Med-Surg Final

Maintaining an aseptic environment in the OR is essential to client safety and infection control. When moving around surgical areas, what distance must the nurse maintain from the sterile field?

1 foot (30cm)

A nurse is caring for a client who is being assessed following complaints of severe and persistent low back pain. The client is scheduled for diagnostic testing in the morning. Which of the following are appropriate diagnostic tests for assessing low back pain? SATA

1. CT 2. Ultrasound 3. x ray 4. MRI

a nurse is creating a care plan for a client who is receiving parenteral nutrition. The client's care plan should include nursing actions relevant to what potential complications? SATA

1. clotted or displaced catheter 2. Hyperglycemia 3. line sepsis 4. pneumothorax

A client reports pain as a result of a gastric ulcer. What clinical findings is the nurse most likely to identify during an assessment of the client's pain? (Select all that apply.)

1Vomiting relieves pain .3Pain described as gnawing. 5Pain occurs a half hour after meals

The nurse knows which is the normal serum value for potassium?

3.5-5.0 mEq/L

The health care provider prescribes daily fasting blood glucose levels for a client with diabetes mellitus. The goal of treatment is that the client will have glucose levels within the range of:

70 to 105 mg/dL of blood

The nurse is creating the plan of care for a post-op client for reduction of femur fracture. What is the most important short-term goal for this client?

Adequate respiratory function

The recovery room nurse is admitting a client from the OR following the clients successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted client?

Airway patency

Which of the following is the most common cause of symptomatic hypomagnesemia in the US?

Alcoholism

A client has chronic asthma. For which complication should the nurse monitor this client?

Atelectasis

The nurse is administering TPN to a client who underwent surgery for gastric cancer. Which of the nurse's assessments most directly addresses a major complication of TPN?

Checking the clients capillary blood glucose levels regularly

A financially struggling, large family is instructed by the home health nurse about ways to increase the dietary intake of calcium. Which suggestion should the nurse make?

Collards or kale in one meal a day

The nurse is caring for a client with labs indicating dehydration. Which clinical symptom is consistent with dehydration?

Dark, concentrated urine

The nurse is caring for a client admitted with a dx of acute kidney injury. When reviewing the client's most recent laboratory reports, the nurse notes that the clients magnesium levels are high. The nurse should prioritize assessment for what health problem?

Diminished deep tendon reflexes

The nurse is packing a clients abdominal wound with sterile, half-inch iodoform gauze. During the procedure, the nurse drops some of the gauze onto the clients abdomen 2 inches from the wound. What should the nurse do?

Discard the gauze packing and repack the wound with new iodoform.

In which instance may a surgeon operate without informed consent?

Emergency

Which nerve is implicated in the Chvosteks sign?

Facial

The nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:

First intention

The nurse is aware that loss of consciousness occurs with which type of anesthesia?

General

To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas results? Select all

HCO3 PH PaCO2

Nursing intervention for a client who is hyperventilating should focus on providing reassurance and:

Having the client breathe into a paper bag

The nurse admits a client to the PACU with a BP of 132/90 and pulse of 68 bpm. After 30 mins, the clients blood pressure is 94/47 and pulse is 110. The nurse documents that the client's skin is cold, moist, and pale. OF what is the client showing signs?

Hypovolemic shock

Which instructions should the nurse include in the teaching plan for a client with hyperlipidemia who is being discharged with a prescription for cholestyramine (Questran)? 1"Increase your intake of fiber and fluid." 2"Take the medication before you go to bed." 3"Check your pulse before taking the medication." 4"Contact your health care provider if your skin or sclera turn yellow."

Increase your intake of fiber and fluid."

The nurse is caring for a hospice client who is scheduled for a surgical procedure to reduce the size of his spinal tumor in an effort to relieve his pain. The nurse should plan this client care with the knowledge that his surgical procedure is classified as which of the following?

Palliative

A male client who is receiving prolonged steroid therapy complains of always being thirsty and urinating frequently. What is the nurse's best initial action?

Perform a finger stick to test the client's blood glucose level.

A client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to:

Place saline-soaked sterile dressings on the wound

The nurse is caring for a client who is post op day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurse's first response?

Place saline-soaked sterile dressings on the wound

The nurse has administered preanesthetic medication. What action should the nurse take next?

Place the client on bed rest with the side rails up

A client is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting "coffee grounds" like emesis. The client is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the client most likely anticipate that the surgery will be scheduled?

