Exam 1
The early stage of AD is characterized by a. no noticeable change in behavior. b. memory problems and mild confusion. c. increased time spent sleeping or in bed. d. incontinence, agitation, and wandering behavior.
B
The nurse anticipates that treatment of the patient with hyperphosphatemia secondary to renal failure will include: a. fluid restriction. b. calcium supplements. c. loop diuretic therapy. d. magnesium supplements.
B
In general, when urine output is measurable, urine output less than ______ mL per hour can reflect volume depletion with poor renal perfusion, and should be reported.
30
The nurse is assigned to care for a newly admitted patient. Number in order the steps for using the nursing process to prioritize care 1. Evaluate whether the plan was effective 2. Identify any health problems 3. Collect patient information 4. Carry out the plan 5. Determine a plan of action
3 2 5 4 1
A priority goal of treatment for the patient with AD is to a. maintain patient safety. b. maintain or increase body weight. c. return to a higher level of self-care. d. enhance functional ability over time.
A
At the end of a very long day involving the death of a patient, the nurse uses her social media account to share her experience and find some support. According to the Health Insurance Portability and Accountability Act (HIPAA), which posting would be acceptable? A. "It was a very difficult day for me due to the death of one of my favorite patients." B. "My shift at Affinity General was so hard today when one of my long-term patients died." C. "It is so sad when a young, healthy guy like the one I have been taking care of dies from cancer." D. "One of my favorite patients died today from pancreatic cancer. It was so difficult because he was only 27."
A
Following admission of a postoperative patient to the clinical unit, which of the following assessment data requires the most immediate attention? A. oxygen saturation of 85% B. respiratory rate of 13/min C. temperature of 100.4F (38C) D. blood pressure of 90/60mmHg
A
The nurse is caring for a diabetic patient in the ambulatory surgical unit who has undergone debridement of an infected toe. Which task is appropriate for the nurse to delegate to UAP? A. Check the patient's VS B. Monitor the patient's pain level C. Assess the patient's IV catheter site D. Evaluate the patient's tibial and pedal pulses
A
The nursing care for a patient with hyponatremia and fluid volume excess includes a. fluid restriction. b. administration of hypotonic IV fluids. c. administration of a cation-exchange resin. d. increased water intake for patients on nasogastric suction.
A
Which of the following patients would be most appropriate for the charge nurse to assign to an LVN? A. Hip fracture patient two days post-operative, planning for discharge to SNF tomorrow B. Stable patient just admitted from the ED for appendicitis, planned to have surgery in 2 hours. C. Patient admitted with cellulitis, prescribed IV antibiotics and PRN IV morphine for pain management D. Patient with shortness of breath, being prepared to be transferred to ICU
A
The nurse's primary responsibility for the care of the patient undergoing surgery is: a.developing an individualized plan of nursing care for the patient. b.carrying out specific tasks related to surgical policies and procedures. c.ensuring that the patient has been assessed for safe administration of anesthesia. d. performing a preoperative history and physical assessment to identify patient needs.
A Rationale: A primary role of the nurse is to assess the patient to develop an individual plan of care.
A 17-year-old patient with a leg fracture is scheduled for surgery. She reports that she is living with a friend and is an emancipated minor. She has a statement from the court for verification. Which intervention is most appropriate? a. Witness the permit after consent is obtained by the surgeon. b. Call a parent or legal guardian to sign the permit, since the patient is under 18. c. Obtain verbal consent, since written consent is not necessary for emancipated minors. d. Investigate your state's nurse practice act related to emancipated minors and informed consent.
A Rationale: An emancipated minor may sign his or her own permit. The nurse should be available to witness the signature, but no further action is required.
When positioning a patient in preparation for surgery, the nurse understands that injury to the patient is most likely to occur as a result of: a.incorrect musculoskeletal alignment. b.loss of perception of pain or pressure. c.pooling of blood in peripheral vessels. d.disregarding the patient's need for modesty
A Rationale: Whatever position is required for the procedure, great care is taken to prevent injury to the patient. -Because anesthesia blocks the sensory nerve impulses, the patient does not feel pain or discomfort or sense stress placed on the nerves, muscles, bones, and skin. - Improper positioning can result in muscle strain, joint damage, pressure ulcers, nerve damage, and other untoward effects.
