first quiz preoperative nursing, 3th and 4th quiz

9. A volume-depleted patient would present with which of the following diagnostic lab results? BUN-to-creatinine ratio of 24:1 Urinary output of 1.2 L/24 hours Urine specific gravity of 1.02 Capillary refill time of 3 seconds

BUN-to-creatinine ratio of 24:1

A patient is admitted to the intensive care unit (ICU) with left-sided heart failure. What clinical manifestations does the nurse anticipate finding when performing an assessment? (Select all that apply.) Ascites Dyspnea Cough Pulmonary crackles Jugular vein distention

Dyspnea Cough Pulmonary crackles

. The nursing priority of care for a client exhibiting signs and symptoms of coronary artery disease should be to: Administer sublingual nitroglycerin Enhance myocardial oxygenation Decrease anxiety Educate the client about his symptoms

Enhance myocardial oxygenation

22. A client with severe hypervolemia is prescribed a loop diuretic. The nurse knows that this drug can cause a significant loss of sodium and has to be carefully monitored. Which of the following drugs is most likely the one that was prescribed? Zaroxolyn Hydrochlorothiazide Furosemide Metolazone

Furosemide

11. When caring for a client who has risk factors for fluid and electrolyte imbalances, which assessment finding is the highest priority for the nurse to follow up? Mild confusion Blood pressure 96/53 mm Hg Weight loss of 4 lb Irregular heart rate

Irregular heart rate

1. A nurse in the neurologic ICU has received a prescription to infuse a hypertonic solution into a client with increased intracranial pressure. This solution will increase the number of dissolved particles in the client's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following? Hydrostatic pressure Active transport Osmosis and osmolality Diffusion

Osmosis and osmolarity

The nurse is caring for an older adult with a diagnosis of hypertension who is being treated with a diuretic and beta-blocker. What should the nurse integrate into the management of this client's hypertension? Recognize that an older adult is less likely to adhere to the medication regimen than a younger client. Ensure that the client receives a larger initial dose of antihypertensive medication due to impaired absorption. Carefully assess for weight loss because of impaired kidney function resulting from normal aging. Pay close attention to hydration status because of increased sensitivity to extracellular volume depletion.

Pay close attention to hydration status because of increased sensitivity to extracellular volume depletion

14. During the surgical procedure, the client's temperature falls to 96.6°F. Which of the following nursing actions is inappropriate? Increase the temperature of the OR environment Warm IV and irrigating fluids Place a cooling blanket under the client. Remove wet gowns and drapes

Place a cooling blanket under the client

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

Postoperative phase

2. The surgical client has been given general anesthesia. The nurse recognizes that the client is in stage II (the excitement stage) of anesthesia. Which intervention would be most appropriate for the nurse to implement during this stage? Restrain the client Stroke the client's hand Rub the client's back Encourage the client to express feelings

Restrain the client

10. A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH? Elevating the head of the client's bed to 90 degrees Restricting fluids to 800 ml/day Restricting sodium intake to 1 gm/day

Restricting fluids to 800 ml/day

The nurse administers propranolol hydrochloride to a patient with a heart rate of 64 beats per minute (bpm). One hour later, the nurse observes the heart rate on the monitor to be 36 bpm. What medication should the nurse prepare to administer that is an antidote for the propranolol? Atropine Protamine sulfate Sodium nitroprusside Digoxin

Atropine

A nurse is checking laboratory values on a client who has crackles in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which laboratory value does the nurse expect to be abnormal? B-type natriuretic peptide (BNP) Platelet count C-reactive protein (CRP) Potassium

B-type natriuretic peptide (BNP)

7. The OR nurse is participating in the appendectomy of a 20 year-old female client who has a dangerously low body mass index. The nurse recognizes the patient's consequent risk for hypothermia. What action should the nurse implement to prevent the development of hypothermia? Ensure that IV fluids are warmed to the client's body temperature. Place warmed bags of normal saline at strategic points around the client's body. Transfuse packed red blood cells to increase oxygen carrying capacity. Monitor the client's blood pressure and heart rate vigilantly.

Ensure that IV fluids are warmed to the client's body temperature.

8. A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? Temperature Respirations Pulse Blood pressure

Pulse

20. A nurse is caring for a client with acute renal failure and hypernatremia. In this case, which action can be delegated to the nursing assistant? Assess the client's weight daily for trends. Monitor for signs and symptoms of dehydration. Teach the client about increased fluid intake. Provide oral care every 2-3 hours.

