Exam 1
A 34-year-old has a new diagnosis of type 2 diabetes. The nurse will discuss the need to schedule a dilated eye exam
as soon as possible
Which of these patients being seen at the human immunodeficiency virus (HIV) clinic should the nurse assess first?
Patient who has had 10 liquid stools in the last 24 hours
A patient is being prepared for a spinal fusion. While in the holding area, which action by a member of the surgical team requires rapid intervention by the charge nurse?
Walking into a hallway outside the operating room without the hair covered
In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72, pulse 74, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first?
encourage the patient to take deep breaths
Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative pressure wound therapy?
Low serum albumin level
A patient receives aspart (NovoLog) insulin at 8:00 AM. Which time will it be most important for the nurse to monitor for symptoms of hypoglycemia?
10 AM
The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon?
200 ml sanguineous fluid in the wound drain
After change-of-shift report, which patient should the nurse assess first?
23-year-old with type 1 diabetes who has a blood glucose of 40 mg/dL
After change-of-shift report, which patient will the nurse assess first?
60-year-old with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa
A patient scheduled to undergo total knee replacement surgery under general anesthesia asks the nurse, "Will the doctor put me to sleep with a mask over my face?" Which response by the nurse is most appropriate?
A drug may be given to you through your IV line first. I will check with the anesthesia care provider.
The nurse should plan to use a wet-to-dry dressing for which patient?
A patient who has a wound with purulent drainage and dry brown areas
A patient who had knee surgery received intramuscular ketorolac (Toradol) 30 minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale). Which action is best for the nurse to take at this time?
Administer the prescribed IV PRN morphine sulfate
The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer?
Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change
A nurse assists a patient on the first postoperative day to ambulate, cough, deep breathe, and turn. Which action by the nurse is most helpful?
Administer ordered analgesic medications before these activities
When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?
Administer the prescribed lisper (Humalog) insulin before transporting the patient to surgery
The nurse reviews the laboratory results for a patient on the first postoperative day after a hiatal hernia repair. Which finding would indicate to the nurse that the patient is at increased risk for poor wound healing?
Albumin level 2.2
While in the holding area, a patient reveals to the nurse that his father had a high fever after surgery. What action by the nurse is a priority?
Alert the anesthesia care provider of the family member's reaction to surgery
A patient who has never had any prior surgeries tells the nurse doing the preoperative assessment about an allergy to bananas and avocados. Which action is most important for the nurse to take?
Alert the surgery center about a possible latex allergy
A diabetic patient who has reported burning foot pain at night receives a new prescription. Which information should the nurse teach the patient about amitriptyline (Elavil)?
Amitriptyline helps prevent transmission of pain impulses to the brain
A patient with rheumatoid arthritis has been taking corticosteroids for 11 months. Which nursing action is most likely to detect early signs of infection in this patient?
Ask about fatigue or feelings of malaise
A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate?
Assess for bladder distention
The nurse is preparing to teach a 43-year-old man who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first?
Assess the patient's perception of what it means to have Diabetes Mellitus
The nasogastric (NG) tube is removed on the second postoperative day, and the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. What action by the nurse is the mostappropriate?
Assist the patient to ambulate
The surgical unit nurse has just received a patient with a history of smoking from the postanesthesia care unit. Which action is most important at this time?
Auscultate for adventitious breath sounds
The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be most appropriate for the nurse to take?
Explain to the patient that this is an expected finding
An active 28-year-old male with type 1 diabetes is being seen in the endocrine clinic. Which finding may indicate the need for a change in therapy?
Blood pressure 146/88
A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with thoughts about dying. Do you think I am just being morbid?" Which response by the nurse is best?
Can you tell me more about the kind of thoughts you are having?
A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is being cared for at home by his mother. To prevent further tissue damage, what instructions are most important for the nurse to teach the mother?
Change the patient's position at least every 2 hours
Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct?
Changes in diet and exercise may control blood glucose levels in type II Diabetes
The health care provider suspects the Somogyi effect in a 50-year-old patient whose 6:00 AM blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take?
Check the blood glucose during the night
A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first?
Check the oxygen saturation
Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen?
Check the patient's class schedule to help determine when the drugs should be taken
A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). Which action by the nurse is most appropriate?
Check the patient's oral temperature again in 4 hours
Which information will the nurse include in teaching a female patient who has peripheral arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs?
Choose flat-soled leather shoes
The nurse identifies a need for additional teaching when the patient who is self-monitoring blood glucose
Chooses a puncture site in the center of the finger pad
On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse ismost appropriate?
