Exam 1 Review

A nurse is teaching a client about the side effects of chemotherapy medication. Which of the following nursing statements should the nurse include in the teaching

"Hair loss is common and includes eyebrows and eyelashes."

A nurse is preparing to witness informed consent for a client who is preoperative. The client asks "do I have to get the surgery?" How should the nurse respond?

"Have you discussed other treatments with your provider?"

A nurse is providing information about pain control for a client who has acute pain following a colon resection. Which of the following client statements indicates an understanding of pain control

"I will call for pain medication before the previous dose wears off."

The client diagnosed with lung cancer is being discharged. Which statement made by the client indicates more teaching is required

"It doesn't matter if I smoke now, I already have cancer"

Husband is asleep and the nurse walks in and sees the wife push his PCA pump, what should the nurse say

"Your husband should decide when more medication is needed."

malignant tumor

Ability to proliferate indefinitely.

Which intervention is appropriate for the nurse to delegate to the unlicensed assistive personnel which caring for the female client experiencing acute pain

Apply an ice pack to the site of pain

A nurse is caring for a client who is postoperative following abdominal surgery. The nurse discovers a loop of bowel through an opening in the surgical incision. Which of the following actions should the nurse take

Apply moistened sterile gauze at site

A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the clients plan of care

Avoid flowers and potted plants in the room.

Signs of Cancer (CAUTION)

C: Change in bowel or bladder habits. A: A sore that does not heal. U: Unusual bleeding or discharge. T: Thickening or lump in the breast or elsewhere. I: Indigestion or difficulty in swallowing. O: Obvious change in a wart or mole. N: Nagging cough or hoarseness.

Separation of wound with copious light brown serous drainage

Cover with wound with a moist, sterile gauze dressing

Before the patient undergoes surgery

Determine what the client knows about the surgery before signing the surgical consent

A nurse is assessing a client who will undergo abdominal surgery in 2hr. The client reports being nervous about the surgery, last had food and fluids at 2330 the previous evening and signed the surgical consent 2 days ago. Which of the following is an appropriate nursing action regarding these findings

Document the findings in the client's medical record

A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications

Encourage the use of an incentive spirometer

Colonoscopy intervals

Every ten years

A nurse is providing teaching to a client about skin cancer prevention. Which of the following indicates further teaching

High fiber will prevent skin cancer. The correct things should be like avoid the sun from 1000-1500, wear sunscreen even when it's cloudy, etc.

A nurse is caring for a client 1 day postoperative who has developed atelectasis

Hypoxemia

A nurse is planning care for a client who is postoperative and at risk for paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis

Increase ambulation

A nurse is developing an education program about skin cancer for a community center, what should the nurse include

Keep a body map of skin lesions

A nurse is reviewing the diagnostic test results of an older adult female client who is preoperative for a knee arthroplasty. The nurse should notify the surgeon of which of the following

Low WBC Count <5,000

Which data indicates to the nurse the client who is one day post operative right total hip replacement is professing as expected

Lungs on auscultation are clear bilaterally in all lobes

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions

Massaging her legs

Circulating nurse

Monitor the position of the client, prepare the surgical site, etc.

A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching

Poor nutritional state, obesity, and wound infection.

A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take

Remove the catheter and insert another into a different site.

Nonverbal behaviors

Restlessness, Grimacing, and Clenching

1-week postop following abdominal surgery

Serosanguineous drainage at this time is a manifestation of possible dehiscence

A nurse is reviewing lab values for a client who has systematic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function

Serum creatinine

A nurse is developing a plan of care for a client who is 12hr postop

Splint the incision coughing every 2 hours

A nurse is assessing a client who received IV conscious sedation for a colonoscopy. Which of the following findings indicated that the client is ready for discharge

The client is cooperative and oriented

Surgical apsis

The scrub nurse should not wear artificial eyelashes/fake nails

A nurse is preparing a teaching plan for a client who speaks limited English and is scheduled for surgical procedure. Which of the following guidelines should the nurse plan to use when selecting written educational materials for the client (select all that apply)

Use culturally diverse materials, use pictures, use materials written in the clients spoken language, provide a variety of educational materials.

Low WBC <5,000 can mean the person is

at risk for infection

Which of the following information regarding prevention of complications after abdominal surgery

compression device

What should the nurse do if yellow-green drainage is on the surgical incision

report to dr

The nurse signs when they know the signature is what

signature is authentic

The nurse's signature on the consent form means

the patient is competent enough to sign for the surgery.