Provide oral care every 2-3 hours.

20. Which of the following mobility criteria must a postoperative client meet to be discharged to home? Select all that apply. Be able to drive to the grocery store Ambulate the length of the client's house Be able to self-toilet Get out of bed without assistance Pass a stress test

Ambulate the length of the client's house Be able to self-toilet Get out of bed without assistance

5. The perioperative nurse is constantly assessing the surgical client for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the client is developing malignant hyperthermia? Oliguria Increased temperature Hypotension Tachycardia

Tachycarida

A client is receiving captopril for heart failure. During the nurse's assessment, what sign indicates that the medication therapy is ineffective? skin rash dry cough postural hypotension peripheral edema

peripheral edema

24. The nurse is correct to state that a client's body needs to have adequate nutrition to maintain energy. Which type of transport of dissolved substances requires adenosine triphosphate (ATP)? Facilitated diffusion Passive diffusion Active transport Osmosis

Active transport

24. A PACU nurse is caring for a postoperative client who received general anesthesia and has a hard, plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and 98% oxygen saturation. The client is minimally responsive to painful stimuli. What action by the nurse is most appropriate? Obtain vital signs, including pulse oximetry, every 5 minutes. Continue with frequent client assessments. Notify the physician of impaired neurological status. Remove the oral airway.

Continue with frequent client assessments.

6. The perioperative nurse has completed the presurgical assessment of an 82-year-old female client who is scheduled for a left total knee replacement. When planning this client's care, the nurse should address the consequences of the client's aging cardiovascular system. These include an increased risk of which of the following? Hyperkalemia Hyponatremia Hypervolemia Hyperphosphatemia

Hypervolemia

25. The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of: Pulmonary edema and embolism Hyperventilation Laryngospasm Hypoxemia and hypercapnia

Hypoxemia and hypercapnia

19. The nurse observes bloody drainage on the surgical dressing of the client who has just arrived on the nursing unit. Which intervention should the nurse plan to do next? Make the client NPO and order a stat hemoglobin and hematocrit. Remove the dressing, assess the wound, and apply a new sterile dressing. Outline the drainage with a pen and record the date and time next to the drainage. Take the client's vital signs and call the surgeon.

Outline the drainage with a pen and record the date and time next to the drainage.

4. A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? Hematocrit of 52% Serum creatinine level of 0.4 mg/dl Serum sodium level of 124 mEq/L Serum blood urea nitrogen (BUN) level of 8.6 mg/dl

Serum sodium level of 124 mEq/L

2. The ED nurse is caring for a client with a suspected MI. What drug should the nurse anticipate administering to this client? Acetaminophen Oxycodone Warfarin Morphine

morphine

14. The nurse has been assigned to care for various clients. Which client is at the highest risk for a fluid and electrolyte imbalance? A 79-year-old client admitted with a diagnosis of pneumonia. A 45-year-old client who had a laparoscopic appendectomy 24 hours ago and is being advanced to a regular diet. A 66-year-old client who had an open cholecystectomy with a T-tube placed that is draining 125 mL of bile per shift. An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide.

An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide.

A client in a hypertensive emergency is admitted to the ICU. The nurse anticipates that the client will be treated with IV vasodilators, and that the primary goal of treatment is what? Lower the BP to reduce onset of neurologic symptoms, such as headache and vision changes. Reduce the BP to ≤ 120/75 mm Hg as quickly as possible. Increase the BP to reduce onset of neurologic symptoms, such as headache and vision changes. Decrease the mean arterial pressure between 20% and 25% in the first hour of treatment.

Decrease the mean arterial pressure between 20% and 25% in the first hour of treatment.

. A client has a significant history of congestive heart failure. What should the nurse specifically assess during the client's semiannual cardiology examination? Select all that apply. Examine the client's neck for distended veins. Examine the client's joints for crepitus. Monitor the client for signs of lethargy or confusion. Examine the client's eyes for excess tears.

Monitor the client for signs of lethargy or confusion. Examine the client's neck for distended veins.

