Final NUR 110
An elder adult client underwent a hip replacement and now states to the nurse, "My parents are coming to visit me today. I need to mow the lawn and run errands." The client is trying to get out of the bed. What does the nurse identify is occurring with this client?
Delirium
Which client most likely requires special preoperative assessment and treatment as a result of the existing medication regimen?
a woman who takes daily anticoagulants to treat atrial fibrillation
Which statement, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction?
"I can have a hamburger and French fries as soon as I wake up."
A client who is scheduled to undergo coronary bypass surgery in a week asks the nurse whether he should discontinue taking his cholesterol medicine ahead of the surgery. Which should be the nurse's response?
"I will need to check with your health care provider about that."
The nurse is educating a client who is preparing for abdominal surgery tomorrow. A teaching demonstration has just been completed by the nurse related to splinting the incision site with a pillow. Which statement by the client best indicates the instructions provided by the nurse were effective?
"I will put the pillow on the incision then cough."
A nurse is caring for a client in the same-day surgery unit. The client asks the nurse, "Do I really need to be put to sleep for this surgery?" Which would be the nurse's best response?
"Tell me what you are most worried about."
A nurse is explaining pain control methods to a patient undergoing a bowel resection. The patient is interested in the PCA pump and asks the nurse to explain how it works. What would be the nurse's correct response?
"The pump allows the patient to self-administer limited doses of pain medication."
The nurse working in the holding area is performing an assessment on a client scheduled for surgery. Which question will the nurse ask prior to the client receiving general anesthesia?
"When was the last time you had anything to eat or drink?"
The nurse is caring for a client after breast augmentation. Before performing a bowel assessment, what education will the nurse provide the client?
"You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or narcotics. By listening for bowel sounds, I can check for a return of peristalsis."
A client has presented to the outpatient surgical center for a scheduled procedure. Which action should the nurse perform prior to the procedure?
Assess the client's allergy status.
Which nursing action should the PACU nurse take to prevent postoperative complications in clients?
Assist the client to do leg exercises to increase venous return.
A patient tells the nurse she is having pain in her right lower leg. How does the nurse determine if the patient has developed a deep vein thrombosis (DVT)?
By documenting daily calf circumference measurements
A responsibility of the nurse is the administration of preoperative medications to patients. Which statements describe the action of these medications? Select all that apply.
Diazepam is given to alleviate anxiety. Atropine is given to decrease oral secretions. Fentanyl citrate-droperidol is given to facilitate a sense of calm.
The nurse is performing a preoperative assessment of a client who has been scheduled for a reduction mammoplasty (breast reduction). The client states, "I'm starting to wonder if I made the right decision in going ahead with this." What should the nurse do next?
Explore the client's feelings and inform the surgeon.
While assessing a patient in the PACU, a nurse notes increased wound drainage, restlessness, a decreasing blood pressure, and an increase in the pulse rate. The nurse interprets these findings as most likely indicating:
Hemorrhage
A nurse is caring for an obese patient who has had surgery. The nurse monitors this patient for what postoperative complication?
Impaired wound healing
A nurse is preparing a patient for a cesarean section and teaches her the effects of the regional anesthesia she will be receiving. Which effects would the nurse expect? Select all that apply.
A localized loss of sensation and possible loss of reflexes
When an older adult client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this is most likely a result of:
a partial airway obstruction.
The preoperative nurse is teaching a client about deep-breathing exercises. The client asks, "Why do I need to learn about this?" Which response by the nurse is correct?
"After surgery, deep-breathing exercises help to remove anesthetic gases and mucus and improve oxygen supply to body tissues."
he nurse is preparing a client for surgery and asks if the client has an advance directive. The client asks "What is an advance directive?" What is the nurse's best response to this?
"An advance directive will communicate your wishes for health care postoperatively in case you are unable to do so."
A 70-year-old male is scheduled for surgery. He says to the nurse, "I am so frightened—what if I don't wake up?" What would be the nurse's best response?
"Let's talk about how you are feeling."
The nurse is providing education about deep-breathing exercises to a postoperative client whose surgery took place earlier today. Which instruction should the nurse provide?
"Try to do your exercises every 1 to 2 hours."
The nurse needs to evaluate the effectiveness of a preoperative teaching session with a client scheduled for abdominal surgery. Which client statement indicates the need for further clarification?
"While my pneumatic compression device is on, I don't need to do leg exercises."
A 72-year-old woman who is scheduled for a hip replacement is taking several medications on a regular basis. Which drug category might create a surgical risk for this patient?
Anticoagulants
A 2-year-old toddler just underwent a tonsillectomy and adenoidectomy surgery. The postanesthesia care unit (PACU) nurse is checking on him. What is the best course of action regarding the developmental care of this child?
Allow the parents into the PACU before the child wakes.
A nurse is teaching a client about the rationale for fasting from food and fluids prior to surgery. What condition does this measure attempt to avoid?
Aspiration
A nurse is explaining the rationale for performing leg exercises after surgery. Which reason would the nurse include in the explanation?
Increase venous return
A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client?
Implement leg exercises and turn the client in bed every 2 hours.