Without delay b/c the bleed is emergent

A client is scheduled for an invasive procedure. What priority documentation is needed regarding the procedure?

a signed consent form from the client

What is the major purpose of withholding food and fluid before surgery?

prevent aspiration

Which statement made by a 28-year-old client recently diagnosed with type 1 diabetes indicates that further education is necessary regarding the teaching plan?

"Once I reach my target weight there is a good chance that I will be able to switch from insulin to an oral medication to control my blood sugar."

The pre-op nurse is providing care for a client who is recovering on the post surgical unit following a transurethral prostate resection. The client is reluctant to ambulate, citing the need to recover in bed. For what complication is the client most at risk?

Atelectasis

A Clients most recent labs show a slight decrease in potassium. The health care provider has opted to forgo drug therapy but has suggested increasing the clients diet intake of potassium. What should the nurse recommend?

Bananas

A client is a candidate for intubation as a result of bleeding esophageal varices. Which type of tube should the nurse anticipate will most likely be used to meet the needs of this client?

Blakemore-Sengstaken

A nurse who is responsible for coordinating and documenting client care in the operating room is a

Circulating nurse

A client with type 2 diabetes is admitted for elective surgery. The health care provider prescribes regular insulin even though oral antidiabetics were adequate before the client's hospitalization. The nurse concludes that regular insulin is needed because the:

Dosage can be adjusted to changing needs during recovery from surgery

A client is admitted with anorexia, weight loss, abdominal distention, and abnormal stools. A diagnosis of malabsorption syndrome is made. What nursing action should the nurse implement to best meet this client's needs?

Encourage the consumption of high-protein foods.

The nurse reinforces instructions about how to use a nebulizer to a client with chronic obstructive pulmonary disease (COPD). The nurse concludes that additional teaching is needed when the client:

Inhales with the lips tightly sealed around the mouthpiece of the nebulizer

After abdominal surgery a client suddenly reports numbness in the right leg and a "funny feeling" in the toes. What should the nurse do first? 1Elevate the legs and tell the client to drink more fluids. 2Instruct the client to remain in bed and notify the health care provider. 3Rub the client's legs to stimulate circulation and cover the client with a blanket. 4Tell the client about the dangers of prolonged bed rest and encourage ambulation

Instruct the client to remain in bed and notify the health care provider.

A nurse is providing pre-op teaching to a client who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a client let exercises prior to sx?

Leg exercises improve circulation and prevent venous thrombosis

Your client has a dx of hypervolemia. What would be an important intervention that you would initiate?

Limit Sodium and water intake

The nurse is caring for a client who has just been transferred to the PACU from the OR. What is the highest priority?

Maintaining pt airway

The ER nurse is caring for a trauma client who has the following ABG results; pH 7.26, PaCO2 28, HCO3 11 mEq/L. How should the nurse interpret these results?

Metabolic acidosis with a compensatory respiratory alkalosis

The nurse is caring for a client admitted to the medical unit 72 hrs ago with pyloric stenosis. A ng tube placed upon admission has been on low intermittent suction ever since. Upon review of the morning bloodwork, the nurse notices that the clients potassium is below reference range. The nurse should assess for signs and symptoms of what imbalance?

Metabolic alkalosis

A client with pancreatic cancer has the following blood chemistry profile: Glucose fasting 204 mg/dl; bUN 12mg/dl; Creatnine 0.9mg/dl;Sodium 136 mEq/L; Chloride 99 mEq/L; CO2 33 mEl/dl; Which result should the nurse identify as critical and report immediately?

Potassium

The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders?

Potassium 5.8

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas is drawn. The ABG has the following values: pH 7.21, PaCO2 64, HCO3 24. What does the ABG reflect?

Respiratory acidosis

A surgical client has been in the PACU for the past 3 hrs. What are the determining factors for the client to be discharged? Select all

Stable BP Sufficient o2 sat Adequate respiratory function

An OR nurse is participating in an interdisciplinary audit of infection control practices in the surgical department. The nurse should know that a basic guideline for maintaining surgical asepsis is what?

Sterile surfaces or articles may touch other sterile surfaces

The OR nurse is taking the client into the OR when the client informs the operating nurse that his grandmother spiked a very high temp in the OR and nearly died 15 yrs ago. What relevance does this information have regarding the client?

The client may be at risk for malignant hyperthermia

The circulating nurse in an outpatient surgery center is assessing a client who is scheduled to recieve moderate sedation. What principle should guide the care of a client receiving this form of anesthesia?