15. The surgical client is at risk for injury related to positioning. Which of the following clinical manifestations exhibited by the client would indicate the goal was met of avoiding injury? Pulse oximetry 98% Absence of itching vital signs within normal limits for the client Peripheral pulses palpable

Peripheral pulses are palpable

. The nurse is discharging a client home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the client and her caregiver. What else should the nurse do before discharging the client from the facility? Select all that apply. Provide the nurse's or surgeon's contact information. Give prescriptions to the client. Administer a bolus dose of an opioid analgesic. Provide all discharge instructions in writing. Irrigate the client's incision and perform a sterile dressing change.

Provide all discharge instructions in writing. Provide the nurse's or surgeon's contact information. Give prescriptions to the client.

The nurse is assessing a patient's blood pressure. What does the nurse document as the difference between the systolic and the diastolic pressure? Auscultatory gap Pulse pressure Korotkoff sound Pulse deficit

Pulse pressure

10.Which client would the nurse recognize as having the greatest risk for complications during the intraoperative or postoperative period? The 72-year-old client who takes no routine medications. The 35-year-old client with non-insulin dependent diabetes. The 28-year-old client who occasionally smoked marijuana in high school. The 47-year-old client who stopped smoking 2 years ago.

The 35-year-old client with non-insulin dependent diabetes.

1. The nurse is caring for an unconscious trauma victim who needs emergency surgery. The client is a 55-year-old man with an adult son. He is legally divorced and is planning to be remarried in a few weeks. His parents are at the hospital with the other family members. The physician has explained the need for surgery, the procedure to be done, and the risks to the children, the parents, and the fiancé. Who should be asked to sign the surgery consent form? The client's father The physician, acting as a surrogate The son The fiance

The Son

21. A client has a serum calcium level of 7.2 mg/dl (1.8 mmol/L). During the physical examination, the nurse expects to assess: Homans' sign Goodell's sign Trousseau's sign Hegar's sign

Trousseau's sign

18. What is the priority action when the circulating nurse is completing a second verification of the surgical procedure and surgical site? Ask the surgeon whether the marked surgical site is correct. Discuss the surgical procedure and surgical site with the client. Review complications and allergies with the anesthesiologist. Obtain the attention of all members of the surgical team.

a)Obtain the attention of all members of the surgical team. Explanation: The second verification of the surgical procedure and surgical site should include all members of the surgical team. This verification should be done at one time with all members of the team involved. The marked surgical site is confirmed with all members of the surgical team, not just the surgeon or patient. Complications, allergies, and anticipated problems are also discussed among the entire surgical team.

4. The nurse is caring for a male client who has had spinal anesthesia. The client is under a physician's order to lie flat postoperatively. When the client asks to go to the bathroom, you encourage him to adhere to the physician's order. What rationale for complying with this order should the nurse explain to the client? Preventing the risk of hypotension Preventing pain at the lumbar injection site Preventing the onset of a headache Preventing respiratory depression

preventing the onset of a headache

The nurse is assessing heart sounds in a patient with heart failure. An abnormal heart sound is detected early in diastole. How would the nurse document this? S2 S1 S4 S3

s3

2. A client with hypertension has been prescribed hydrochlorothiazide. What nursing action will best reduce the client's risk for electrolyte disturbances? Maintain a low sodium diet. Encourage fluid intake. Ensure the client has sufficient potassium intake. Encourage the use of over-the-counter calcium supplements.

Ensure the client has sufficient potassium intake.

The nurse cares for a client in the emergency department who has a B-type natriuretic peptide (BNP) level of 115 pg/mL. The nurse recognizes that this finding is most indicative of which condition? Ventricular hypertrophy Pulmonary edema Myocardial infarction heart failure

heart failure

. Early signs of hypervolemia include a decrease in blood pressure. thirst increased breathing effort and weight gain. moist breath sounds

increased breathing effort and weight gain.

3. A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which test result is most significant? Urine specific gravity of 1.025 Blood urea nitrogen (BUN) level of 29 mg/dl Serum sodium level of 132 mEq/L Serum potassium level of 3 mEq/L

Serum potassium level of 3 mEq/L

16. Which intervention should the nurse plan to implement to decrease the client's risk for injury during the intraoperative period? Assess the client for allergies. Keep the family informed of the client's status. Allow the client to verbalize fears. Verify the client's preoperative vital signs.

Assess the client for allergies

The nurse is providing health education to an older adult client. What should the nurse teach the client about the relationship between hypertension and age? "Structural and functional changes in the cardiovascular system that occur with age contribute to an increase in blood pressure." "The neurologic system of older adults is less efficient at monitoring and regulating blood pressure." "Decreases in the strength of arteries and the presence of venous insufficiency cause hypertension in the elderly." "Because of reduced smooth muscle tone in blood vessels, blood pressure tends to go down with age, not up."