A nurse is caring for a client who is preparing to have a hip replacement. What is the responsibility(ies) of the nurse related to informed consent? Select all that apply.
Inspecting the informed consent documentation for completeness Ensuring the informed consent documentation is signed by client and a witness Confirming the informed consent documentation is a part of the client's medical record before surgery
Which surgical clients will return to activities in their everyday lives more quickly?
Laparoscopic cholecystectomy
The nurse cares for a client following surgery to repair an abdominal aortic aneurysm. Which nursing intervention assists with healing and maintaining client comfort?
Maintaining a calm environment
A scrub nurse is assisting a surgeon with a kidney transplant. What are the patient responsibilities of the scrub nurse? Select all that apply.
Maintaining sterile technique Draping and handling instruments and supplies
A perioperative nurse is preparing a patient for surgery for treatment of a ruptured spleen as the result of an automobile crash. For what type of surgery would the nurse prepare this patient?
Major, emergency
Which nursing action will best promote pain management for a client in the postoperative phase?
Performing relaxation techniques
The healthy adult client is given a narcotic prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do first?
Notify the physician of the oversight.
The nurse is caring for a client postoperatively. The vital signs are blood pressure 88/50 mm Hg, heart rate 110 beats/min, respiratory rate 24 breaths/min. The client stated the pain in the abdomen will not stop. The abdominal dressing is saturated with fresh blood. Along with notifying the surgeon, what is the nurse's priority in this situation?
Place in supine position
A nurse caring for clients in a PACU assesses a client who is displaying signs and symptoms of shock. What is the priority nursing intervention for this client?
Place the client in a flat position with legs elevated 45 degrees.
The nurse is teaching the client who recently experienced abdominal surgery to deep breathe and cough effectively. What observable action serves to best minimize pain that may result from the intervention?
Providing support to abdominal and accessory respiratory muscles
The preoperative nurse has prepared a client for surgery and has been notified that the operating room staff is ready for the client. The client states, "My bladder feels full. I need to go to the bathroom!" Which action by the nurse is appropriate?
Providing support to abdominal and accessory respiratory muscles
A patient had a surgical procedure that necessitated a thoracic incision. The nurse anticipates that the patient will have a higher risk for postoperative complications involving which body system?
Respiratory system
The nurse is caring for a confused older adult client who requires surgery for a broken hip. What steps does the nurse take to determine if the client has a durable power of attorney for health care and how to contact that person?
Review the medical chart for a copy of a durable power of attorney for health care or permission for disclosure contact.
The nurse is caring for a client who had a procedure under moderate sedation at the ambulatory surgical center. Which assessment finding indicates to the nurse that the client may be ready for discharge to home?
The client is alert and oriented with a blood pressure 118/70 mm Hg and respirations 18 breaths/minute, is able to ambulate, is not nauseated or vomiting, pain is controlled with medication, and has no excessive bleeding and drainage is as expected.
The nurse is caring for a client postoperatively. The vital signs are blood pressure 88/50 mm Hg, heart rate 110 beats/min, respiratory rate 24 breaths/min. The client stated the pain in the abdomen will not stop. The abdominal dressing is saturated with fresh blood. Along with notifying the surgeon, what is the nurse's priority in this situation?A female client age 54 years has been scheduled for a bunionectomy (removal of bone tissue from the base of the great toe) which will be conducted on an ambulatory basis. Which characteristic applies to this type of surgery?
The client will be admitted the day of surgery and return home the same day.
A nurse has been asked to witness a patient signature on an informed consent form for surgery. What information should be included on the form? Select all that apply.
The option of nontreatment The underlying disease process and its natural course Name and qualifications of the provider of the procedure or treatment Explanation of the risks and benefits of the procedure or treatment
A client has arrived to the postanesthesia care unit (PACU) and is drowsy with a respiratory rate of 12 breaths per minute. What would be an accurate interpretation by the nurse?
This is an expected finding in the immediate postoperative period.
A nurse is providing teaching for a patient scheduled to have same-day surgery. Which teaching method would be most effective in preoperative teaching for ambulatory surgery?
Written instructions
The recovery nurse is caring for a surgical client in the PACU. The client's blood pressure is dropping and the heart rate is increasing. The nurse suspects the client is:
developing shock.
A nurse is employed in an operative setting. Which of these roles is within the registered nurse (RN) scope of practice? Select all that apply.
counting sponges before and after surgery monitoring the client's vital signs positioning the client on the operating table
A nurse preparing an older adult client for hip replacement surgery is aware of the surgical risks related to the client's age. Which of the following accurately describes these risks? Select all that apply.
decreased peripheral circulation increased vascular rigidity decreased thermoregulation ability
The nurse is preparing a client for a surgical procedure that is scheduled for the next morning. What nursing action is important for the preparation to limit the risk of intraoperative and postoperative complications? Select all that apply.
educating client about postoperative care measuring baseline vital signs having the client void immediately before surgery checking that all diagnostic tests are completed
Older adults often have reduced vital capacity as a result of normal physiologic changes. Which nursing intervention would be most important for the postoperative care of an older surgical patient specific to this change?
patient turn, cough, and deep breathe every 4 hours
As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site?
procedural pause (time-out)