Continue to take vital signs every 15 minutes
A young adult female patient who is human immunodeficiency virus (HIV)-positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan?
Continue to use contraception while on this medication
The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next?
Give the patient 4 to 6 oz more orange juice
The nurse working in the postanesthesia care unit (PACU) notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5° F (35.8° C). Which action should the nurse take?
Cover the patient with a warm blanket and put on socks
Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for abdominal surgery for an open cholecystectomy?
Deep breathing and coughing techniques
In order to assist an older diabetic patient to engage in moderate daily exercise, which action is most important for the nurse to take?
Determine what type of activities the patient enjoys
A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk, with wasting of the arms, legs, and face. What instructions will the nurse give to the patient?
Discuss a change in antiretroviral therapy
The nurse obtains a health history from a patient who is scheduled for elective hip surgery in 1 week. The patient reports use of garlic and ginkgo biloba. Which action by the nurse is most appropriate?
Discuss the herb and supplement use with the patient's health care provider
An older patient is being discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, "I do not know if I can take care of myself with this patch over my eye." Which action by the nurse ismost appropriate?
Discuss the specific concerns regarding self-care
Which question during the assessment of a diabetic patient will help the nurse identify autonomic neuropathy?
Do you feel bloated after eating?
The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate?
Document the assessment
A patient's T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate?
Document the color and amount of drainage
A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is most appropriate?
Elevate the ankle above heart level
Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+ cell count of 800/µL and an undetectable viral load. What is the priority nursing intervention at this time?
Encourage adequate nutrition, exercise, and sleep
Which action should the perioperative nurse take to best protect the patient from burn injury during surgery?
Ensure correct placement of the grounding pad
Which action should the nurse take after a 36-year-old patient treated with intramuscular glucagon for hypoglycemia regains consciousness?
Give the patient a snack of peanut butter and crackers
A few weeks after an 82-year-old with a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy and taught about appropriate diet and exercise, the home health nurse makes a visit. Which finding by the nurse is most important to discuss with the health care provider?
Glomerular filtration rate is decreased
Which information will the nurse include when teaching a 50-year-old patient who has type 2 diabetes about glyburide (Micronase, DiaBeta, Glynase)?
Glyburide stimulates insulin production and release from the pancreas
A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient?
Glycosylated hemoglobin level
When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8° F. Which action should the nurse take first?
Have the patient use the incentive spirometer
The nurse is assessing a 22-year-old patient experiencing the onset of symptoms of type 1 diabetes. Which question is most appropriate for the nurse to ask?
Have you lost weight lately?
Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help with the transfer of a patient to the clinical unit?
Help with the transfer of a patient onto a stretcher
Which data identified during the perioperative assessment alert the nurse that special protection techniques should be implemented during surgery?
History of spinal and hip arthritis
A patient's 4 ´ 3-cm leg wound has a 0.4 cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound?
Hydrocolloid dressing (DuoDerm)
The nurse determines a need for additional instruction when the patient with newly diagnosed type 1 diabetes says which of the following?
I can choose any foods, as long as I use enough insulin to cover the calories
Which statement by a patient scheduled for surgery is most important to report to the health care provider?
I had a heart valve replacement last year
Which statement by the patient indicates a need for additional instruction in administering insulin?
I need to rotate injection sites among my arms, legs, and abdomen each day
After the nurse has finished teaching a patient who has a new prescription for exenatide (Byetta), which patient statement indicates that the teaching has been effective?
I should take my daily aspirin at least an hour before the Byetta
Which statement, if made by a new circulating nurse, is appropriate?
I will assist in preparing the operating room for the patient
A 54-year-old patient is admitted with diabetic ketoacidosis. Which admission order should the nurse implement first?
Infuse 1 L of normal saline per hour
An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to
Insert a large-bore IV catheter
A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best?
It is important to participate in a needle-exchange program
A patient received inhalation anesthesia during surgery. Postoperatively the nurse should monitor the patient for which complication?
Laryngospasm
A 32-year-old patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage?
Lispro (Humalog)
A patient undergoing an emergency appendectomy has been using St. John's wort to prevent depression. Which complication would the nurse expect in the postanesthesia care unit?
Longer time to recover from anesthesia
A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse's highest priority?
Maintaining the patient's blood glucose within the normal range
Which nursing action should the operating room (OR) nurse manager delegate to the registered nurse first assistant (RNFA) when caring for a surgical patient?
Make surgical incisions and suture incisions as needed
An older adult who takes medications for coronary artery disease has just been diagnosed with asymptomatic chronic human immunodeficiency virus (HIV) infection. Which information will the nurse include in patient teaching?