By infusing a bolus of fluid, the physician is attempting to: (Select all that apply) A. increase kidney perfusion B. determine Rusty's volume status C. increase Rusty's urine output D. determine Rusty's kidney function E. determine Rusty's cardiac function
A B C D Long-standing fluid volume depletion can lead to acute tubular necrosis. Increasing circulating fluid volume can help prevent potential kidney damage by increasing perfusion of this vital organ. Despite IV fluids, Rusty's blood pressure and urine specific gravity (SG) are relatively unchanged, and his urine output is low. Volume status can be determined by evaluating Rusty's response to increased fluids. A rise in blood pressure and an increase in urine output would indicate that fluid volume deficit was responsible for Rusty's low urine output, and that the deficit was now corrected. Assuming normal kidney function, increasing Rusty's circulating fluid volume should increase his urine output. With normal kidney function, infusion of a large amount of fluid (if it substantially corrects fluid deficit) should result in improved renal perfusion and an increase in urine output. Despite IV fluids, Rusty's blood pressure and urine specific gravity (SG) are relatively unchanged, and his urine output is low. Kidney function can be determined by evaluating Rusty's response to increased fluids. If prolonged volume depletion has resulted in acute tubular necrosis, infused fluids will not be eliminated and urine output will continue to be low.
You assess Mr. Hale specifically for any signs of deep vein thrombosis (DVT) in his legs. Signs of DVT secondary to surgery generally become evident after 24 hours. With DVT, the area of thrombosis may be: Select all that apply A. painful B. swollen C. reddened D. necrotic E. pruritic F. warm to touch
A B C F R: DVT associated with inflammation
If a postoperative patient is not catheterized and has not yet voided, other indicators of volume depletion are important. Besides a decreased urine output, other indicators of volume depletion can include: Select all that apply A. decreasing blood pressure B. tachycardia C.flushed skin D. dry mouth
A B D
Surgical site marking is required for some procedures. For which of the following procedures would site marking be required? A. Left leg above the knee amputation B. Right inguinal hernia repair C. Cesarean section D. Cataract removal left eye E. Exploratory laparotomy
A B D
An older woman was admitted to the medical unit with dehydration. Clinical indications of this problem are (select all that apply) a. weight loss b. dry oral mucosa. c. full bounding pulse. d. engorged neck veins. e. decreased central venous pressure.
A B E
Which nursing assessments are essential during Rusty's rapid IV infusion? (Select all that apply) A. Vital signs B. Urine specific gravity (SG) C. Breath sounds D. Neck veins
A C D Vital signs should be closely monitored during Rusty's rapid infusion, to evaluate responsiveness to treatment, and also to detect complications. Even though Rusty's heart condition is currently stable, he is at risk for heart failure and pulmonary edema with this rapid infusion rate. It is possible that his heart might not be able to deal with an increased fluid load. It is important to remain alert for vital sign changes suggestive of heart failure. These primarily include increasing heart rate (tachycardia) and increasing respiratory rate (tachypnea). Even though Rusty's heart condition is currently stable, he is at risk for heart failure and pulmonary edema with this rapid infusion rate. It is possible that his heart might not be able to deal with an increased fluid load. If the left side of the heart becomes inefficient as a pump, backflow of blood from the left side of the heart into the lungs could result in buildup of fluid in the lungs, with onset of dyspnea and cough. Breath sounds should be auscultated for the presence of crackles, which could occur with pulmonary edema. Assessment of neck veins is indicated. Even though Rusty's heart condition is currently stable, he is at risk for heart failure and pulmonary edema with this rapid infusion rate. It is possible that his heart might not be able to deal with an increased fluid load. This could be reflected in jugular venous distention. Jugular neck veins directly reflect right atrial pressure. Distended jugular neck veins reflect inability of the heart to accept and pump the current circulating fluid volume.