The client must never be unattended by the nurse

The preoperative nurse is preparing to discharge a female client home from day surgery performed under general anesthesia. What instruction should the nurse give the client prior to the client leaving the hospital?

The client should not drive herself home

A client waiting int the presurgical holding area asks the nurse, "Why exactly do they have to put a breathing tube into me? My surgery is on my knee". What is the best rationale for intubation during a surgical procedure that the nurse should describe?

The tube provides airway for ventilation

What causes electrolyte imbalances

Too many electrolytes in one compartment inadequate intake of food vomiting diarrhea medications(diuretics) kidney failure endocrine disorders

A client has a serum calcium level of 7.2 mg/dl. During the physical exam, the nurse expects to assess:

Trousseau's sign

The nurse is making rounds on a patient who has developed severe bone marrow depression after receiving chemotherapy for cancer. Which of these actions by the nurse is appropriate? (Select all that apply.) 1Monitor for signs of alopecia. 2Encourage an increase in fluids. 3Wash hands before entering the client's room. 4Advise use of a soft toothbrush for oral hygiene. 5Report an elevation in temperature immediately. 6Encourage the client to eat raw, fresh fruits and vegetables

Wash hands before entering the client's room. Advise use of a soft toothbrush for oral hygiene. Report an elevation in temperature immediately

A client with a diagnosis of tuberculosis is receiving isoniazid (INH) as part of a chemotherapy protocol. The nurse assesses the client for adverse responses to the medication. The nurse determines that prompt intervention is needed for which client response?

Yellow sclera

A client has been brought to the ED with abdominal pain and is subsequently diagnosed with appendicitis. The client is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of the appendix. How should the nurse best respond?

Your appendix doesn't play a major role so you won't notice and difference after your recovery from surgery.

An intraoperative nurse is applying interventions that will address surgical clients risk for perioperative positioning injury. What factors contribute to this increased rick for injury in the intraoperative phase of the surgical experience?

absence of reflexes loss of pain sensation diminished ability to communicate

A client comes into the emergency dept with reports of abdominal pain. What should the nurse first ask?

characteristics and duration of pain

The nurse provides discharge teaching to a client with tuberculosis and reinforces that the treatment measure with thehighest priority is:

consistently taking the prescribed meds

The surgical nurse is caring for a client who is post-op day 1 following a thyroidectomy. The client reports tingling in her lips and fingers. She states that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should the nurse first suspect?

hypocalcemia

At 4:30 PM, a client who is receiving human insulin (Humulin N) every morning states, "I feel very nervous." The nurse observes that the client's skin is moist and cool. What is the nurse's most accurate interpretation of what the client is likely experiencing?

hypoglycemia

The nurse is performing a pre-op assessment on a client going to surgery. The client informs the nurse that he drinks approximately two bottles of wine each day and has for the last several years. What post-op difficulties should the nurse anticipate for this client?

increased risk for post-op complications

The nurse is creating the care plan for a 70 year old obese client who has been admitted to the post surgical unit following a colon resection. This clients age and increased body mass index mean that she is at increased risk for what complication in the post op period?

infection

Verification that all required documentation is completed is an important function of the intraoperative nurse. The intraoperative nurse should confirm that the clients accompanying documentation includes which?

informed consent

A client recovering from an acute asthma attack experiences respiratory alkalosis. The nurse measures a respiratory rate of 46 breaths/min, a heart rate of 110, a bp of 162/90 and a temp of 98.6. To help correct respiratory alkalosis, the nurse should:

instruct the client to breathe into a paper bag

A client asks about the purpose of withholding food and fluid before surgery. Which response by the nurse is appropriate?

it prevents aspiration and respiratory complications

The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates. What principle should the educator promote?

knots in the rope should not be resting against pulleys

A client with Guillian-Barre syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of ABG value confirms respiratory acidosis?

pH 7.25, PaCO2 50 mm Hg

Which set of ABG results requires further investigation?

pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3 18 mEq/l

The nurse is promoting increased protein intake to enhance a clients wound healing. What is the enzyme that will initiate the digestion of the protein that the client consumes?

pepsin

In which phase of preoperative care will the nurse prepare the client's skin, encourage the client to void, and remove the clients dentures?

pre-operative

A client with a longstanding dx of generalized anxiety disorder present to the ER. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?

respiratory alkalosis