Many medications have interactions with antiretroviral drugs
Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP) who are working in the diabetic clinic?
Measure the ankle-brachial index
A 26-year-old female with type 1 diabetes develops a sore throat and runny nose after caring for her sick toddler. The patient calls the clinic for advice about her symptoms and a blood glucose level of 210 mg/dL despite taking her usual glargine (Lantus) and lispro (Humalog) insulin. The nurse advises the patient to
Monitor the blood glucose every 4 hours and notify the clinic if it continues to rise
A pregnant woman with a history of asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient?
Most infants born to HIV-positive mothers are not infected with the virus
The nurse has been teaching a patient with type 2 diabetes about managing blood glucose levels and taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching?
My Diabetes won't cause complications because I don't need insulin
Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown?
Needle stick with a needle and syringe used to draw blood
Which laboratory value reported to the nurse by the unlicensed assistive personnel (UAP) indicates the most urgent need for the nurse's assessment of the patient?
Noon blood glucose of 52
When caring for a patient who has received a general anesthetic, the circulating nurse notes red, raised wheals on the patient's arms. Which action should the nurse take immediately?
Notify the anesthesia care practitioner (NCP) immediately
The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I do not really understand what the doctor said." Which action is best for the nurse to take?
Notify the surgeon that the informed consent process is not complete
After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first?
Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating
A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first?
Obtain a glucose reading using a finger stick
A patient with an open leg wound has a white blood cell (WBC) count of 13, 500/µL and a band count of 11%. What action should the nurse take first?
Obtain wound cultures
Five minutes after receiving the ordered preoperative midazolam (Versed) by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate?
Offer a urinal or bedpan and position the patient in the bed to promote voiding
The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the right time?
Oral saquinavir (Invarase)
Which action included in the perioperative patient plan of care can the charge nurse delegate to a surgical technologist?
Pass sterile instruments and supplies to the surgeon
Which information would be most important to help the nurse determine if the patient needs human immunodeficiency virus (HIV) testing?
Patient age
The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient?
Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis
A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/µL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient?
Patient's ability to comply with ART schedule
A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed?
Patient's breath sounds are clear to auscultation
A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first?
Perform a bladder scan
The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago. Which action should the nurse take first?
Perform the jaw-thrust maneuver
A 27-year-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse takefirst?
Place the patient on a cardiac monitor
An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient?
Potential complication: venous thromboembolism
The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority?
Prevention of HIV transmission between sexual partners
Which action will the nurse take immediately after surgery for a patient who received ketamine (Ketalar) as an anesthetic agent?
Provide a quiet environment in the post-anesthesia care unit
The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision deficits. His wife usually answers most questions that are directed to the patient. Which action should the nurse take when doing the teaching?
Provide additional time for the patient to understand preoperative instructions and carry out procedures
A patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. How would the nurse document this wound?
Red wound
A patient with a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time?
Remind the patient about the need to return for retesting in order to verify the results
A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to
Request that if testing is further delayed, the patient be returned to the unit to eat
When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the health care provider prescribes prednisone (Deltasone). The nurse will anticipate that the patient may
Require administration of insulin while taking Prednisone
A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next?
Rising body temperature
The nurse is taking a health history from a 29-year-old pregnant patient at the first prenatal visit. The patient reports no personal history of diabetes but has a parent who is diabetic. Which action will the nurse plan to take first?
Schedule the patient for a fasting blood glucose level
The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider?
Separation of the proximal wound edges by 1 cm
A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure ulcer?
Stage III
The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)?
Stock the patient's room with all the necessary personal protective equipment
A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first?
Take the patient's vital signs
The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first?
Take the patient's vital signs
A patient scheduled for an elective hysterectomy tells the nurse, "I am afraid that I will die in surgery like my mother did!" Which response by the nurse is most appropriate?
Tell me more about what happened with your mother
A patient has received atropine before surgery and complains of dry mouth. Which action by the nurse is best?
Tell the patient dry mouth is an expected side effect
A patient who has vague symptoms of fatigue, headaches, and a positive test for human immunodeficiency virus (HIV) antibodies using an enzyme immunoassay (EIA) test. What instructions should the nurse give to this patient?
The EIA test will need to be repeated in order to verify the results
After the home health nurse teaches a patient's family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed?
The family member dries the wound using a hair dryer set on a low setting
A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care?
The new nurse cleans the ulcer with a sterile dressing soaked in half-strength peroxide
An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful?