"Structural and functional changes in the cardiovascular system that occur with age contribute to an increase in blood pressure."

A client, who has undergone a percutaneous transluminal coronary angioplasty (PTCA), has received discharge instructions. Which statement by the client would indicate the need for further teaching by the nurse? "I should expect a low-grade fever and swelling at the site for the next week." "I should expect bruising at the catheter site for up to 3 weeks." "I should avoid taking a tub bath until my catheter site heals." "I should avoid prolonged sitting."

"I should expect a low-grade fever and swelling at the site for the next week."

13. The nurse assesses an older adult patient who complains of dimmed vision. What does this alert the nurse to plan for? A safe environment Referral to an ophthalmologist Restrictions of the patient's unassisted mobility activities Probable cataract extractions

A safe enviornment

The nurse is performing a physical assessment on a client suspected of having heart failure. The presence of what sound would signal the possibility of impending heart failure? Faint breath sounds A heart murmur Pleural friction rub An S3 heart sound

An S3 heart sound

The client states, "My doctor says that because I am now taking this water pill, I need to eat more foods that contain potassium. Can you give me some ideas about what foods would be good for this?" What is the appropriate response by the nurse? Cranberries, apples, popcorn Apricots, dried peas and beans, dates Asparagus, blueberries, green beans Bok choy, cooked leeks, alfalfa sprouts

Apricots, dried peas and beans, dates

16. The nurse is caring for a client being treated with isotonic IV fluid for hypernatremia. What complication of hypernatremia should the nurse continuously monitor for? Red blood cell crenation Cerebral edema Renal failure Red blood cell hydrolysis

Cerebral edema

The nurse is developing a nursing care plan for a client who is being treated for hypertension. What is a measurable client outcome that the nurse should include? Client will abstain from fat intake and reduce calorie intake. Client will have a stable BUN and serum creatinine levels. Client will maintain a normal body weight. Client will reduce Na+ intake to no more than 2.4 g daily.

Client will reduce Na+ intake to no more than 2.4 g daily.

5. Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? Confusion and seizures Flaccidity and thirst Tetany and increased blood urea nitrogen (BUN) levels Sunken eyeballs and spasticity

Confusion and seizures

A client presents to the clinic complaining of intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the client that angina is most often attributable to what cause? Coronary arteriosclerosis Infarction of the myocardium Decreased cardiac contractility Decreased cardiac output

Coronary arteriosclerosis

7. A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. Laboratory values are as follows: Na + 147 mEq/L K + 3.0 mEq/L Cl - 112 mEq/L Mg ++ 2.3 mg/dL Ca ++ 1.5 mg/dL Which of the following is consistent with the client's findings? Hypokalemia Mypophosphatemia Hypernatremia Hyperchloremia

Correct! Hypokalemia

The nurse is caring for a geriatric client. The client is ordered Lanoxin (digoxin) tablets 0.125mg daily for a cardiac dysrhythmias. Which of the following assessment considerations is essential when caring for this age-group? Activity level Dyspnea Digoxin level Cardiac output

Digoxin level

17. The nurse is assisting with positioning the patient on the operating table. The nurse understands that the most commonly used position is which of the following? Sims Dorsal recumbent Trendelenburg Lithotomy

Dorsal Recumbent

19. The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? Subnormal temperature Elevated blood pressure Rapid respiration Low heart rate

Elevated blood pressure

17. A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following? Extracellular fluid volume deficit Altered blood urea nitrogen (BUN) value Respiratory acidosis Metabolic alkalosis

Extracellular fluid volume deficit

. Which nerve is implicated in the Chvostek's sign? Spinal accessory Hypoglossal Optic Facial

Facial

18. The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified? In dehydration, only extracellular is depleted. Both conditions result in abnormal laboratory studies. Hypovolemia contains only low blood volume. Similar causes are present in both conditions.

In dehydration, only extracellular is depleted.

