Fundamental exam 5

A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first? a. Administer the prescribed opioid. b. Check the oxygen (O2) saturation. c. Take the blood pressure and pulse. d. Apply wrist restraints to secure IV lines.

b. Check the oxygen (O2) saturation. Emergence delirium may be caused by a variety of factors. However, the nurse should first assess for hypoxemia. The other actions also may be appropriate, but are not the best initial action. DIF: Cognitive Level: Analyze (analysis) REF: 338

A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient? a. Renal b. Endocrine c. Respiratory d. Gastrointestinal

a. Renal The kidneys (renal) are responsible for respiratory acidosis compensation. A problem with the respiratory system causes respiratory acidosis, so another organ system (renal) needs to compensate. Problems with the gastrointestinal and endocrine systems can cause acid-base imbalances, but these systems cannot compensate for an existing imbalance. DIF:Understand (comprehension)REF:943-944

A patient who is scheduled for a therapeutic abortion tells the nurse, "Having an abortion is wrong." Which functional health pattern should the nurse further assess? a. Value-belief b. Cognitive-perceptual c. Sexuality-reproductive d. Coping-stress tolerance

a. Value-belief The value-belief pattern includes information about conflicts between a patient's values and proposed medical care. In the cognitive-perceptual pattern, the nurse will ask questions about pain and sensory intactness. The sexuality-reproductive pattern includes data about the impact of the surgery on the patient's sexuality. The coping-stress tolerance pattern assessment will elicit information about how the patient feels about the surgery. DIF: Cognitive Level: Understand (comprehension) REF: 303

The nurse observes that the patient's calcium is elevated. When checking the phosphate level, what does the nurse expect to see? a. Increased b. Decreased c. Equal to calcium d. No change in phosphate

b. Decreased Phosphate will decrease. Serum calcium and phosphate have an inverse relationship. When one is elevated, the other decreases, except in some patients with end-stage renal disease. DIF:Apply (application)REF:941

A patient's blood pressure in the postanesthesia care unit (PACU) has dropped from an admission blood pressure of 140/86 to 102/60 mm Hg with a pulse change of 70 to 96 beats/min. SpO2 is 92% on 3 L of oxygen. In which order should the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Increase the IV infusion rate. b. Assess the patient's dressing. c. Increase the oxygen flow rate. d. Check the patient's temperature.

A, C, B, D The first nursing action should be to increase the IV infusion rate. Because the most common cause of hypotension is volume loss, the IV rate should be increased. The next action should be to increase the oxygen flow rate to maximize oxygenation of hypoperfused organs. Because hemorrhage is a common cause of postoperative volume loss, the nurse should check the dressing. Finally, the patient's temperature should be assessed to determine the effects of vasodilation caused by rewarming. DIF: Cognitive Level: Analyze (analysis) REF: 338

While ambulating in the room, a patient complains of feeling dizzy. In what order will the nurse accomplish the following activities? (Put a comma and a space between each answer choice [A, B, C, D].) a. Have the patient sit down in a chair. b. Give the patient something to drink. c. Take the patient's blood pressure (BP). d. Inform the patient's health care provider.

A, C, B, D The first priority for the patient with syncope is to prevent a fall, so the patient should be assisted to a chair. Assessment of the BP will determine whether the dizziness is due to orthostatic hypotension, which occurs because of hypovolemia. Increasing the fluid intake will help prevent orthostatic dizziness. Because this is a common postoperative problem that is usually resolved through nursing measures such as increasing fluid intake and making position changes more slowly, there is no urgent need to inform the health care provider. DIF: Cognitive Level: Analyze (analysis) REF: 338

Which statement, if made by a new circulating nurse, reflects understanding of the circulating nurse role? a. "I will assist in preparing the operating room for the patient." b. "I will don sterile gloves to obtain items from the unsterile field." c. "I will remain gloved while performing activities in the sterile field." d. "I will assist with suturing of incisions and maintaining hemostasis as needed."

a. "I will assist in preparing the operating room for the patient." Preparing the operating room for the patient describes the role of a circulating nurse. All other answer options describe specific roles and actions of scrub nurses. The circulating nurse performs activities in the unsterile field and is not scrubbed, gowned, or gloved. The scrub nurse follows the designated scrub procedure, is gowned and gloved in sterile attire, and performs activities in the sterile field. DIF: Cognitive Level: Understand (comprehension) REF: 319

The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare? a. 0.45% sodium chloride (1/2 NS) b. 0.9% sodium chloride (NS) c. Lactated Ringer's (LR) d. Dextrose 5% in Lactated Ringer's (D5LR)

a. 0.45% sodium chloride (1/2 NS) 0.45% sodium chloride is a hypotonic solution. NS and LR are isotonic. D5LR is hypertonic. DIF:Apply (application)REF:956

The patient has an intravenous (IV) line and the nurse needs to remove the gown. In which order will the nurse perform the steps, starting with the first one? 1. Remove the sleeve of the gown from the arm without the IV. 2. Remove the sleeve of the gown from the arm with the IV. 3. Remove the IV solution container from its stand. 4. Pass the IV bag and tubing through the sleeve. a. 1, 2, 3, 4 b. 2, 3, 4, 1 c. 3, 4, 1, 2 d. 4, 1, 2, 3

a. 1, 2, 3, 4 Change regular gowns by following these steps for maximum speed and arm mobility: (1) To remove a gown, remove the sleeve of the gown from the arm without the IV line, maintaining the patient's privacy. (2) Remove the sleeve of the gown from the arm with the IV line. (3) Remove the IV solution container from its stand, and pass it and the tubing through the sleeve. (If this involves removing the tubing from an EID, use the roller clamp to slow the infusion to prevent the accidental infusion of a large volume of solution or medication.) DIF:Understand (comprehension)REF:959-960

The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with D5W hanging with the blood b. A patient with type A blood receiving type O blood c. A patient with intravenous potassium chloride that is diluted d. A patient with a right mastectomy and an intravenous site in the left arm

a. A patient with D5W hanging with the blood The nurse will see the patient with D5W and blood to prevent a medication error. When preparing to administer blood, prime the tubing with 0.9% sodium chloride (normal saline) to prevent hemolysis or breakdown of RBCs. All the rest are normal. A patient with type A blood can receive type O. Type O is considered the universal donor. A patient with a mastectomy should have the IV in the other arm. Potassium chloride should be diluted, and it is never given IV push. DIF:Analyze (analysis)REF:962

A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300-mL output. The patient has voided 400 mL of urine. After reporting these values to the health care provider, which order does the nurse anticipate? a. Add a potassium supplement to replace loss from output. b. Decrease the rate of intravenous fluids to 100 mL/hr. c. Administer a diuretic to prevent fluid volume excess. d. Discontinue the nasogastric suctioning.

a. Add a potassium supplement to replace loss from output. The total fluid intake and output equals 700 mL, which meets the provider goals. Patients with nasogastric suctioning are at risk for potassium deficit, so the nurse would anticipate a potassium supplement to correct this condition. Remember to record half the volume of ice chips when calculating intake. The other measures would be unnecessary because the net fluid volume is equal. DIF:Analyze (analysis)REF:949 | 951 | 955

A patient who had knee surgery received IV ketorolac 30 minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale). Which action is most effective for the nurse to take at this time? a. Administer the prescribed PRN IV morphine sulfate. b. Notify the health care provider about the ongoing pain. c. Reassure the patient that postoperative pain is expected after knee surgery. d. Teach the patient that the effects of ketorolac typically last about 6 to 8 hours.

a. Administer the prescribed PRN IV morphine sulfate. The priority at this time is pain relief. Concomitant use of opioids and nonsteroidal antiinflammatory drugs improves pain control in postoperative patients. Patient teaching and reassurance are appropriate but should be done after the patient's pain is relieved. If the patient continues to have pain after the morphine is administered, the health care provider should be notified. DIF: Cognitive Level: Analyze (analysis) REF: 339

Four patients arrive at the emergency department at the same time. Which patient will the nurse see first? a. An infant with temperature of 102.2° F and diarrhea for 3 days b. A teenager with a sprained ankle and excessive edema c. A middle-aged adult with abdominal pain who is moaning and holding her stomach d. An older adult with nausea and vomiting for 3 days with blood pressure 112/60

a. An infant with temperature of 102.2° F and diarrhea for 3 days The infant should be seen first. An infant's proportion of total body water (70% to 80% total body weight) is greater than that of children or adults. Infants and young children have greater water needs and immature kidneys. They are at greater risk for extracellular volume deficit and hypernatremia because body water loss is proportionately greater per kilogram of weight. A teenager with excessive edema from a sprained ankle can wait. A middle-aged adult moaning in pain can wait as can an older adult with a blood pressure of 112/60. DIF:Analyze (analysis)REF:947