Which nursing interventions should not be delegated to unlicensed assistive personnel (UAP) but rather performed by the RN? (select all that apply) A. Administering patient medications B. Ambulating a stable patient C. Performing patient assessments D. Evaluating the effectiveness of patient care E. Feeding patients at mealtime F. Performing sterile procedures G. Providing patient teaching H. Obtaining vital signs on a stable patient I. Assisting with patient bathing
A C D F G
It is especially important for the nurse to assess for which clinical manifestation(s) in a patient who has just undergone a total thyroidectomy (select all that apply)? a. Confusion b. Weight gain c. Depressed reflexes d. Circumoral numbness e. Positive Chvostek's sign
A D E
Versed (midazolam hydrochloride) is often used as preanesthesia medication prior to general anesthesia. You expect that the Versed (midazolam hydrochloride) will: A. promote systemic muscle relaxation B. induce local analgesia C. induce systemic analgesia. D. decrease Mr. Hale's anxiety E. provide for amnesia of perioperative events
A D E
A patient is admitted to the PACU following major abdominal surgery. During the initial assessment, the patient tells the nurse that he thinks he is going to "throw up". A priority nursing intervention would be to: A. obtain vital signs, including O2 saturation B. position the patient in a lateral recovery position C. administer antiemetic medications as ordered D. apply intermittent compression devices (ICDs)
B
Which of the following techniques should be used when checking Rusty's postural vital signs? A. First take blood pressure and pulse while he is supine, then repeat them in the upright position B. First take blood pressure and pulse while he is supine, then repeat them in sitting and standing positions C. First take blood pressure and pulse while he is in the Fowler's position, then repeat them with him recumbent D. First take blood pressure and pulse in his left arm, and then in his right
A Postural vital signs are taken by first taking blood pressure and pulse supine, then in an upright position (preferably sitting on the side of the bed with feet dangling). If Rusty were not lethargic and able to get out of bed and stand, you could also check his standing blood pressure and pulse. If his systolic blood pressure falls 20 mm Hg or more, his diastolic blood pressure falls 10 mm Hg or more, or his pulse increases by 15 or more beats per minute, Rusty has a significant intravascular volume deficit. As fluid deficit worsens, blood pressure becomes low and pulse is rapid in all positions.
Which actions on your part are indicated in response to Mr. Hale's reluctance to use the incentive spirometer? Select all that apply A. Continue to encourage Mr. Hale to use his incentive spirometer and cough B. Suggest that Mr. Hale self-administer morphine before using the incentive spirometer C. Ask the respiratory therapist to work with Mr. Hale D. Call the physician
A & B
Rusty's urine is amber-colored with a specific gravity (SG) of 1.037, and his urine output is low. Which of the following are responsible for these findings? (Select all that apply) A. An increase in the secretion of antidiuretic hormone (ADH) B. A decrease in the secretion of antidiuretic hormone (ADH) C. An increase in the secretion of aldosterone D. A decrease in the secretion of aldosterone
A & C When body fluids are detected as more concentrated than normal, the posterior pituitary is stimulated to secrete increased amounts of antidiuretic hormone (ADH, arginine vasopressin or AVP), which causes water to be conserved by the kidneys. Subsequently, more concentrated urine with a high specific gravity (SG) (normal is 1.010-1.025) is eliminated in small amounts. When volume receptors in the kidney detect a low blood volume, the renin-angiotensin system is activated. Aldosterone is secreted in increased amounts from the adrenal cortex, causing sodium and water to be retained. Subsequently, less urine is eliminated.
The nurse is caring for a patient undergoing surgery for a knee replacement. What is critical to the patient's safety during the procedure(select all that apply)? a.Universal protocol is followed. b.The ACP is an anesthesiologist. c.The patient has adequate health insurance. d.The circulating nurse is a registered nurse. e.The patient's allergies are conveyed to the surgical team.
A & E Rationale: - Intraoperative nursing care includes determining the patient's allergy status in response to food, drugs, and latex. -Preventing use of the wrong site, wrong procedure, and wrong surgery has become known as the Universal Protocol. -The Universal Protocol is part of a global patient safety initiative.
Besides mental status assessment, what other assessments are relevant at this time for Rusty? (Select all that apply) A. Heart rate B. Blood pressure C. Skin D. Reflexes E. Urine glucose F. Urine specific gravity G. Respirations
A. Heart rate B. Blood pressure C. Skin F. Urine specific gravity G. Respirations Assessment of heart rate is important. With significant fluid volume deficit, which can lead to hypovolemic shock, perfusion of tissues is decreased because less fluid is being circulated. Heart rate (pulse) quickens to increase cardiac output. An increase of 15 beats per minute is considered significant. Although Rusty's usual heart rate is not known, a heart rate of 120 is fast and indicates tachycardia. With fluid volume deficit, the palpated pulse is often weak and 'thready.' Assessment of blood pressure is important. With significant fluid volume deficit, which can lead to hypovolemic shock, perfusion of tissues is decreased because less fluid is being circulated. A compensatory vasoconstriction occurs in response to maintain arterial pressure, and coronary and cerebral perfusion, at least initially. Blood pressure is maintained initially, but decreases with significant, prolonged volume depletion. Hypotension is accompanied by postural dizziness. Currently, Rusty's BP is 98/70. Skin assessment is important. With significant fluid volume deficit, peripheral vasoconstriction occurs to maintain blood pressure and shift circulation to major organs. In response, skin may be pale and cool. Skin turgor may be poor and oral mucous membranes may be dry, as fluid shifts from cells to the vascular compartment (although these assessments are not especially good indicators of interstitial fluid deficit). If done, skin turgor assessment in the older adult is best done over the forehead and sternum, and at the inner thigh. This is because there is decreased skin elasticity with aging. It would be useful to determine the degree of urine concentration. Urine specific gravity (SG) is a gross measurement of urine concentration, and can be determined quickly. Normal kidneys usually excrete less water when fluid volume deficit is present, creating dark amber (concentrated) urine. A specific gravity value greater than 1.025 is high, indicative of urine concentration. Assessment of respirations is important. With significant fluid volume deficit, which can lead to hypovolemic shock, perfusion of tissues is decreased because less fluid is being circulated. Respiratory rate increases in an attempt to provide increased amounts of oxygen to body tissues that are not being adequately perfused with oxygenated blood. Rusty's respiratory rate is 30.