A client's medication regimen for the treatment of hypertension includes hydrochlorothiazide. Following administration of this medication, the nurse should anticipate what effect? Decreased heart rate Mild agitation Drowsiness or lethargy Increased urine output

Increased urine output

25. The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which? Lung function Insensible fluid loss Cardiovascular compromise Summer allergies

Insensible fluid loss

15. The nurse is caring for a client who was admitted with fluid volume excess (FVE). Which nursing assessments should the nurse include in the ongoing monitoring of the client? Select all that apply. Blood pressure, heart rate, and rhythm Skin assessment for edema and turgor 15. The nurse is caring for a client who was admitted with fluid volume excess (FVE). Which nursing assessments should the nurse include in the ongoing monitoring of the client? Select all that apply. Strength testing for muscle wasting Intake and output, urine volume, and color

Intake and output, urine volume, and color Skin assessment for edema and turgor Blood pressure, heart rate, and rhythm

13. The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see a decrease in which fluid location which contains the most body water? Intravascular fluid Intracellular fluid Interstitial fluid Extracellular fluid

Intracellular fluid

8. The intraoperative nurse is transferring a client from the OR to the PACU after replacement of the right knee. The client is an 83-year-old woman. The nurse should prioritize which of the following actions? Keeping the client warm Keeping the client hydrated Keeping the client restrained Keeping the client sterile

Keeping the client warm

Which action will the nurse include in the plan of care for a client admitted with acute decompensated heart failure (ADHF) who is receiving milrinone? Titrate milrinone rate slowly before discontinuing Teach the client about safe home use of the medication Monitor blood pressure frequently Encourage the client to ambulate in room

Monitor blood pressure frequently

23.The nurse is caring for a postoperative client with an indwelling urinary catheter. The hourly urinary output is 80 mL at 9 am. At 10 am, the nurse assesses the hourly urinary output as 20 mL. What is the priorityaction by the nurse? Document the findings. Notify the primary care provider immediately. Reassess the output at 11 am. Irrigate the catheter with sterile normal saline.

Notify the primary care provider immediately.

The nurse is caring for a client presenting to the emergency department (ED) reporting chest pain. Which electrocardiographic (ECG) finding would be most concerning to the nurse? Frequent premature atrial contractions (PACs) Isolated premature ventricular contractions (PVCs) Sinus tachycardia ST elevation

ST elevation

12. The nurse is caring for an older adult client who has been involved in a motor vehicle accident. The client's labs indicate minimally elevated serum creatinine levels. The nurse should assess for signs of what change? Alterations in ratio of body fluids to muscle mass Substantially reduced renal function Decreased cardiac output Acute kidney injury

Substantially reduced renal function

22. The nurse is assessing the postoperative client on the second postoperative day. Which assessment finding requires immediate physician notification? The client states a moderate amount of pain at the incisional site A moderate amount of serous drainage is noted on the operative dressing The client has an absence of bowel sounds The client's lungs reveal rales in the bases

The client has an absence of bowel sounds

3. The circulating nurse in an outpatient surgery center is assessing a client who is scheduled to receive moderate sedation. What principle should guide the care of a client receiving this form of anesthesia? The client must be able to maintain his or her own airway. The client must never be left unattended by the nurse. The client should be informed that he or she will remember most of the procedure. The client should begin a course of antiemetics the day before surgery.

The client must never be left unattended by the nurs

21. The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract? The client is passing flatus. The client reports a small bowel movement. The client is tolerating sips of water. The client states being hungry.

The client reports a small bowel movement.

perioperative experience. What education provided by the nurse is most appropriate? Three phases of surgery and safety measures for each phase Risks and benefits of the surgical procedures Expected pain levels and narcotic medications used to treat the pain Intraoperative techniques used to perform the surgery

Three phases of surgery and safety measures for each phase

Which nursing actions would be of greatest importance in the management of a client preparing for angioplasty? Remove hair from skin insertion sites Inform client of diagnostic tests Assess distal pulses Withold anticoagulant therapy

Withold anticoagulant therapy

The nurse is caring for a client with an elevated blood pressure and no previous history of hypertension. At 0900, the blood pressure was 158/90 mm Hg. At 0930, the blood pressure is 142/82 mm Hg. The nurse is most correct when relating the fall in blood pressure to which structure? Chemoreceptors Vagus nerve Sympathetic nerve fibers Baroreceptors

baroreceptors

The nurse cares for a client with an intra-arterial blood pressure monitoring device. The nurse recognizes the most preventable complication associated with hemodynamic monitoring includes which condition? catheter-related bloodstream infections air embolism hemorrhage pneumothora

catheter-related bloodstream infections