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? a. Auscultate for adventitious breath sounds. b. Obtain the blood pressure and temperature. c. Remind the patient about harmful effects of smoking. d.Ask the health care provider to prescribe a nicotine patch.

a. Auscultate for adventitious breath sounds. The nurse should first ensure a patent airway and check for breathing and circulation (airway, breathing, and circulation [ABCs]) in a responsive patient. Circulation and temperature can be assessed after a patent airway and breathing have been established. The immediate postoperative period is not the optimal time for patient teaching about the harmful effects of smoking. Requesting a nicotine patch may be appropriate but is not a priority at this time. DIF: Cognitive Level: Analyze (analysis) REF: 307

A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take? (Select all that apply.) a. Check for contraindications to the extremity. b. Start proximally and move distally on the arm. c. Choose a vein with minimal curvature. d. Choose the patient's dominant arm. e. Select a vein that is rigid. f. Avoid areas of flexion.

a. Check for contraindications to the extremity. c. Choose a vein with minimal curvature. f. Avoid areas of flexion. The vein should be relatively straight to avoid catheter occlusion. Contraindications to starting an IV catheter are conditions such as mastectomy, AV fistula, and central line in the extremity and should be checked before initiation of IV. Avoid areas of flexion if possible. The nurse should start distally and move proximally, choosing the nondominant arm if possible. The nurse should feel for the best location; a good vein should feel spongy, a rigid vein should be avoided because it might have had previous trauma or damage. DIF:Apply (application)REF:957 | 972

Which assessments will alert the nurse that a patient's IV has infiltrated? (Select all that apply.) a. Edema of the extremity near the insertion site b. Reddish streak proximal to the insertion site c. Skin discolored or pale in appearance d. Pain and warmth at the insertion site e. Palpable venous cord f. Skin cool to the touch

a. Edema of the extremity near the insertion site c. Skin discolored or pale in appearance f. Skin cool to the touch Infiltration results in skin that is edematous near the IV insertion site. Skin is cool to the touch and may be pale or discolored. Pain, warmth, erythema, a reddish streak, and a palpable venous cord are all symptoms of phlebitis. DIF:Understand (comprehension)REF:960-961

Which action should the perioperative nurse take to best protect the patient from burn injury during surgery? a. Ensure correct placement of the grounding pad. b. Check emergency sprinklers in the operating room. c. Verify that a fire extinguisher is available during surgery. d. Confirm that all electrosurgical equipment is working properly.

a. Ensure correct placement of the grounding pad. Care must be taken to correctly place the grounding pad and all electrosurgical equipment to prevent injury from burns or fire. It is important to ensure that fire extinguishers are available and that sprinklers protect everyone in the operating room in the event of a fire, but placing the grounding pad will best prevent injury to the patient. Verifying that electrosurgical equipment is working properly does not protect the patient unless the grounding pad is placed correctly. DIF: Cognitive Level: Apply (application) REF: 321

A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed. The patient is afebrile and dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. On which transfusion complication will the nurse focus interventions? a. Fluid volume overload b. Hemolytic reaction c. Anaphylactic shock d. Septicemia

a. Fluid volume overload The signs and symptoms are concurrent with fluid volume overload. Anaphylactic shock would have presented with urticaria, dyspnea, and hypotension. Septicemia would include a fever. A hemolytic reaction would consist of flank pain, chills, and fever. DIF:Apply (application)REF:963-964

The nurse administers an intravenous (IV) hypertonic solution to a patient. In which direction will the fluid shift? a. From intracellular to extracellular b. From extracellular to intracellular c. From intravascular to intracellular d. From intravascular to interstitial

a. From intracellular to extracellular Hypertonic solutions will move fluid from the intracellular to the extracellular (intravascular). A hypertonic solution has a concentration greater than normal body fluids, so water will shift out of cells because of the osmotic pull of the extra particles. Movement of water from the extracellular (intravascular) into cells (intracellular) occurs when hypotonic fluids are administered. Distribution of fluid between intravascular and interstitial spaces occurs by filtration, the net sum of hydrostatic and osmotic pressures. DIF:Understand (comprehension)REF:936 | 956

The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the nurse document in the patient's medical record? a. Intake 255; output 375 b. Intake 285; output 375 c. Intake 505; output 125 d. Intake 535; output 125

a. Intake 255; output 375 Intake = 150 mL of orange juice, 60 mL of ice chips (but only counts as 30 since ice chips are half of the amount), and 75 mL of chicken broth; 150 + 30 + 75 = 255. Output = 125 mL of urine (void) and 250 mL of vomitus; 125 + 250 = 375. DIF:Apply (application)REF:949 | 951 | 955

A patient has dehydration. While planning care, the nurse considers that the majority of the patient's total water volume exists in with compartment? a. Intracellular b. Extracellular c. Intravascular d. Transcellular

a. Intracellular Intracellular (inside the cells) fluid accounts for approximately two thirds of total body water. Extracellular (outside the cells) is approximately one third of the total body water. Intravascular fluid (liquid portion of the blood) and transcellular fluid are two major divisions of the extracellular compartment. DIF:Understand (comprehension)REF:935

After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first? a. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating b. Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery c. Patient who has bibasilar crackles and a temperature of 100° F (37.8 °C) on the first postoperative day after chest surgery d. Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) was given

a. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating The patient's history and assessment suggests possible wound dehiscence, which should be reported immediately to the surgeon. Although the information about the other patients indicates a need for ongoing assessment and possible intervention, the data do not suggest any acute complications. Small amounts of red drainage are common in the first postoperative hours. Bibasilar crackles and a slightly elevated temperature are common after surgery, although the nurse will need to have the patient deep breathe and cough. Oral medications typically take more than 15 minutes for effective pain relief. DIF: Cognitive Level: Analyze (analysis) REF: 343

The nurse is teaching about the process of passively moving water from an area of lower particle concentration to an area of higher particle concentration. Which process is the nurse describing? a. Osmosis b. Filtration c. Diffusion d. Active transport

a. Osmosis The process of moving water from an area of low particle concentration to an area of higher particle concentration is known as osmosis. Filtration is mediated by fluid pressure from an area of higher pressure to an area of lower pressure. Diffusion is passive movement of electrolytes or other particles down the concentration gradient (from areas of higher concentration to areas of lower concentration). Active transport requires energy in the form of adenosine triphosphate (ATP) to move electrolytes across cell membranes against the concentration gradient (from areas of lower concentration to areas of higher concentration). DIF:Understand (comprehension)REF:936

A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first? a. Perform a bladder scan. b. Insert a straight catheter. c. Encourage increased oral fluid intake. d. Assist the patient to ambulate to the bathroom.

a. Perform a bladder scan. The initial action should be to assess the bladder for distention. If the bladder is distended, providing the patient with privacy (by walking with the patient to the bathroom) will be helpful. Because of the risk for urinary tract infection, catheterization should only be done after other measures have been tried without success. There is no indication to notify the surgeon about this common postoperative problem unless all measures to empty the bladder are unsuccessful. DIF: Cognitive Level: Analyze (analysis) REF: 341

A nurse is caring for a patient with peripheral intravenous (IV) therapy. Which task will the nurse assign to the nursing assistive personnel? a. Recording intake and output b. Regulating intravenous flow rate c. Starting peripheral intravenous therapy d. Changing a peripheral intravenous dressing

a. Recording intake and output A nursing assistive personnel (NAP) can record intake and output. An RN cannot delegate regulating flow rate, starting an IV, or changing an IV dressing to an NAP. DIF:Understand (comprehension)REF:951

The nurse is reviewing laboratory results. Which cation will the nurse observe is the most abundant in the blood? a. Sodium b. Chloride c. Potassium d. Magnesium

a. Sodium Sodium is the most abundant cation in the blood. Potassium is the predominant intracellular cation. Chloride is an anion (negatively charged) rather than a cation (positively charged). Magnesium is found predominantly inside cells and in bone. DIF:Apply (application)REF:935-936

Monitored anesthesia care (MAC) is going to be used for a closed, manual reduction of a dislocated shoulder. What action does the nurse anticipate? a. Starting an IV in the patient's unaffected arm b. Securing an airtight fit for the inhalation mask c. Preparing for placement of an epidural catheter d. Giving deep sedation under physician supervision.

a. Starting an IV in the patient's unaffected arm For MAC, IV sedatives, such as the benzodiazepines, are given. Therefore the patient needs IV access. Inhaled and epidural agents are not included in MAC. RNs who are trained and are allowed by agency protocols and state nurse practice acts can provide moderate to deep sedation. However, the provider of MAC must be an anesthesia care provider, since it may be necessary to change to general anesthesia during the procedure. DIF: Cognitive Level: Apply (application) REF: 322