Rusty called his son complaining that he wasn't feeling well. He had vomiting and diarrhea the past few days, and was unable to eat or drink very much, despite being thirsty. Upon arrival at Rusty's apartment, his son found him lethargic and disoriented. Data suggest that Rusty is at risk for and could be experiencing which of the following? A. fluid imbalance B. Congestive heart failure C. Urinary retention
A. fluid imbalance Recent episodes of vomiting and diarrhea, and the presence of dark amber urine and disorientation, suggest that Rusty is fluid deprived. He may also be experiencing electrolyte disturbances, which often accompany fluid imbalances.
Mrs. Morgan is taking celecoxib, which is a COX-2 enzyme inhibitor (a type of nonsteroidal anti-inflammatory drug). This drug is able to suppress pain and inflammation. When caring for a client receiving celecoxib, you should assess for which side effects? A. Dizziness B. GI distress C. Fluid retention D. Increased bleeding tendency E. Increased risk of heart attacked and stroke
All but D
In identifying patients at the greatest risk for health disparities, the nurse would note that A. Patients who live in urban areas have readily available access to health care access B. Cultural differences exist in patients' ability to communicate with their own HCP C. A patient receiving care from a HCP of a different culture would have decreased quality of care D. Men are more likely than women to have their cardiovascular disease symptoms ignored by their HCP
B
Mrs. Morgan has osteoarthritis of her right hip. Osteoporotic changes in the elderly are major medical and social problems. The most important clinical characteristic of osteoarthritis is activity-related joint pain relieved by a short rest. Joint symptoms are a result of which physiological process? A. thrombosis in the joint capsule B. degeneration of articular cartilage C. bleeding into the joint D. inflammation of the synovial membrane
B
A 70-kg postoperative patient has an average urine output of 25ml/hr during the first 8 hours. The priority nursing intervention(s) given this assessment would be to: A. place in indwelling urinary catheter and assess urine characteristics B. evaluate the patient's fluid volume status and obtain a bladder ultrasound C. notify the physician and anticipate the patient returning to the operating room D. continue to monitor the patient as this is a normal, expected finding after surgery
B
The nurse teaches a student nurse about how to apply the nursing process when providing patient care. Which statement, if made by the student nurse, indicates that teaching was successful? A. "The nursing process is a scientific-based method of diagnosing the patient's health care problems. B. "The nursing process is a problem-solving tool used to identify and treat patients' health care needs." C. "The nursing process is used primarily to explain nursing interventions to other health care professionals. D. "The nursing process is based on nursing theory that incorporates the biopsychosocial nature of humans."