The new nurse turns an unconscious patient to the side upon arrival to the PACU
Which patient action indicates good understanding of the nurse's teaching about administration of aspart (NovoLog) insulin?
The patient cleans the skin with soap and water before insulin administration
Which action by a patient indicates that the home health nurse's teaching about glargine and regular insulin has been successful?
The patient disposes of the open vials of glargine and regular insulin after 4 weeks
The nurse is interviewing a new patient with diabetes who receives rosiglitazone (Avandia) through a restricted access medication program. What is most important for the nurse to report immediately to the health care provider?
The patient has chest pressure when walking
A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/mL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct?
The patient has developed acquired immunodeficiency syndrome (AIDS)
A 28-year-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching?
The patient increases daily exercise when ketones are present in the urine
A patient arrives at the ambulatory surgery center for a scheduled laparoscopy procedure in outpatient surgery. Which information is of most concern to the nurse?
The patient is planning to drive home after surgery
Which patient action indicates a good understanding of the nurse's teaching about the use of an insulin pump?
The patient programs the pump for an insulin bolus after eating
The nurse cares for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care?
The patient states, "Sometimes I miss a dose of Zidovudine (AZT)"
Which information in the preoperative patient's medication history is most important to communicate to the health care provider?
The patient takes garlic capsules daily but did not take any on the surgical day
When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing?
The patient takes insulin daily
Which information is most important for the nurse to report to the health care provider before a patient with type 2 diabetes is prepared for a coronary angiogram?
The patient took the prescribe Metformin (Glucophage) today
A female patient is scheduled for an oral glucose tolerance test. Which information from the patient's health history is most important for the nurse to communicate to the health care provider?
The patient uses oral contraceptives
After receiving a change-of-shift report, which patient should the nurse assess first?
The patient who has been receiving chemotherapy and has a temperature of 102 F
The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)?
The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer
A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care?
The patient will maintain intact perineal skin
A 55-year-old female patient with type 2 diabetes has a nursing diagnosis of imbalanced nutrition: more than body requirements. Which goal is most important for this patient?
The patient will reach a glycosylated hemoglobin level of less than 7%
Which finding indicates a need to contact the health care provider before the nurse administers metformin (Glucophage)?
The patient's blood urea nitrogen level is 52
The nurse interviews a patient scheduled to undergo general anesthesia for a hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery?
The patient's father died after receiving general anesthesia for abdominal surgery
A 38-year-old female is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery?
The patient's statement that her last menstrual period was 8 weeks previously
The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?
The right calf is swollen, warm, and painful
The nurse educator facilitates student clinical experiences in the surgical suite. Which action, if performed by a student, would require the nurse educator to intervene?
The student wears surgical scrubs in the semi-restricted area
A patient who is scheduled for a therapeutic abortion tells the nurse, "Having an abortion is not right." Which functional health pattern should the nurse further assess?
Value-belief
To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review?
Viral load testing
A 26-year-old patient with diabetes rides a bicycle to and from work every day. Which site should the nurse teach the patient to administer the morning insulin?
abdomen
As the nurse prepares a patient the morning of surgery, the patient refuses to remove a wedding ring, saying, "I have never taken it off since the day I was married." Which response by the nurse is best?
suggest that the patient give the ring to a family member to keep
Which action best describes how the scrub nurse maintains aseptic technique during surgery?
changes gloves after touching the upper arm of the surgeon's gown
A 38-year-old patient who has type 1 diabetes plans to swim laps daily at 1:00 PM. The clinic nurse will plan to teach the patient to
check blood glucose level before, during, and after swimming
A patient who takes a diuretic and a b-blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the health care provider before surgery?
serum potassium 3.2
Monitored anesthesia care (MAC) is going to be used for a closed, manual reduction of a dislocated shoulder. What action does the nurse anticipate?
starting a 20-gauge IV in the patient's unaffected arm
Which action most effectively demonstrates that a new staff member understands the role of scrub nurse?
keeps both hands above the operating table level
A 48-year-old male patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). The nurse will plan to teach the patient about
lifestyle changes to lower blood glucose
A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action should the nurse take?
obtain a blood glucose measurement before administration of insulin
Which action best describes the role of the certified registered nurse anesthetist (CRNA) on the surgical care team?
releases or discharges patients from the post-anesthesia care unit
The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery in a few days. The results are white blood cell (WBC) count 10.2 ´ 103/µL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 ´ 103/µL. Which action should the nurse take?
send the patient to the holding area when the operating room calls
A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. While in the postanesthesia care unit (PACU), what assessment finding is most important for the nurse to report?
weak chest wall movement