Which information in the preoperative patient's medication history is most important to communicate to the health care provider? a. The patient takes garlic capsules every day. b. The patient quit using cocaine 10 years ago. c. The patient took a prescribed sedative the previous night. d. The patient uses acetaminophen (Tylenol) for aches and pains.

a. The patient takes garlic capsules every day. Chronic use of garlic may predispose to intraoperative and postoperative bleeding. The use of a sedative the previous night, occasional acetaminophen use, and a distant history of cocaine use will not usually affect the surgical outcome. DIF: Cognitive Level: Analyze (analysis) REF: 304

The nurse interviews a patient scheduled to undergo general anesthesia for a bilateral hernia repair. Which information is mostimportant to communicate to the surgeon and anesthesiologist before surgery? a. The patient's father died after general anesthesia for abdominal surgery. b. The patient drinks 3 cups of coffee every morning before going to work. c. The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago. d. The patient drank 4 ounces of apple juice 3 hours before coming to the hospital.

a. The patient's father died after general anesthesia for abdominal surgery. The information about the patient's father suggests that there may be a family history of malignant hyperthermia and that precautions may need to be taken to prevent this complication. Current research indicates that having clear liquids 3 hours before surgery does not increase the risk for aspiration in most patients. Patients are instructed to discontinue aspirin 1 to 2 weeks before surgery. The patient should be offered caffeinated beverages postoperatively to prevent a caffeine-withdrawal headache, but this does not have preoperative implications. DIF: Cognitive Level: Analyze (analysis) REF: 304

The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which laboratory findings are consistent with metabolic acidosis? a. pH 7.3, PaCO2 36 mm Hg, HCO3 - 19 mEq/L b. pH 7.5, PaCO2 35 mm Hg, HCO3 - 35 mEq/L c. pH 7.32, PaCO2 47 mm Hg, HCO3 - 23 mEq/L d. pH 7.35, PaCO2 40 mm Hg, HCO3 - 25 mEq/L

a. pH 7.3, PaCO2 36 mm Hg, HCO3 - 19 mEq/L The laboratory values that reflect metabolic acidosis are pH 7.3, PaCO2 36 mm Hg, HCO3 - 19 mEq/L. A laboratory finding of pH 7.5, PaCO2 35 mm Hg, HCO3 - 35 mEq/L is metabolic alkalosis. pH 7.32, PaCO2 47 mm Hg, HCO3 - 23 mEq/L is respiratory acidosis. pH 7.35, PaCO2 40 mm Hg, HCO3 - 25 mEq/L values are within normal range. DIF:Analyze (analysis)REF:944-945

Which statement by a patient scheduled for surgery is most important to report to the health care provider? a. "I have a strong family history of cancer." b. "I had a heart valve replacement last year." c. "I had bacterial pneumonia 3 months ago." d. "I have knee pain whenever I walk or jog."

b. "I had a heart valve replacement last year." A patient with a history of valve replacement is at risk for endocarditis associated with invasive procedures and may need antibiotic prophylaxis. A current respiratory infection may affect whether the patient should have surgery, but a history of pneumonia is not a reason to postpone surgery. The patient's knee pain is the likely reason for the surgery. A family history of cancer does not have implications for the current surgery. DIF: Cognitive Level: Apply (application) REF: 311

Which finding would indicate to the nurse that a postoperative patient is at increased risk for poor wound healing? a. Potassium 3.5 mEq/L b. Albumin level 2.2 g/dL c. Hemoglobin 10.2 g/dL d. White blood cells 11,900/µL

b. Albumin level 2.2 g/dL Because proteins are needed for an appropriate inflammatory response and wound healing, the low serum albumin level (normal level, 3.5 to 5.0 g/dL) indicates a risk for poor wound healing. The potassium level is normal. Because a small amount of blood loss is expected with surgery, the hemoglobin level is not indicative of an increased risk for wound healing. WBC count is expected to increase after surgery as a part of the normal inflammatory response. DIF: Cognitive Level: Apply (application) REF: 343

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. "Only your surgeon can tell you what method of anesthesia will be used." b. "I will check with the anesthesia care provider to find out what is planned." c. "General anesthesia is now given by injecting drugs into your veins, so you will not need a mask over your face." d. "Masks are no longer used for anesthesia. A tube will be inserted into your throat to deliver gas that will put you to sleep."

b. "I will check with the anesthesia care provider to find out what is planned." Routine general anesthesia is usually induced by the IV route with a hypnotic, anxiolytic, or dissociative agent. However, general anesthesia may be induced by IV or inhalation. The nurse should consult with the anesthesia care provider to determine the method selected for this patient. The anesthesia care provider will select the method of anesthesia, not the surgeon. Inhalation agents may be given through an endotracheal tube or a laryngeal mask airway. DIF: Cognitive Level: Apply (application) REF: 322

A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 50 mL/hr. At what time should the infusion be completed? a. 2300 Monday b. 2345 Monday c. 0015 Tuesday d. 0045 Tuesday

b. 2345 Monday 250 mL ÷ 50 mL/hr = 5 hr 1845 + 5 hr = 2345, which would be 2345 on Monday. DIF:Apply (application)REF:978

In which patient will the nurse expect to see a positive Chvostek sign? a. A 7-year-old child admitted for severe burns b. A 24-year-old adult admitted for chronic alcohol abuse c. A 50-year-old patient admitted for an acute exacerbation of hyperparathyroidism d. A 75-year-old patient admitted for a broken hip related to osteoporosis

b. A 24-year-old adult admitted for chronic alcohol abuse A positive Chvostek sign is representative of hypocalcemia or hypomagnesemia. Hypomagnesemia is common with alcohol abuse. Hypocalcemia can be brought on by alcohol abuse and pancreatitis (which also can be affected by alcohol consumption). Burn patients frequently experience extracellular fluid volume deficit. Hyperparathyroidism causes hypercalcemia. Immobility is associated with hypercalcemia. DIF:Apply (application)REF:942

A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia. Which assessment finding will the nurse expect? a. Dry mucous membranes b. Abdominal distention c. Distended neck veins d. Flushed skin

b. Abdominal distention Signs and symptoms of hypokalemia are muscle weakness, abdominal distention, decreased bowel sounds, and cardiac dysrhythmias. Distended neck veins occur in fluid overload. Thready peripheral pulses indicate hypovolemia. Dry mucous membranes and flushed skin are indicative of dehydration and hypernatremia. DIF:Apply (application)REF:942

Which action by the nurse will be most helpful to a patient who is expected to ambulate, deep breathe, and cough on the first postoperative day? a. Schedule the activity to begin after the patient has taken a nap. b. Administer prescribed analgesic medications before the activities. c. Ask the patient to state two possible complications of immobility. d. Encourage the patient to state the purpose of splinting the incision.

b. Administer prescribed analgesic medications before the activities. An important nursing action to encourage these postoperative activities is administration of adequate analgesia to allow the patient to accomplish the activities with minimal pain. Even with motivation provided by proper teaching, positive reinforcement, concern about complications, and with rest and sleep, patients will have difficulty if there is a great deal of pain involved with these activities. DIF: Cognitive Level: Analyze (analysis) REF: 340

The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern? a. Sodium of 145 mEq/L b. Calcium of 15.5 mg/dL c. Potassium of 3.5 mEq/L d. Chloride of 100 mEq/L

b. Calcium of 15.5 mg/dL Normal calcium range is 8.4 to 10.5 mg/dL; therefore, a value of 15.5 mg/dL is abnormally high and of concern. The rest of the laboratory values are within their normal ranges: sodium 136 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L; and chloride 98 to 106 mEq/L. DIF:Apply (application)REF:935

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? a. Place a medical alert sticker on the front of the patient's chart. b. Alert the anesthesia care provider of the family member's reaction to surgery. c. Give 650 mg of acetaminophen (Tylenol) per rectum as a preventive measure. d. Reassure the patient that his temperature will be closely monitored after surgery.

b. Alert the anesthesia care provider of the family member's reaction to surgery. The anesthesia care provider (ACP) needs to be notified and made aware of the patient's family history in regards to anesthesia reactions. Malignant hyperthermia (MH) is a valid concern because the patient's father appears to have had a reaction to surgery. The ACP needs to be notified immediately rather than waiting for a sticker to be noticed on the chart. Administering acetaminophen may not prevent MH. General anesthesia can be administered to patients with MH as long as precautions to avoid MH are taken and preparations are made to treat MH if it does occur. DIF: Cognitive Level: Analyze (analysis) REF: 327