B
What change occurs in pulse pressure as volume depletion progresses to hypovolemic shock? A. Pulse pressure increases B. Pulse pressure decreases
B
Which statement(s) accurately describe(s) mild cognitive impairment (select all that applies)? a. Always progresses to AD b. Caused by variety of factors and may progress to AD c. Should be aggressively treated with acetylcholinesterase drugs d. Caused by vascular infarcts that, if treated, will delay progression to AD e. Patient is usually not aware that there is a problem with his or her memory
B
While caring for his dying wife, the husband states that his wife is a devout Roman Catholic but he is a Baptist. Who is considered the most reliable source for spiritual preferences concerning EOL care for the dying wife? A. a priest B. dying wife C. hospice staff D. husband of dying wife
B
You palpate Mr. Hale's lower abdomen and note suprapubic distention. This is most likely a result of: A. bleeding B. a distended urinary bladder C. tension in abdominal muscles D. inflammation secondary to surgical manipulation
B
You teach Mrs. Morgan about ways to prevent deep vein thrombosis (DVT) after hip surgery. Which action by the client will help prevent DVT? A. Lying very still in bed for the first 24 hours after surgery B. Drinking plenty of fluids after surgery C. Deep breathing every few hours D. Eating a low-fat diet during the week before surgery
B
When checking for evidence of cyanosis, which of the following body areas should be observed? A. Axillae B. Nailbeds C. Lips D. Palms of the hands E. Sternum F.. Earlobes
B C D F
Activities that the nurse might perform in the role of a scrub nurse during surgery include (select all that apply) A. Checking electrical equipment B. Preparing the instrument table C. Passing instruments to the surgeon and assistants D. Coordinating activities occurring in the OR E. Maintaining accurate counts of sponges, needles, and instruments
B C E
Rusty's urine output is measured as 40 mL over two hours. Which nursing actions are indicated? (Select all that apply) A. Speed up Rusty's IV B. Notify the physician C. Check the specific gravity (SG) of Rusty's urine D. Slow down Rusty's IV E. Check Rusty's blood pressure
B C E
What nursing actions are indicated to facilitate voiding? Select all that apply A. Increase Mr. Hale's IV flow rate B. Suggest to the physician that Mr. Hale be permitted to stand to attempt to void C. Allow Mr. Hale to drink some sips of water D. Run the water in the Mr. Hale's room
B D Rationale for not C: Drinking oral fluids can be a stimulus for voiding in a person who is not voiding. However, Mr. Hale is NPO. He is not allowed to have sips of water by mouth, although he could rinse his mouth with water. Mouth rinsing might be a stimulus for voiding.
You talk with Mrs. Morgan about her surgery and she mentions possible complications, which she has discussed with her healthcare provider (HCP). Which complications are potential risks with hip replacement surgery? A. leg paralysis B. wound infection C. peritonitis D. dislocation of the prosthetic hip E. blood clotting in the leg F. bleeding
B D E F
An appropriate nonopioid analgesic for mild pain is (select all that apply) a. oxycodone. b. ibuprofen (Advil). c. lorazepam (Ativan). d. acetaminophen (Tylenol). e. codeine with acetaminophen (Tylenol #3).
B & D
A patient receiving a PCA infusion after surgery to repair a hip fracture. She is sleeping soundly but awakens when the nurse speaks to her in a normal tone of voice. Her respirations are 8 breaths/minute. The most appropriate nursing action in this situation is to a. stop the PCA infusion. b. obtain an oxygen saturation level. c. continue to closely monitor the patient. d. administer naloxone and contact the physician.
C
It is important to take note of changes in Rusty's pulse pressure when you monitor his vital signs. What is pulse pressure? A. The diastolic pressure reading B. The difference between the apical pulse rate and the diastolic pressure reading C. The difference between the systolic and diastolic pressure readings D. The difference between the apical and radial pulse rates
C
The nurse should be alert for which manifestations in a patient receiving a loop diuretic? a. Restlessness and agitation b. Paresthesias and irritability c. Weak, irregular pulse and poor muscle tone d. Increased blood pressure and muscle spasms
C
The term used to describe body fluids when they are more concentrated than normal is: A. isotonic B. hypotonic C. hypertonic
C
The typical fluid replacement for the patient with a fluid volume deficit is a. dextran. b. 0.45% saline. c. lactated Ringer's. d. 5% dextrose in 0.45% saline.
C
Unlicensed assistive personnel (UAP) working for a home care agency report a change in the alertness and language of an 82-year-old female patient. The home care nurse plans a visit to evaluate the patient's cognitive function. Which assessment would be most appropriate? A) Glasgow Coma Scale (GCS) B) Confusion Assessment Method (CAM) C) Mini-Mental State Examination (MMSE) D) National Institutes of Health Stroke Scale (NIHSS)
C
When a patient is admitted to the PACU, what are the priority interventions the nurse performs? A. assess the surgical site, noting the presence and character of drainage B. assess the amount of urinary output and the presence of bladder distention C. assess the airway for patency and quality of respirations and obtain vital signs D. review the results of intraoperative laboratory values and medications received
C
Which intervention by a nurse would best help to reduce health care disparities? A. The nurse becomes fluent in the languages of the most common minority groups in the country. B. The nurse monitors differences in the prevalence of specific diseases in the population served. C. The nurse encourages individuals from minority populations to choose careers in the health professions. D. The nurse uses guidelines for the management of common diseases that are based on the patient's gender, age, and culture.
