Med Sure exam 1

A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states," I don't know what I will do if they find I have cancer." Which of the following responses should the nurse make?

I'm hearing that you are concerned that it might turn out that you have cancer

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

Remove the catheter and insert another into a different site. catheter could be up against a valve or against a nerve

A nurse in a provider's office is reviewing the laboratory findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse?

Platelet count 60,000/mmm3 This platelet count is low and places the client at risk for bleeding.

A nurse is caring for a client who is 1-day postoperative following spinal fusion. Which of the following actions should the nurse take?

log roll the client every 2 hr

A nurse in the PACU is caring for a client who is post op following a thoracotomy and lobectomy. Which of the following post op assessments should the nurse give the highest priority to?

Arterial blood gases

A nurse is caring for a client who is postoperative following abdominal surgery and reports incisional pain. The surgeon has prescribed morphine 4 mg IV bolus every 6 hr as needed. Before administering the medication, the nurse should complete which priority assessment?

respiratory rate

A nurse is assessing a client who has developed atelectasis post op. Which of the following findings should the nurse expect?

increasing dyspnea

A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?

A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg

A nurse is caring for a client who is preoperative. The nurse signs as a witness on the client's content form. The nurse's signature on the consent form indicates which of the following?

Confirms the client appears competent to provide consent

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

Encourage the use of an incentive spirometer

A nurse is caring for a client who is post op following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus?

dull, aching calf pain

A nurse is monitoring a client who is receiving a unit of RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload?

dyspnea

A nurse is assessing a client who is post op and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?

fatigue

A nurse is providing discharge instructions to a client who developed DVT post op and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include?

flexing her knees and feet frequently

A nurse is admitting a client to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority?

oxygen saturation

A nurse is admitting a client who is arriving back to the unit from PACU following hip arthroplasty. Which of the following tasks should the nurse assign to the AP?

record the amount of urine in the catheter drainage bag.

A nurse is changing the dressing of a client who is 1 week postoperative following abdominal surgery and notes the presence of serosanguineous drainage. The nurse should recognize that this is in an indication of which of the following circumstances?

serosanguineous drainage at this time is a manifestation of possible dehiscence. beyond the 5th post day --> possible dehiscence

A nurse is assessing a client who is receiving one info the RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?

stop the infusion of blood the client is experiencing an acute intravascular hemolytic transfusion reaction.

A nurse is assisting with the admission of a client who is about to have elective surgery. The client tells the nurse she feels anxious. Which of the following responses should the nurse make?

Tell me more about your concerns

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

Apple moistened sterile gauze to the site

A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?

It facilitates the client's deep breathing.

A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate. The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?

check the tubing for kinks

a nurse is caring for a client who is 2 days post following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, which of the following actions should the nurse take first?

cover the area with a sterile dressing with 0.9% sodium chloride irrigation

A client who is about to undergo hip arthroplasty tells the nurse she is afraid of not receiving adequate anesthesia during the procedure. Which of the following responses should the nurse make?

Can you tell me more about this concern?

A nurse is planning care for a client who states he is anxious concerning abdominal surgery. Which of the following actions should the nurse take?

Encourage the client to express negative emotions

A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Yellow-green drainage on the surgical incision yellow-green drainage is indicative of an infection

a nurse is planning prep care for a client who will undergo surgery. Which of the following is the priority action by the nurse?

determine what the client knows about the surgery

A nurse is caring for a client following an abdominal surgery. The client has a prescription for dressing changes every 4 hr and as needed. Which of the following objects should the nurse use to reduce skin irritation around the incision area?

montgomery straps adhesive stips that are applied to the skin on either side of the wound. The strips have holes so the two sides of the dressing can be tied together and re-opened for dressing changes without having to remove the adhesive strips

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

Increase in the heart rate from 88 to 110/min hypovolemic shock is a condition in which the heart is unable to supply enough blood to the body because of blood loss or inadequate blood volume. Heart rate increases in order to compensate for this

A nurse is caring for a client who has a JP drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes?

To prevent fluid from accumulating in the wound

A nurse is caring for a client who is using a PCA pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make?

Your husband should decide when more medication is needed

A nurse is monitoring a child for manifestations of hemorrhage following a tonsillectomy. Which of the following findings is a manifestation of this post op complication?

frequent swallowing

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

increase ambulation

A nurse is planning for a client who has DVT of the lower leg. Which of the following interventions should the nurse include in the plan of care?

keep the client's affected leg elevated while in bed

A nurse is caring for a client who is post op following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning/

passage of flatus passing flatus and belching indicate the return of peristaltic activity

a nurse is teaching a client who is preoperative how to do deep-breathing exercises and cough effectively after surgery. Which of the following statements by the client indicates an understanding of the teaching?

I'll splint my incision with a pillow to cough