A patient who has not had any prior surgeries tells the nurse doing the preoperative assessment about allergies to avocados and bananas. Which action is most important for the nurse to take? a. Notify the dietitian about the specific food allergies. b. Alert the surgery center about a possible latex allergy. c. Reassure the patient that all allergies are noted on the health record. d. Ask whether the patient uses antihistamines to reduce allergic reactions.

b. Alert the surgery center about a possible latex allergy. Certain food allergies (e.g., eggs, avocados, bananas, chestnuts, potatoes, peaches) are related to latex allergies. When a patient is allergic to latex, special nonlatex materials are used during surgical procedures. The staff will need to know about the allergy in advance to obtain appropriate nonlatex materials and have them available during surgery. The other actions also may be appropriate, but prevention of allergic reaction during surgery is the most important action. DIF: Cognitive Level: Analyze (analysis) REF: 305

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 mostappropriate? a. Increase the IV fluid rate. b. Assess for bladder distention. c. Notify the anesthesia care provider (ACP). d. Demonstrate the use of the nurse call bell button.

b. Assess for bladder distention. Because the patient's assessment indicates physiologic stability, the most likely cause of the patient's agitation is emergence delirium, which will resolve as the patient wakes up more fully. The nurse should look for a cause such as bladder distention. Although hypoxemia is the most common cause, the patient's oxygen saturation is 96%. Emergence delirium is common in patients recovering from anesthesia, so there is no need to notify the ACP. Orientation of the patient to bed controls is needed but is not likely to be effective until the effects of anesthesia have resolved more completely. DIF: Cognitive Level: Analyze (analysis) REF: 337

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 next? a. Notify the anesthesia care provider. b. Cover the patient with a warm blanket. c. Avoid giving opioid analgesics until the patient is warmer. d. Give acetaminophen (Tylenol) 650 mg suppository rectally.

b. Cover the patient with a warm blanket. The patient assessment indicates the need for active rewarming. There is no indication of a need for acetaminophen. Opioid analgesics may help reduce shivering. Because hypothermia is common in the immediate postoperative period, there is no need to notify the anesthesia care provider unless the patient continues to be hypothermic after active rewarming. DIF: Cognitive Level: Apply (application) REF: 338

Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for an open cholecystectomy? a. Care for the surgical incision b. Deep breathing and coughing c. Oral antibiotic therapy after discharge d. Medications to be used during surgery

b. Deep breathing and coughing Preoperative teaching, demonstration, and re-demonstration of deep breathing and coughing are needed on patients having abdominal surgery to prevent postoperative atelectasis. Incisional care and the importance of completing antibiotics are better discussed after surgery, when the patient will be more likely to retain this information. The patient does not usually need information about medications that are used intraoperatively. DIF: Cognitive Level: Apply (application) REF: 309

In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72 mm Hg, pulse 74 beats/min, respirations 12 breaths/min, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first? a. Place the patient in a side-lying position. b. Encourage the patient to take deep breaths. c. Prepare to transfer the patient to a clinical unit. d. Increase the rate of the postoperative IV fluids.

b. Encourage the patient to take deep breaths. The patient's borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. The stable blood pressure and pulse indicate that no changes in fluid intake are required. The patient is not fully awake and has a low SpO2, indicating that transfer from the PACU to a clinical unit is not appropriate. DIF: Cognitive Level: Analyze (analysis) REF: 333

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 (38.2° C). Which action should the nurse take next? a. Place ice packs in the patient's axillae. b. Have the patient use the incentive spirometer. c. Request an order for acetaminophen (Tylenol). d. Ask the health care provider to prescribe a different antibiotic.

b. Have the patient use the incentive spirometer. A temperature of 100.8° F (38.2° C) in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient deep breathe, cough, and use the incentive spirometer. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen or ice packs will reduce the temperature, but it will not resolve the underlying respiratory congestion. DIF: Cognitive Level: Apply (application) REF: 334

Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help to transport a patient to the clinical unit? a. Clarify the postoperative orders with the surgeon. b. Help with the transfer of the patient onto a stretcher. c. Document the appearance of the patient's incision in the chart. d. Provide hand off communication to the surgical unit charge nurse.

b. Help with the transfer of the patient onto a stretcher. The scope of practice of UAP includes repositioning and moving patients under the supervision of a nurse. Providing report to another nurse, assessing and documenting the wound appearance, and clarifying physician orders with another nurse require registered-nurse (RN) level education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 334

Which data identified during the preoperative assessment alerts the nurse that special protection techniques should be implemented during surgery? a. Stated allergy to cats and dogs b. History of spinal and hip arthritis c. Verbalization of anxiety by the patient d. Having a sip of water 3 hours previously

b. History of spinal and hip arthritis The patient with arthritis may require special positioning to avoid injury and postoperative discomfort. Preoperative anxiety (unless severe) and having a sip of water 3 hours before surgery are not contraindications to having surgery. An allergy to cats and dogs will not affect the care needed during the intraoperative phase. DIF:Cognitive Level: Apply (application)REF:327

Which nursing action should the operating room (OR) nurse manager delegate to the registered nurse first assistant (RNFA) when caring for a surgical patient? a. Adjust the doses of administered anesthetics. b. Make surgical incisions and suture as needed. c. Provide postoperative teaching about coughing. d. Coordinate transfer of the patient to the operating table.

b. Make surgical incisions and suture as needed. The role of the RNFA includes skills such as making and suturing incisions and maintaining hemostasis. The other actions should be delegated to other staff members such as the circulating nurse, scrub nurse, or surgical technician. The anesthesia care provider should adjust the doses of anesthetics for patients, not the RNFA. DIF: Cognitive Level: Apply (application) REF: 317

A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe? a. Respiratory alkalosis b. Metabolic alkalosis c. Metabolic acidosis d. Respiratory acidosis

b. Metabolic alkalosis The patient is losing acid from the nasogastric tube so the patient will have metabolic alkalosis. Lung problems will produce respiratory alkalosis or acidosis. Metabolic acidosis will occur when too much acid is in the body like kidney failure. DIF:Apply (application)REF:948-949

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I don't understand what the doctor said about the surgery." Which action should the nurse take next? a. Provide a thorough explanation of the planned surgical procedure. b. Notify the surgeon that the informed consent process is not complete. c. Give the prescribed preoperative antibiotics and withhold sedative medications. d. Notify the operating room nurse to give a more complete explanation of the procedure.

b. Notify the surgeon that the informed consent process is not complete. The surgeon is responsible for explaining the surgery to the patient. The nurse should wait until the surgeon has clarified the surgery before having the patient sign the consent form. The nurse should communicate directly with the surgeon about the consent form rather than asking other staff to pass on the message. It is not within the nurse's legal scope of practice to explain the surgical procedure. No preoperative medications should be given until the patient understands the surgical procedure and signs the consent form. DIF: Cognitive Level: Apply (application) REF: 309

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? a. Withhold the usual scheduled insulin dose because the patient is NPO. b. Obtain a blood glucose measurement before any insulin administration. c. Give the patient the usual insulin dose because stress will increase the blood glucose. d. Give half the usual dose of insulin because there will be no oral intake before surgery.

b. Obtain a blood glucose measurement before any insulin administration. Preoperative insulin administration is individualized to the patient, and the current blood glucose will provide the most reliable information about insulin needs. It is not possible to predict whether the patient will require no insulin, a lower dose, or a higher dose without blood glucose monitoring. DIF: Cognitive Level: Apply (application) REF: 311

Five minutes after receiving the ordered preoperative midazolam by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate? a. Assist the patient to the bathroom. b. Offer the patient a urinal or bedpan. c. Ask the patient to wait until the drug has been fully metabolized. d. Tell the patient that a bladder catheter will be placed in the operating room.

b. Offer the patient a urinal or bedpan. The patient will be at risk for a fall after receiving the sedative, so the best nursing action is to have the patient use a bedpan or urinal. Having the patient get up either with assistance or independently increases the risk for a fall. The drug is timed to be in effect during transportation to the operating room. The patient will be uncomfortable and risk involuntary incontinence if the bladder is full during transport to the operating room. DIF: Cognitive Level: Apply (application) REF: 311

Which action in the perioperative patient plan of care can the charge nurse delegate to a surgical technologist? a. Teach the patient about what to expect in the operating room (OR). b. Pass sterile instruments and supplies to the surgeon and scrub technician. c. Monitor and interpret the patient's echocardiogram (ECG) during surgery. d. Give the postoperative report to the postanesthesia care unit (PACU) nurse.

b. Pass sterile instruments and supplies to the surgeon and scrub technician. The education and certification for a surgical technologist includes the scrub and circulating functions in the OR. Patient teaching, communication with other departments about a patient's condition, and the admission assessment require registered-nurse (RN) level education and scope of practice. A surgical technologist is not usually trained to interpret ECG rhythms. DIF: Cognitive Level: Apply (application) REF: 317