C
Which patient would be at great risk for the potential development of hypermagnesemia? a. 83- year-old man with lung cancer and hypertension b. 65-year-old woman with hypertension taking B-adrenergic blockers c. 42-year-old woman with systemic lupus erythematosus and renal failure d. 50-year-old man with benign prostatic hyperplasia and a urinary tract infection
C
Which patient would the nurse determine is at highest risk for untreated hypertension? A. 62-year-old Asian American female who is able to read B. 74-year-old upper middle class female who is not married C. 46-year-old African American male without health insurance D. 58-year-old white male who has a high school education
C
While assisting a patient in feeding, the student nurse notices the patient begin to cough and choke. The student nurse reports this to the primary RN in SBAR format. Which of the following interdisciplinary care team providers should the nurse recommend be consulted first for this issue? A. Respiratory therapist B. Dietician C. Speech therapist D. Case manager
C
With tetany, Chvostek's sign and Trousseau's sign are usually present. To assess for Chvostek's sign, you: A. inflate a blood pressure cuff on Rusty's upper arm and observe for muscle spasm in the hand B. ask Rusty to move his index finger to his nose and observe for tremor and spasm C. tap one side of Rusty's face over the area of the facial nerve and observe for local spasm
C
IV induction for general anesthesia is the method of choice for most patients because A. The patient is not intubated B. The agents are nonexplosive C. Induction is rapid and pleasant D. Emergence is longer, but when fewer complications
C Rationale: Routine general anesthesia is usually established with an intravenous (IV) induction agent, which may be a hypnotic, anxiolytic, or dissociative agent. -When used during the initial period of anesthesia, these agents induce a pleasant sleep with a rapid onset of action that patients find desirable.
Preoperative considerations for older adults include (select all that apply) a.only using large-print educational materials. b.speaking louder for patients with hearing aids. c.recognizing that sensory deficits may be present. d.providing warm blankets to prevent hypothermia. e.teaching important information early in the morning.
C D
Because Mr. Hale is receiving morphine, it is important to know its possible effects. These include which of the following? Select all that apply A. Increase in heart rate B. Increase in gastrointestinal peristalsis C. Decrease in blood pressure D. Decrease in respiratory rate E. Pupillary constriction F. Urinary retention
C D E F
What is a post-op patient at risk for fluid volume deficit?
Circulating fluid volume may be decreased because of fluid restrictions, or fluid/blood loss during surgery. After major surgeries, shift of fluids to the surgical site, secondary to inflammatory responses, can temporarily decrease circulating fluid volume. This is called third-spacing.
After hip replacement surgery, muscle-setting isometric exercises will be important. These exercises involve active muscle contraction and relaxation without joint movement. Which exercises will Mrs. Morgan perform with instruction from the physical therapist during her rehabilitation process? Knee-chest exercises Quadriceps setting exercises Toe-touch exercises Deep knee bends
Quadriceps setting exercises
Proper attire for the semi restricted area of the surgery department is
Surgical attire Head cover
You have just started your shift and begin your care of Mrs. Morgan by completing a thorough assessment. Which outcomes are expected at this time? Select all that apply Bright red drainage from incision Suture line dry and intact Verbalizes a reduction in pain Vital signs stable Skin of right heel pink/red
Suture line dry and intact Verbalizes a reduction in pain Vital signs stable
Dementia is defined as
Syndrome characterized by cognitive dysfunction and loss of memory
Why does when a patient first gets out of bed after hip replacement surgery an abductor pillow or splint is kept between her legs?
The operative hip is kept extended, and the person pivots on the nonoperative leg. The operative hip is protected from adduction, flexion, internal or external rotation, and excessive weight bearing.
A patient is scheduled for surgery requiring general anesthesia at an ambulatory surgical center. The nurse asks him when he ate last. He replies that he had a light breakfast a couple of hours before coming to the surgery center. What should the nurse do first? a.Tell the patient to come back tomorrow, since he ate a meal. b. Proceed with the preoperative checklist, including site identification. c. Notify the anesthesia care provider of when and what the patient last ate. d. Have the patient void before administering any preoperative medications.
c Rationale: The nothing by mouth (NPO) protocol of each surgical facility should be followed. -Restriction of fluids and food is designed to minimize the potential risk of pulmonary aspiration and to decrease the risk of postoperative nausea and vomiting. -If a patient has not followed the NPO instructions, surgery may be delayed or canceled. -The nurse should notify the anesthesia care provider immediately.
