusion is found and treated, your loved one will be better than ever." "Several possible underlying factors could be causing the confusion. Alzheimer's usually does not present with sudden confusion."

assess cardiovascular function

An older adult seeks medical attention for a new onset of epigastric distress and bilateral arm pain. Which action will the nurse complete? Encourage the client to ambulate. Assess cardiovascular function. Recommend taking an over-the-counter antacid. Review the contents of the client's most recent meal.

more than one body system may be affected

An older adult seeks medical attention for a new onset of rectal bleeding. For which reason will the nurse perform a complete physical assessment with the client? The symptom of rectal bleeding is vague More than one body system may be affected The bleeding may be coming from another body orifice Older adult clients may be poor historians of symptoms

Asthma Arthritis Diabetes Body mass index 32

The nurse is reviewing information collected from a client during a preoperative assessment. Which condition(s) will the nurse highlight that increases the client's risk for a surgical complication? Select all that apply. Asthma Arthritis Diabetes Body mass index 32 Urinary incontinence

The nurse will explain the details of the surgery before I sign a consent."

The nurse has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statement, made by the client, would indicate that further instruction is needed? "If I do not follow the instructions, my surgery could be cancelled." "The nurse will explain the details of the surgery before I sign a consent." "My medical records will be sent to the ambulatory care center prior to my surgery." "The physician will update my family after the procedure and provide specific discharge instructions."

Empty and measure the drainage and compress the Hemovac.

The nurse is caring for a postoperative client with a Hemovac. The Hemovac is expanded and contains approximately 25 cc of serosanguineous drainage. The best nursing action would be to: Assess the client's wound and apply a pressure dressing. Notify the surgeon that the Hemovac is not functioning. Remove the Hemovac because it is expanded. Empty and measure the drainage and compress the Hemovac.

Position the client to maintain a patent airway

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

Cheeseburger, french fries, coleslaw, and ice cream

The nurse is evaluating the client's understanding of diet teaching aimed at promoting wound healing following surgery. The nurse would conclude teaching was ineffective if the client selects which of the following? Baked chicken, mashed potatoes, broccoli, and strawberries Grilled salmon, rice pilaf, green beans, and cantaloupe Turkey breast, baked sweet potato, asparagus, and an orange Cheeseburger, french fries, coleslaw, and ice cream

Make sure the client understands what will happen during surgery. Listen empathetically to the client's concerns about the procedure Review the client's postoperative goals following the procedure. Ask the client if he would like to speak with a clergyperson.

The nurse is providing preoperative care to a client who is anxious about total hip replacement surgery. "What if I can never walk again? I don't want to end up like my father!" What are some ways the nurse might help alleviate the client's anxiety? Select all that apply. Make sure the client understands what will happen during surgery. Listen empathetically to the client's concerns about the procedure. Remind the client that the chances of something going wrong are statistically low. Offer a sedative to help the client relax and feel more comfortable. Review the client's postoperative goals following the procedure. Ask the client if he would like to speak with a clergyperson.

"I'll eat plenty of fruits and vegetables."

The nurse is providing teaching about tissue repair and wound healing to a client who has a leg ulcer. Which of the following statements by the client indicates that teaching has been effective? "I'll make sure to limit my intake of protein." "I'll make sure that the bandage is wrapped tightly." "My foot should feel cool or cold while my leg's healing." "I'll eat plenty of fruits and vegetables."

Central venous pressure

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function? Complete blood count Central venous pressure Upper endoscopy Chest x-ray

Actions aimed at preventing surgical site infections

The policies and procedures on a preoperative unit are being amended to bring them closer into alignment with the focus of the Surgical Care Improvement Project (SCIP). What intervention most directly addresses the priorities of the SCIP? Actions aimed at increasing participation of families in planning care Actions aimed at preventing surgical site infections Actions aimed at increasing interdisciplinary collaboration Actions aimed at promoting the use of complementary and alternative medicine (CAM)

Dantrolene sodium*****

What medication should the nurse prepare to administer in the event the client has malignant hyperthermia? Dantrolene sodium Fentanyl citrate Naloxone Thiopental sodium

Up to 72 hours after alcohol withdrawal

When a client with a history of chronic alcoholism is admitted to the hospital for surgery, the nurse anticipates that the client may show signs of alcohol withdrawal delirium during which time period?

Up to 72 hours after alcohol withdrawal

When a client with a history of chronic alcoholism is admitted to the hospital for surgery, the nurse anticipates that the client may show signs of alcohol withdrawal delirium during which time period? Immediately upon admission Upon awakening in the postanesthesia care unit Up to 72 hours after alcohol withdrawal Up to 24 hours after alcohol withdrawal

The patient participates willingly in the preoperative preparation.

When does the nurse understand the patient is knowledgeable about the impending surgical procedure? The patient participates willingly in the preoperative preparation. The patient discusses stress factors causing the patient to feel depressed. The patient expresses concern about postoperative pain. The patient verbalizes fears to family.

directing all health decisions to the older adults child

Which action by the nurse demonstrates ageism? Providing the same high quality of care to all clients Encouraging the older adult to develop routines not associated with work Directing all health decisions to the older adult's child Allowing adequate time for the older adult to complete tasks

Encourage the client to keep a list of medications and review it frequently for updates easy to open lids provide a written medication schedule

Which actions by the nurse will assist in promoting an older adult's adherence to medication therapy? Select all that apply. Educate the client to keep all medications and bottles for future reference. Encourage the client to keep a list of medications and review it frequently for updates. Use easy-to-open lids. Instruct the client not to take herbal supplements. Provide a written medication schedule. Encourage the patient to use multiple pharmacies to obtain cheapest prices.

stage II decubitus ulcer on coccyx; "No one is able to turn or lift me anymore."

Which assessment finding by the nurse and statement by an older adult would require the nurse to report suspected elder abuse? BMI 24; "My family never gives me my favorite foods." Stage II decubitus ulcer on coccyx; "No one is able to turn or lift me anymore." Diabetic with fasting blood sugar 92; "It is difficult to afford food with all of these medication costs." Obvious deformity to right arm; "I tripped on the rug and fell on my arm."