A nurse is assessing a patient. Which assessment finding should cause a nurse to further assess for extracellular fluid volume deficit? a. Moist mucous membranes b. Postural hypotension c. Supple skin turgor d. Pitting edema

b. Postural hypotension Physical examination findings of deficit include postural hypotension, tachycardia, thready pulse, dry mucous membranes, and poor skin turgor. Pitting edema indicates that the patient may be retaining excess extracellular fluid. DIF:Apply (application)REF:940

A nurse is administering a diuretic to a patient and teaching the patient about foods to increase. Which food choices by the patient will best indicate successful teaching? a. Milk and cheese b. Potatoes and fresh fruit c. Canned soups and vegetables d. Whole grains and dark green leafy vegetables

b. Potatoes and fresh fruit Potatoes and fruits are high in potassium. Milk and cheese are high in calcium. Canned soups and vegetables are high in sodium. Whole grains and dark green leafy vegetables are high in magnesium. DIF:Apply (application)REF:941

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? a. Potential complication: hypovolemic shock b. Potential complication: venous thromboembolism c. Potential complication: fluid and electrolyte imbalance d. Potential complication: impaired surgical wound healing

b. Potential complication: venous thromboembolism The patient is older and relatively immobile, which are two risk factors for development of deep vein thrombosis. The other potential complications are possible postoperative problems, but they are not at a high risk based on the data about this patient. DIF: Cognitive Level: Analyze (analysis) REF: 337

A 2-year-old child is brought into the emergency department after ingesting a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis

b. Respiratory acidosis Respiratory depression leads to hypoventilation. Hypoventilation results in retention of CO2 and respiratory acidosis. Respiratory alkalosis would result from hyperventilation, causing a decrease in CO2 levels. Metabolic acid-base imbalance would be a result of kidney dysfunction, vomiting, diarrhea, or other conditions that affect metabolic acids. DIF:Analyze (analysis)REF:944- 945

A nurse is discontinuing a patient's peripheral IV access. Which actions should the nurse take? (Select all that apply.) a. Wear sterile gloves and a mask. b. Stop the infusion before removing the IV catheter. c. Use scissors to remove the IV site dressing and tape. d. Apply firm pressure with sterile gauze during removal. e. Keep the catheter parallel to the skin while removing it. f. Apply pressure to the site for 2 to 3 minutes after removal.

b. Stop the infusion before removing the IV catheter. e. Keep the catheter parallel to the skin while removing it. f. Apply pressure to the site for 2 to 3 minutes after removal. The nurse should stop the infusion before removing the IV catheter, so the fluid does not drip on the patient's skin; keep the catheter parallel to the skin while removing it to reduce trauma to the vein; and apply pressure to the site for 2 to 3 minutes after removal to decrease bleeding from the site. Scissors should not be used because they may accidentally cut the catheter or tubing or may injure the patient. During removal of the IV catheter, light pressure, not firm pressure, is indicated to prevent trauma. Clean gloves are used for discontinuing a peripheral IV access because gloved hands will handle the external dressing, tubing, and tape, which are not sterile. DIF:Understand (comprehension)REF:985-986

A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately? a. Blood pressure 110/60 b. Temperature 101.3° F c. Poor skin turgor and pallor d. Heart rate of 100 beats/min

b. Temperature 101.3° F A fever should be reported immediately and the blood transfusion stopped. All other assessment findings are expected. Blood is given to elevate blood pressure, improve pallor, and decrease tachycardia. DIF:Apply (application)REF:962 | 964

A patient arrives at the outpatient surgical center for a scheduled laparoscopy under general anesthesia. Which information requires the nurse's preoperative intervention to maintain patient safety? a. The patient has never had general anesthesia. b. The patient is planning to drive home after surgery. c. The patient had a sip of water 4 hours before arriving. d. The patient's insurance does not cover outpatient surgery.

b. The patient is planning to drive home after surgery After outpatient surgery, the patient should not drive that day and will need assistance with transportation and home care. Clear liquids only require a minimum preoperative fasting period of 2 hours. The patient's experience with anesthesia and the patient's insurance coverage are important to establish, but these are not safety issues. DIF: Cognitive Level: Apply (application) REF: 30

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? a. The patient's temperature is 100.3° F (37.9° C). b. The patient's calf is swollen, warm, and painful. c. The 24-hour oral intake is 600 mL greater than the total output. d. The patient reports abdominal pain at level 6 (0 to 10 scale) when ambulating.

b. The patient's calf is swollen, warm, and painful. The calf pain, swelling, and warmth suggest that the patient has a venous thromboembolism (VTE). This will require the health care provider to order diagnostic tests, anticoagulants, or both and is most critical because a VTE could result in a pulmonary embolism. Because the stress response causes fluid retention for the first 2 to 5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 100.3° F on the second postoperative day is suggestive of atelectasis and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before patient activities. DIF: Cognitive Level: Analyze (analysis) REF: 337

The nurse facilitates student clinical experiences in the surgical suite. Which action, if performed by a student, would require the nurse to intervene? a. The student wears a mask in the semirestricted area. b. The student wears street clothes in the semirestricted area. c. The student wears surgical scrubs in the semirestricted area. d. The student covers head and facial hair in the semirestricted area.

b. The student wears street clothes in the semirestricted area. Wearing street clothes in the semirestricted area is not permitted. The surgical suite is divided into three distinct areas: unrestricted—staff and others in street clothes can interact with those in surgical attire; semirestricted—staff must wear surgical attire and cover all head and facial hair; and restricted—includes the operating room, the sink area, and clean core where masks are required in addition to surgical attire. DIF:Cognitive Level: Apply (application)REF:315

Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis? a. pH 7.60, PaCO2 40 mm Hg, HCO3 - 30 mEq/L b. pH 7.53, PaCO2 30 mm Hg, HCO3 - 24 mEq/L c. pH 7.35, PaCO2 35 mm Hg, HCO3 - 26 mEq/L d. pH 7.25, PaCO2 48 mm Hg, HCO3 - 23 mEq/L

b. pH 7.53, PaCO2 30 mm Hg, HCO3 - 24 mEq/L Respiratory alkalosis should show an alkalotic pH and decreased CO2 (respiratory) values, with a normal HCO3 - . In this case, pH 7.53 is alkaline (normal = 7.35 to 7.45), PaCO2 is 30 (normal 35 to 45 mm Hg), and HCO3 - is 24 (normal = 22 to 26 mEq/L). A result of pH 7.60, PaCO2 40 mm Hg, HCO3 - 30 mEq/L is metabolic alkalosis. pH 7.35, PaCO2 35 mm Hg, HCO3 - 26 mEq/L is within normal limits. pH 7.25, PaCO2 48 mm Hg, HCO3 - 23 mEq/L is respiratory acidosis. DIF:Analyze (analysis)REF:944-945

A patient scheduled for an elective hysterectomy tells the nurse, "I am afraid that I will die in surgery like my mother did!" Which initial response by the nurse is appropriate? a."Surgical techniques have improved in recent years." b."Tell me more about what happened to your mother." c."You will receive medication to reduce your anxiety." d."You should talk to the doctor again about the surgery."

b."Tell me more about what happened to your mother." The patient's statement may indicate an unusually high anxiety level or a family history of problems such as malignant hyperthermia, which will require precautions during surgery. The other statements may also address the patient's concerns, but further assessment is needed first. DIF: Cognitive Level: Analyze (analysis) REF: 302

A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse prepare? a. 0.225% sodium chloride (1/4 NS) b. 0.45% sodium chloride (1/2 NS) c. 0.9% sodium chloride (NS) d. 3% sodium chloride (3% NaCl)

c. 0.9% sodium chloride (NS) Patients with prolonged vomiting and diarrhea become hypovolemic. A solution to replace extracellular volume is 0.9% sodium chloride, which is an isotonic solution. 0.225% and 0.45% sodium chloride are hypotonic. 3% sodium chloride is hypertonic. DIF:Apply (application)REF:956

A patient is to receive 1000 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. Which rate will the nurse calculate for the minute flow rate (drops/min)? a. 12 drops/min b. 24 drops/min c. 125 drops/min d. 150 drops/min

c. 125 drops/min Microdrip tubing delivers 60 drops/mL. Calculation for a rate of 125 mL/hr using microdrip tubing: (125 mL/1 hr)(60 drops/1 mL)(1 hr/60 min) = 125 drop/min. DIF:Apply (application)REF:978