In addition to muscle setting exercises, you teach Mrs. Morgan: Select all that apply how to use an overhead trapeze for moving in bed after surgery how to adduct her operative hip after surgery how to sit in bed at a 90-degree angle after surgery relaxation techniques to be used after surgery techniques for turning in bed after surgery
how to use an overhead trapeze for moving in bed after surgery relaxation techniques to be used after surgery techniques for turning in bed after surgery
As you assist Mrs. Morgan with hygiene, you assess her for signs of deep vein thrombosis (DVT) in her legs. Signs of DVT secondary to surgery generally become evident after 24 hours. Nursing assessment for deep vein thrombosis (DVT) includes which signs and symptoms? tenderness at the calf area increase in calf girth reddened area in the calf loss of sensation in the leg skin pallor at the calf area elevated body temperature
tenderness at the calf area increase in calf girth reddened area in the calf elevated body temperature
A priority nursing intervention to assist a preoperative patient in coping with fear of postoperative pain would be to a.inform the patient that pain medication will be available. b.teach the patient to use guided imagery to help manage pain. c.describe the type of pain expected with the patient's particular surgery. d.explain the pain management plan, including the use of a pain rating scale.
D Rationale: If a patient has fear of pain and discomfort after surgery, the nurse should reassure the patient that a pain management plan will be in place. - The nurse should teach the patient to ask for medications after surgery when pain is present and assure him or her that taking these medications will not contribute to an addiction. - The nurse should instruct the patient on the use of some form of pain rating scale (e.g., 0 to 10, FACES) and to request pain medication before the pain becomes severe.
Rusty's previous specific gravity (SG) was 1.036. Which of the following SG measurements might you expect as Rusty's condition improves? A. SG 1.040 B. SG 1.037 C. SG 1.006 D. SG 1.025
D This specific gravity (SG) is reasonable to expect. It reflects a moderate decrease in the concentration of Rusty's urine.
The nurse uses the Situation-Background-Assessment-Recommendation (SBAR) format to communicate a change in patient status to a health care provider. In which order should the nurse make the following statements? A. "The patient needs to be evaluated immediately and may need intubation and mechanical ventilation." B. "The patient was admitted yesterday with heart failure and has been receiving furosemide (Lasix) for diuresis, but urine output has been low." C. "The patient has crackles audible throughout the posterior chest, and the most recent oxygen saturation is 89%. Her condition is very unstable." D. "This is the nurse on the surgical unit. After assessing the patient, I am very concerned about increased shortness of breath over the past hour."
D B C A
When a postoperative patient is not responsive, or when an alert postoperative patient is vomiting, which position is preferred? A. Semi-Fowler's (30 degrees) B. Fowler's (90 degrees) C. Supine D. Side-lying
D. R: to prevent aspiration
How should a person in hypovolemic shock be positioned? A. Trendelenburg with legs elevated B. Fowler's C. Left side D. Supine with legs elevated
D. Supine with legs elevated The supine position with the head slightly elevated and the legs elevated about 30 degrees is the preferred position for patients with fluid volume deficit and hypovolemic shock. This position increases preload and facilitates perfusion of all parts of the body, especially the vital organs.
How can the nurse monitor bleeding associated with LMW heparin?
Easy bruising (ecchymosis), melena (black, tarry stools), pink, red, or dark brown urine, bleeding gums or sputum, nosebleeds, and excessive bleeding at IV or injection sites. Cerebral bleeding, if it occurs, usually results in a gradual change in level of consciousness
You assess a postoperative patient and find calf tenderness and swelling. What should you do in response to these findings? Massage the calf to relieve venous congestion Raise the knee gatch of the bed to alleviate venous stasis Encourage the patient to walk to increase peripheral blood flow Elevate the patient's legs to promote venous return to the heart
Elevate the patient's legs to promote venous return to the heart
Should abduction or adduction exercises be taught to the post-op THA patient?
Immediately after total hip replacement surgery, abduction of the newly implanted hip prosthesis helps to position it firmly in place. Abduction exercises (moving the operative hip away from the midline) are taught to Mrs. Morgan.
You assess Mrs. Morgan for signs of dislocation of the prosthetic hip. Which signs/symptoms would suggest dislocation? Both legs appearing the same length A decrease in pain in the operative leg Footdrop in the operative leg Inability to move the operative leg
Inability to move the operative leg
Additional discharge teaching should include which of the following? Select all that apply Reminding Mrs. Morgan to cross her legs when lying in bed Instructing Mrs. Morgan to have antibiotic prophylaxis before any invasive procedure, including dental work Reinforcing importance of advising the HCP if joint pain persists as healing progresses Encouraging Mrs. Morgan to bend from the waist when picking up objects Discouraging Mrs. Morgan from sitting for extended periods
Instructing Mrs. Morgan to have antibiotic prophylaxis before any invasive procedure, including dental work Reinforcing importance of advising the HCP if joint pain persists as healing progresses Discouraging Mrs. Morgan from sitting for extended periods
You also check post-op patient's temperature. Which body temperature variation do you expect?