A nurse has just received a bag of packed red blood cells (RBCs) for a patient. What is the longest time the nurse can let the blood infuse? a. 30 minutes b. 2 hours c. 4 hours d. 6 hours

c. 4 hours Ideally a unit of whole blood or packed RBCs is transfused in 2 hours. This time can be lengthened to 4 hours if the patient is at risk for extracellular volume excess. Beyond 4 hours there is a risk for bacterial contamination of the blood. DIF:Understand (comprehension)REF:962-963

A nurse is preparing to start a blood transfusion. Which type of tubing will the nurse obtain? a. Two-way valves to allow the patient's blood to mix and warm the blood transfusing b. An injection port to mix additional electrolytes into the blood c. A filter to ensure that clots do not enter the patient d. An air vent to let bubbles into the blood

c. A filter to ensure that clots do not enter the patient When administering a transfusion you need an appropriate-size IV catheter and blood administration tubing that has a special in-line filter. The patient's blood should not be mixed with the infusion blood. Air bubbles should not be allowed to enter the blood. The only substance compatible with blood is normal saline; no additives should be mixed with the infusing blood. DIF:Apply (application)REF:962

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 frequent, cramping gas pains. What action by the nurse is the most appropriate? a. Reinsert the NG tube. b. Give the PRN IV opioid. c. Assist the patient to ambulate. d. Place the patient on NPO status.

c. Assist the patient to ambulate. Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient's discomfort. If distention persists, the patient may need to be placed on NPO status, but usually this is not necessary. Morphine administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will not relieve the pains. DIF: Cognitive Level: Analyze (analysis) REF: 342

Which action describes how the scrub nurse protects the patient with aseptic technique during surgery? a. Uses waterproof shoe covers b. Wears personal protective equipment c. Changes gloves after touching the upper arm of the surgeon's gown d. Requires that all operating room (OR) staff perform a surgical scrub

c. Changes gloves after touching the upper arm of the surgeon's gown The sleeves of a sterile surgical gown are considered sterile only to 2 inches above the elbows, so touching the surgeon's upper arm would contaminate the nurse's gloves. Shoe covers are not sterile. Personal protective equipment is designed to protect caregivers, not the patient, and is not part of aseptic technique. Staff members such as the circulating nurse do not have to perform a surgical scrub before entering the OR. DIF: Cognitive Level: Apply (application) REF: 320

The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery. 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? a. Notify the surgeon and anesthesiologist immediately. b. Ask the patient about any symptoms of a recent infection. c. Continue to prepare the patient for the surgical procedure. d. Discuss the possibility of blood transfusion with the patient.

c. Continue to prepare the patient for the surgical procedure. The CBC count results are normal. With normal results, the patient can go to the holding area when the operating room is ready for the patient. There is no need to notify the surgeon or anesthesiologist, discuss blood transfusion, or ask about recent infection. DIF: Cognitive Level: Apply (application) REF: 308

On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate? a. Increase the IV fluid rate. b. Notify the anesthesia care provider (ACP). c. Continue to take vital signs every 15 minutes. d. Administer oxygen therapy at 100% per mask.

c. Continue to take vital signs every 15 minutes. A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration. DIF:Cognitive Level: Analyze (analysis)REF:337

An older patient is being discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, "I don't know if I can take care of myself once I'm home." Which action by the nurse is most appropriate? a. Provide written instructions for the care. b. Assess the patient's home support system. c. Discuss specific concerns regarding self-care. d. Refer the patient for home health care services.

c. Discuss specific concerns regarding self-care. The nurse's initial action should be to assess exactly the patient's concerns about self-care. Referral to home health care and assessment of the patient's support system may be appropriate actions but will be based on further assessment of the patient's concerns. Written instructions should be given to the patient, but these are unlikely to address the patient's stated concern about self-care. DIF: Cognitive Level: Analyze (analysis) REF: 344

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? a. Teach the patient that these products may be continued preoperatively. b. Advise the patient to stop the use of herbs and supplements at this time. c. Discuss the herb and supplement use with the patient's health care provider. d. Reassure the patient that there will be no interactions with anesthetic agents.

c. Discuss the herb and supplement use with the patient's health care provider. Both garlic and ginkgo biloba increase the risk for bleeding. The nurse should discuss the herb and supplement use with the patient's health care provider. The nurse should not advise the patient to stop the supplements or to continue them without consulting with the health care provider and the anesthesia care provider. DIF: Cognitive Level: Apply (application) REF: 304

A patient's T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate? a. Notify the patient's surgeon. b. Place the patient on bed rest. c. Document the color and amount of drainage. d. Irrigate the T-tube with sterile normal saline.

c. Document the color and amount of drainage. A T-tube normally drains dark green to bright yellow drainage so no action other than to document the amount and color of the drainage is needed. The other actions are not necessary. DIF: Cognitive Level: Apply (application) REF: 344

While the nurse is taking a patient history, the nurse discovers the patient has a type of diabetes that results from a head injury and does not require insulin. Which dietary change should the nurse share with the patient? a. Reduce the quantity of carbohydrates ingested to lower blood sugar. b. Include a serving of dairy in each meal to elevate calcium levels. c. Drink plenty of fluids throughout the day to stay hydrated. d. Avoid food high in acid to avoid metabolic acidosis.

c. Drink plenty of fluids throughout the day to stay hydrated. The patient has diabetes insipidus, which places the patient at risk for dehydration and hypernatremia. Dehydration should be prevented by drinking plenty of fluids to replace the extra water excreted in the urine. Foods high in acid are not what causes metabolic acidosis. A reduction in carbohydrates to lower blood sugar will not help a patient with diabetes insipidus but it may help a patient with diabetes mellitus. Calcium-rich dairy products would be recommended for a hypocalcemic patient. DIF:Apply (application)REF:949

Which actions will the nurse include in the surgical time-out procedure before surgery (select all that apply)? a. Check for patency of IV lines. b. Have the surgeon identify the patient. c. Have the patient state name and date of birth. d. Verify the patient identification band number. e. Ask the patient to state the surgical procedure.

c. Have the patient state name and date of birth. d. Verify the patient identification band number. e. Ask the patient to state the surgical procedure. These actions are included in surgical time-out procedure. IV line placement and identification of the patient by the surgeon are not included in the surgical time-out procedure. DIF: Cognitive Level: Understand (comprehension) REF: 321

The nurse observes edema in a patient who has venous congestion from right heart failure. Which type of pressure facilitated the formation of the patient's edema? a. Osmotic b. Oncotic c. Hydrostatic d. Concentration

c. Hydrostatic Venous congestion increases capillary hydrostatic pressure. Increased hydrostatic pressure causes edema by causing increased movement of fluid into the interstitial area. Osmotic and oncotic pressures involve the concentrations of solutes and can contribute to edema in other situations, such as inflammation or malnutrition. Concentration pressure is not a nursing term. DIF:Understand (comprehension)REF:937

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? a. Increased discomfort b. Increased blood pressure c. Increased anesthesia recovery time d. Increased postoperative wound bleeding

c. Increased anesthesia recovery time St. John's wort may prolong the effects of anesthetic agents and increase the time to waken completely after surgery. It is not associated with increased bleeding risk, hypertension, or increased pain. DIF: Cognitive Level: Apply (application) REF: 304

The operating room nurse is providing orientation to a student nurse. Which action would the nurse list as a major responsibility of a scrub nurse? a. Document all patient care accurately. b. Label all specimens to send to the laboratory. c. Keep both hands above the operating table level. d. Take the patient to the postanesthesia recovery area.

c. Keep both hands above the operating table level. The scrub nurse role includes maintaining asepsis in the operating field. The other actions would be performed by the circulating nurse. DIF: Cognitive Level: Apply (application) REF: 320

When caring for a preoperative patient on the day of surgery, which actions included in the plan of care can the nurse delegate to unlicensed assistive personnel (UAP) (select all that apply)? a. Teach incentive spirometer use. b. Explain routine preoperative care. c. Obtain and document baseline vital signs. d. Remove nail polish and apply pulse oximeter. e. Transport the patient by stretcher to the operating room.

c. Obtain and document baseline vital signs. d. Remove nail polish and apply pulse oximeter. e. Transport the patient by stretcher to the operating room. Obtaining vital signs, removing nail polish, pulse oximeter placement, and transport of the patient are routine skills that are appropriate to delegate. Teaching patients about the preoperative routine and incentive spirometer use require critical thinking and should be done by the registered nurse. DIF: Cognitive Level: Apply (application) REF: 309

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? a. Patient drinks 2 to 3 L of fluid in 24 hours. b. Patient uses the spirometer 10 times every hour. c. Patient's breath sounds are clear to auscultation. d. Patient's temperature is less than 100.2°F orally.

c. Patient's breath sounds are clear to auscultation One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as crackles, so clear breath sounds are an indication of resolution of the problem. Spirometer use and increased fluid intake are interventions for ineffective airway clearance but may not always improve breath sounds. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory problems. DIF: Cognitive Level: Apply (application) REF: 331

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? a. Suction the patient's mouth. b. Increase the oxygen flow rate. c. Perform the jaw-thrust maneuver. d. Elevate the patient's head on two pillows.

c. Perform the jaw-thrust maneuver. In an unconscious postoperative patient, a likely cause of hypoxemia is airway obstruction by the tongue, and the first action is to clear the airway by maneuvers such as the jaw thrust or chin lift. Increasing the oxygen flow rate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the patient's head will not be effective in correcting the obstruction but may help with oxygenation after the patient is awake. DIF: Cognitive Level: Analyze (analysis) REF: 333

Which action will the perioperative nurse take after surgery is completed for a patient who received ketamine as an anesthetic agent? a. Question the order for giving a benzodiazepine. b. Ensure that atropine is available in case of bradycardia. c. Provide a quiet environment in the postanesthesia care unit. d. Anticipate the need for higher than usual doses of analgesic agents.

c. Provide a quiet environment in the postanesthesia care unit. Hallucinations are an adverse effect associated with the dissociative anesthetics such as ketamine. Therefore the postoperative environment should be kept quiet to decrease the risk of hallucinations. Because ketamine causes profound analgesia lasting into the postoperative period, higher doses of analgesics are not needed. Ketamine causes an increase in heart rate. Benzodiazepine may be used with ketamine to decrease the incidence of hallucinations and nightmares. DIF:Cognitive Level: Apply (application)REF:323

The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision deficits. His wife answers most questions that are directed to the patient. Which action should the nurse take when doing the teaching? a. Use printed materials for instruction so that the patient will have more time to review the material. b. Direct all the teaching toward the wife because she is the obvious support and caregiver for the patient. c. Provide additional time for the patient to understand preoperative instructions and carry out procedures. d. Ask the patient's wife to wait in the hall in order to focus preoperative teaching with the patient himself.

c. Provide additional time for the patient to understand preoperative instructions and carry out procedures. The nurse should allow more time when doing preoperative teaching and preparation for older patients with sensory deficits. Because the patient has visual deficits, he will not be able to use written material for learning. The teaching should be directed toward both the patient and wife because both will need to understand preoperative procedures and teaching. DIF: Cognitive Level: Apply (application) REF: 308

The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. Which action will the nurse take first? a. Offer calcium-rich foods. b. Administer diuretic. c. Raise head of bed. d. Increase fluids.

c. Raise head of bed. The patient is in fluid overload. Raising the head of the bed to ease breathing is the first action. Offering calcium-rich foods is for hypocalcemia, not fluid overload. Administering a diuretic is the second action. Increasing fluids is contraindicated and would make the situation worse. DIF:Apply (application)REF:940 | 950 | 960

Which action best describes the role of the certified registered nurse anesthetist (CRNA) on the surgical care team? a. Performs the same responsibilities as the anesthesiologist. b. Gives intraoperative anesthetics ordered by the anesthesiologist. c. Releases or discharges patients from the postanesthesia care area. d. Manages a patient's airway under the direct supervision of the anesthesiologist.

c. Releases or discharges patients from the postanesthesia care area. A nurse anesthetist is a registered nurse who has graduated from an accredited nurse anesthesia program (minimally a master's degree program) and successfully completed a national certification examination to become a CRNA. The CRNA scope of practice includes, but is not limited to, the following: 1. Performing and documenting a preanesthetic assessment and evaluation 2. Developing and implementing a plan for delivering anesthesia 3. Selecting and initiating the planned anesthetic technique 4. Selecting, obtaining, and administering the anesthesia, adjuvant drugs, and fluids 5. Selecting, applying, and inserting appropriate noninvasive and invasive monitoring devices 6. Managing a patient's airway and pulmonary status 7. Managing emergence and recovery from anesthesia 8. Releasing or discharging patients from a postanesthesia care area DIF: Cognitive Level: Understand (comprehension) REF: 318

A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, and elevated white blood cell count. Which primary purpose for starting total parenteral nutrition (TPN) will the nurse add to the care plan? a. Stimulate the patient's appetite to eat. b. Deliver antibiotics to fight off infection. c. Replace fluid, electrolytes, and nutrients. d. Provide medication to raise blood pressure.

c. Replace fluid, electrolytes, and nutrients. Total parenteral nutrition is an intravenous solution composed of nutrients and electrolytes to replace the ones the patient is not eating or losing. TPN does not stimulate the appetite. TPN does not contain blood pressure medication or antibiotics. DIF:Apply (application)REF:955

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? a. Hematocrit 36% b. Blood pressure 144/82 c. Serum potassium 3.2 mEq/L d. Pulse rate 54-58 beats/minute

c. Serum potassium 3.2 mEq/L The low potassium level may increase the risk for intraoperative complications such as dysrhythmias. Slightly elevated blood pressure is common before surgery because of anxiety. The lower heart rate would be expected in a patient taking a b-blocker. The hematocrit is in the low normal range but does not require any intervention before surgery. DIF: Cognitive Level: Apply (application) REF: 305

The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement? a. Urine output increases to 150 mL/hr. b. Systolic and diastolic blood pressure decreases. c. Serum sodium concentration returns to normal. d. Large amounts of emesis and diarrhea decrease.

c. Serum sodium concentration returns to normal Hypernatremia is diagnosed by elevated serum sodium concentration. Blood pressure is not an accurate indicator of hypernatremia. Emesis and diarrhea will not stop because of intravenous therapy. Urine output is influenced by many factors, including extracellular fluid volume. A large dilute urine output can cause further hypernatremia. DIF:Apply (application)REF:940 | 966

The nurse is preparing a patient on the morning of surgery. The patient refuses to remove a wedding ring, saying, "I've never taken it off since the day I was married." Which response by the nurse is best? a. Have the patient sign a release form and leave the ring on. b. Tell the patient that the hospital is not liable for loss of the ring. c. Suggest that the patient give the ring to a family member to keep. d. Inform the operating room personnel that the patient is wearing a ring.

c. Suggest that the patient give the ring to a family member to keep. Jewelry is not allowed to be worn by the patient, especially if electrocautery will be used. Safety is the issue here. There is no need for a release form or to discuss liability with the patient. DIF: Cognitive Level: Apply (application) REF: 310

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? a. Assess the patient's pain. b. Orient the patient to the unit. c. Take the patient's vital signs. d. Read the postoperative orders.

c. Take the patient's vital signs. Because the priority concerns after surgery are airway, breathing, and circulation, the vital signs are assessed first. The other actions should take place after the vital signs are obtained and compared with the vital signs before transfer. DIF: Cognitive Level: Analyze (analysis) REF: 337

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? a. Reinforce the dressing. b. Apply an abdominal binder. c. Take the patient's vital signs. d. Recheck the dressing in 1 hour.

c. Take the patient's vital signs. New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patient's vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced, based on the surgeon's orders or agency policy. The nurse should not wait an hour to recheck the dressing. DIF: Cognitive Level: Analyze (analysis) REF: 337

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? a. The new nurse assists a nauseated patient to a supine position. b. The new nurse positions an unconscious patient supine with the head elevated. c. The new nurse positions an unconscious patient on the side upon arrival in the PACU. d. The new nurse places a patient in the Trendelenburg position for a low blood pressure.

c. The new nurse positions an unconscious patient on the side upon arrival in the PACU. The patient should initially be positioned in the lateral "recovery" position to keep the airway open and avoid aspiration. The Trendelenburg position is avoided because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness. DIF: Cognitive Level: Apply (application) REF: 336

A 38-yr-old woman is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to communicate to the anesthesiologist and surgeon before surgery? a. The patient's lack of knowledge about postoperative pain control b. The patient's history of an infection following a cholecystectomy c. The patient's report that her last menstrual period was 8 weeks ago d. The patient's concern about being able to resume lifting heavy items

c. The patient's report that her last menstrual period was 8 weeks ago This statement suggests that the patient may be pregnant and pregnancy testing is needed before administration of anesthetic agents. Although the other data may also be communicated with the surgeon and anesthesiologist, they will affect postoperative care and do not indicate a need for further assessment before surgery. DIF: Cognitive Level: Analyze (analysis) REF: 306