Low body temperature
Which of the following can be included in a full liquid diet? (Select all that apply) A. Jello B. Clear chicken broth C. Ice cream D. Custard E. Scrambled eggs F. Tea G. Ginger ale
Not eggs
You assess Mrs. Morgan and review her plan of care. Which assessment finding should be reported immediately to the HCP? Bloody wound drainage A temperature of 37.8 degrees C (100 degrees F) Numbness in the operative leg Pedal pulses equal in strength bilaterally
Numbness R: A slight temperature elevation of 37.8 degrees C (100 degrees F) is not unusual or abnormal after surgery. Postoperative inflammation and slight dehydration can be expected to cause a slight fever after surgery. This assessment finding would not need to be reported. Often, temperature over 38.4 degrees C (101.1 degrees F) is reportable, although protocols vary
The clinical diagnosis of dementia is based on
Patient history and cognitive assessment
Mrs. Morgan is receiving the low molecular weight heparin (enoxaparin). Which lab values is monitored to assess therapeutic anticoagulation? Prothrombin time (PT) Platelet count Activated partial thromboplastin time (APTT) International normalized ratio (INR)
Platelet count
What type of fluids do post-op patients receive?
Postoperative patients initially receive isotonic solutions, such as 0.9% sodium chloride (normal saline) or Lactated Ringer's, to avoid a fluid shift that can result in a hypotonic state. Dextrose 5% in 0.45% sodium chloride is also commonly used. This fluid is slightly hypertonic
During the postoperative care of a 76-year-old patient, the nurse monitors the patient's intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because a. older adults have an impaired thirst mechanism and need reminding to drink fluids b. water accounts for a greater percentage of body weight in the older adult than in younger adults c. older adults are more likely than younger adults to lose extracellular fluid during surgical procedures d. small losses of fluid are more significant because body fluids account for only about 50% of body weight in older adults
D
Nurses play an important role in reducing health disparities. An important mechanisms to do this is to A. Discourage use of evidence-based practice guidelines B. Insist that patients adhere to the Healthy People 2020 guidelines C. Teach patients to use the internet to find rescues related to their health D. Engage in active listening and establish relationships with patients and families
D
The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to a. apply warm moist compresses to the insertion site. b. attempt to force 10 mL of normal saline into the device. c. place the patient on the left side with head-down position. d. instruct the patient to change positions, raise arm, and cough.
D
When scrubbing at the scrub sink, the nurse should: a.scrub from elbows to hands. b.scrub without mechanical friction. c.scrub for a minimum of 10 minutes. d.hold the hands higher than the elbows.
D
Which patient is most at risk for developing delirium? a. A 50-year-old woman with cholecystitis b. A 19-year-old man with a fractured femur c. A 42-year-old woman having an elective hysterectomy d. A 78-year-old man admitted to the medical unit with complications related to heart failure
D
The home care nurse is visiting patients in the community. Which patient is exhibiting an early warning sign of Alzheimer's disease? A) A 65-year-old male does not recognize his family members and close friends. B) A 59-year-old female misplaces her purse and jokes about having memory loss. C) A 79-year-old male is incontinent and not able to perform hygiene independently. D) A 72-year-old female is unable to locate the address where she has lived for 10 years.
D Rationale: An early warning sign of Alzheimer's disease is disorientation to time and place such as geographic disorientation. Occasionally misplacing items and joking about memory loss are examples of normal forgetfulness. Impaired ability to recognize family and close friends is a clinical manifestation of middle or moderate dementia (or Alzheimer's disease). Incontinence and inability to perform self-care activities are clinical manifestations of severe or late dementia (or Alzheimer's disease).
Mrs. Morgan has a moderate risk for developing deep vein thrombosis (DVT) after surgery. For DVT prophylaxis, low molecular weight heparin (enoxaparin) will be given subcutaneously every day after surgery for seven to ten days. The nurse is aware that an overdose of enoxaparin is treated with which drug? Fondaparinux Protamine sulfate Aspirin Vitamin K
Protamine sulfate
The primary purpose of hospice is to
Provide comfort and support for dying patients and their families