A patient in the surgical holding area is being prepared for a spinal fusion. Which action by a member of the surgical team requires immediate intervention by the charge nurse? a. Wearing street clothes into the nursing station b. Wearing a surgical mask into the holding room c. Walking into the hallway outside the operating room with hair uncovered d. Putting on a surgical mask, cap, and scrubs before entering the operating room

c. Walking into the hallway outside the operating room with hair uncovered The corridors outside the operating room (OR) are part of the semirestricted area where personnel must wear surgical attire and head coverings. Surgical masks may be worn in the holding room, although they are not necessary. Street clothes may be worn at the nursing station, which is part of the unrestricted area. Wearing a mask and scrubs is essential when going into the OR. DIF: Cognitive Level: Apply (application) REF: 315

The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients? a. Assess the patients for edema in extremities. b. Ask the patients to record their intake and output. c. Weigh the patients every morning before breakfast. d. Measure the patients' blood pressures every 4 hours.

c. Weigh the patients every morning before breakfast. An effective measure of fluid retention or loss is daily weights; each kilogram (2.2 pounds) change is equivalent to 1 liter of fluid gained or lost. This measurement should be performed at the same time every day using the same scale and the same amount of clothing. Although intake and output records are important assessment measures, some patients are not able to keep their own records themselves. Blood pressure can decrease with extracellular volume (ECV) deficit but will not necessarily increase with recent ECV excess (heart failure patient). Edema occurs with ECV excess but not with clinical dehydration. DIF:Apply (application)REF:949 | 968

A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse is mostappropriate? a. "Are you following any weight loss program?" b. "How many calories a day do you consume?" c. "Do you have dry mouth or feel thirsty?" d. "How many times a day do you urinate?"

d. "How many times a day do you urinate?" A rapid gain in weight usually indicates extracellular volume (ECV) excess if the person began with normal ECV. Asking the patient about urination habits will help determine whether the body is trying to excrete the excess fluid or if renal dysfunction is contributing to ECV excess. This is too rapid a weight gain to be dietary; it is fluid retention. Asking about following a weight loss program will not help determine the cause of the problem. Caloric intake does not account for rapid weight changes. Dry mouth and thirst accompany ECV deficit, which would be associated with rapid weight loss. DIF:Apply (application)REF:940 | 948-949

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? a. Tympanic temperature 99.2° F (37.3° C) b. Fine crackles audible at both lung bases c. Redness and swelling along the suture line d. 200 mL sanguineous fluid in the wound drain

d. 200 mL sanguineous fluid in the wound drain Wound drainage should decrease and change in color from sanguineous to serosanguineous by the second postoperative day. The color and amount of drainage for this patient are abnormal and should be reported. Redness and swelling along the suture line and a slightly elevated temperature are normal signs of postoperative inflammation. Atelectasis is common after surgery. The nurse should have the patient cough and deep breathe, but there is no urgent need to notify the surgeon. DIF: Cognitive Level: Analyze (analysis) REF: 343

A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the nurse perform the steps starting with the first one? 1. Clean site. 2. Select vein. 3. Apply tourniquet. 4. Release tourniquet. 5. Reapply tourniquet. 6. Advance and secure. 7. Insert vascular access device. a. 1, 3, 2, 7, 5, 4, 6 b. 1, 3, 2, 5, 7, 6, 4 c. 3, 2, 1, 5, 7, 6, 4 d. 3, 2, 4, 1, 5, 7, 6

d. 3, 2, 4, 1, 5, 7, 6 The steps for inserting an intravenous catheter are as follows: Apply tourniquet; select vein; release tourniquet; clean site; reapply tourniquet; insert vascular access device; and advance and secure. DIF:Apply (application)REF:971-974

The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority? a. Gastrointestinal b. Neurological c. Respiratory d. Cardiac

d. Cardiac Cardiac is the priority. Hyperkalemia places the patient at risk for potentially serious dysrhythmias and cardiac arrest. Potassium balance is necessary for cardiac function. Respiratory is the priority with hypokalemia. Monitoring of gastrointestinal and neurological systems would be indicated for other electrolyte imbalances. DIF:Apply (application)REF:941-942 | 956

A nurse is caring for a patient who is receiving peripheral intravenous (IV) therapy. When the nurse is flushing the patient's peripheral IV, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse's initial action? a. Record a phlebitis grade of 4. b. Assign an infiltration grade. c. Apply moist compress. d. Discontinue the IV.

d. Discontinue the IV. The IV site has phlebitis. The nurse should discontinue the IV. The phlebitis score is 3. The site has phlebitis, not infiltration. A moist compress may be needed after the IV is discontinued. DIF:Apply (application)REF:960 | 982

A patient has received atropine before surgery and complains of dry mouth. Which action by the nurse is most appropriate? a. Check for skin tenting. b. Notify the health care provider. c. Ask the patient about any weakness or dizziness. d. Explain that dry mouth is an expected side effect.

d. Explain that dry mouth is an expected side effect. Anticholinergic medications decrease oral secretions, so the patient is taught that a dry mouth is an expected side effect. The dry mouth is not a symptom of dehydration in this case. Therefore there is no immediate need to check for skin tenting. The health care provider does not need to be notified about an expected side effect. Weakness, forgetfulness, and dizziness are side effects associated with other preoperative medications such as opioids and benzodiazepines. DIF: Cognitive Level: Apply (application) REF: 311

Postoperatively, the nurse should monitor the patient who received inhalation anesthesia for which complication? a. Tachypnea b. Myoclonus c. Hypertension d. Laryngospasm

d. Laryngospasm Possible complications of inhalation anesthetics include coughing, laryngospasm, and increased secretions. Hypertension and tachypnea are not associated with general anesthetics. Myoclonus may occur with nonbarbiturate hypnotics but not with the inhalation agents. DIF: Cognitive Level: Apply (application) REF: 323

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? a. Apply lotion to the affected areas. b. Cover the arms with sterile drapes. c. Recheck the patient's arms during surgery. d. Notify the anesthesia care practitioner (ACP).

d. Notify the anesthesia care practitioner (ACP). The presence of wheals indicates a possible allergic or anaphylactic reaction, which may have been caused by latex or by medications administered as part of general anesthesia. Because general anesthesia may mask anaphylaxis, the nurse should report this to the ACP. The other actions are not appropriate at this time. DIF: Cognitive Level: Apply (application) REF: 324

A patient has an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing the blood transfusion, which is the nurse's next action? a. Discontinue the IV catheter. b. Return the blood to the blood bank. c. Run normal saline through the existing tubing. d. Start normal saline at TKO rate using new tubing.

d. Start normal saline at TKO rate using new tubing. The nurse should first attach new tubing and begin running in normal saline at a rate to keep the vein open, in case any medications need to be delivered through an IV site. The existing tubing should not be used because that would infuse the blood in the tubing into the patient. It is necessary to preserve the IV catheter in place for IV access to treat the patient. After the patient has been assessed and stabilized, the blood can be returned to the blood bank. DIF:Apply (application)REF:963-964

Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL? a. Weak quadriceps muscles b. Decreased deep tendon reflexes c. Light-headedness when standing up d. Tingling of extremities with possible tetany

d. Tingling of extremities with possible tetany This patient has hypocalcemia because the normal calcium range is 8.4 to 10.5 mg/dL. Hypocalcemia causes muscle tetany, positive Chvostek's sign, and tingling of the extremities. Sodium and potassium values are within their normal ranges: sodium 135 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L. Light-headedness when standing up is a manifestation of ECV deficit or sometimes hypokalemia. Weak quadriceps muscles are associated with potassium imbalances. Decreased deep tendon reflexes are related to hypercalcemia or hypermagnesemia. DIF:Analyze (analysis)REF:935 | 942 | 950

A nurse is assisting the health care provider in inserting a central line. Which action indicates the nurse is following the recommended bundle protocol to reduce central line-associated bloodstream infections (CLABSI)? a. Preps skin with povidone-iodine solution. b. Suggests the femoral vein for insertion site. c. Applies double gloving without hand hygiene. d. Uses chlorhexidine skin antisepsis prior to insertion.

d. Uses chlorhexidine skin antisepsis prior to insertion. A recommended bundle at insertion of a central line is hand hygiene prior to catheter insertion; use of maximum sterile barrier precautions upon insertion; chlorhexidine skin antisepsis prior to insertion and during dressing changes; avoidance of the femoral vein for central venous access for adults; and daily evaluation of line necessity, with prompt removal of non-essential lines. Povidone-iodine is not recommended. DIF:Apply (application)REF:957

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? a. Lethargy b. Complaint of nausea c. Disorientation to time d. Weak chest movement

d. Weak chest movement The most serious adverse effect of the neuromuscular blocking agents is weakness of the respiratory muscles, which can lead to postoperative hypoxemia. Nausea, lethargy, and disorientation are possible adverse effects of anesthetic drugs, but they are not as great of concern as respiratory depression. DIF: Cognitive Level: Analyze (analysis) REF: 326