Med surg quiz 4

a client experiences abdominal distension following surgery. which nursing actions are appropriate? select all a. encouraging ambulation b. giving sips of ginger ale c. auscultating bowel sounds d. providing a straw for drinking e. offering the prescribed opioid analgesic

A C

Which patient is most at risk for post op nausea and vomiting? A. the patient with a hx of motion sickness B. the patient with a NG tube C. the patient who recently experienced a weight loss of 50 lbs D. the patient who had minimally invasive surgery

A

A nurse is preparing to change a clients dressing what is the reason for using surgical asepsis during this procedure? a. keeps the area free of microorganisms b. confines microorganisms to the surgical site c. protects self from microogranisms in the wound d. reduces the risk for growing opportunistic microorganisms

A

A patient arrives in the PACU. Which action does the nurse perform first? A. assess for a patent airway and adequate gas exchange B. assess the patients pain level using the 0-10 assessment scale C. position the patient in a supine position to prevent aspiration D. calculate the patient controlled anaglesia pump maximum dose per hour to avoid an overdose

A

The nurse is caring for a patient who has had abdominal surgery. After a hard sneeze the patient reports pain in the surgical area and the nurse immediately sees that the patient has a wound evisceration. What priority action must the nurse do first? A. call for help and stay with the patient B. leave the patient to immediately call the surgeon C. cover the wound with a nonadherent dressing moistened with normal saline D. take the patients vital signs

A

Which indicator of return to consciousness occurs first as a patient recovers from general anesthesia? A. muscular irritability B. restlessness and delirium C. recognition of pain D. ability to reason and control behavior

A

Which members of the surgical team usually accompany a post op patient to the PACU? A. anesthesia and circulating nurse B. circulating nurse and surgeon C. surgeon and anesthesia D. surgical assistant and surgeon

A

Which statement best describes phase I after surgery? A. Phase I care occurs immediately after surgery, most often in the PACU B. Phase I care focuses on preparing the patient for care in an extended care environment C. phase I care discharge occurs when presurgery level of consciousness has returned, oxygen saturation is at baseline, and vital signs are stable. D. phase I care most often occurs on a hospital unit, in an extended care facility, or at home.

A

a client is extubated in the PACU after surgery. for which common response should the nurse be alert when monitoring the client for acute respiratory distress? a. restlessness b. bradycardia c. constricted pupils d. clubbing of the fingers

A

after undergoing a modified radical mastectomy a client is transferred to the PACU. which nursing action is best to assign to an experienced LPN? a. monitoring the clients dressing for any signs of bleeding b. documenting the initial assessment on the clients chart c. communicating the clients status report to the charge nurse on the surgical unit d. teaching the client about the importance of using pain medication as needed

A

on which concern should the nurse focus when caring for a client after abdominal surgery? a. identifying signs of bleeding b. preventing pressure on the suture site c. encouraging use of an incentive spirometer d. detecting clinical manifestations of inflammation

A

which intervention by the nurse will help a post op patient with compliance in getting up to ambulate? A. offer the patient pain medication 30-45 mins before ambulation b. assist the patient to turn from side to side every 2 hours c. remind the patient to perform extremity exercises every 4 hours d. teach the patient that activity helps prevent post op complications

A

The PACU nurse is assessing an older adult patient for post op pain. Which nonverbal manifestations by the patient suggest pain to the nurse? Select all A. restlessness B. profuse sweating C. difficult to arouse D. confusion E. increased BP F. decreased HR

A B D E

The PACU nurse is receiving the handoff report for a patient transferred in from the OR. Which statements about this report are accurate? Select all A. A handoff report requires clear, concise language B. a handoff report is a two way verbal interaction between the health care professional giving the report and the nurse receiving it C. a handoff report should be individualized based on the patient and his or her surgery D. the receiving nurse takes the time to restate the information to verify what was said E. the receiving nurse takes the time to ask questions and the reporting professional must respond to the questions until a common understanding is established F. the receiving nurse continues assessing other patients while the handoff report is being given

A B D E

What information should be included in the handoff report when a patient is transferred fro the OR to the PACU staff? Select all A. type and extent of surgical procedure B. intraoperative complications and how they were handled C. list of usual daily medications D. type and amount of IV fluids and blood products given E. location and type of incisions, dressings, catheters, tubes, drains, or packing F. name, address, and phone number of next of kin

A B D E

A patient cared for in the PACU had a colostomy placed for treatment of crohns disease. The nurse assesses that an abdominal dressing is 25% saturated with serosanguineous drainage and the incision is intact. An IV infusing with D5/lactated ringers at 100 mL through a 20g peripheral IV access. Auscultation of abdomen reveals hypoactive bowel sounds in all 4 quadrants, abdomen soft, and no distension. Foley catheter in place and draining yellow urine with sediment 375 mL output in foley bag. Which body systems have been assessed by the nurse? Select all A. renal/urinary B. GI C. respiratory D. muscoskeletal E. integumentary F. cardiovascular

A B E

A post op patient in the PACU has had an open reduction internal fixation of a left fractured femur. Vital signs are BP 87/49 HR 100 sinus rhythm RR 22 temp 98.3. The foley catheter has a total of 110 mL of clear yellow urine in the last 4 hours. Which body systems have been assessed by the nurse? select all A. respiratory B. cardiovascular C. neurovascular D. integumentary E. renal/urinary F. GI

A B E

the provider removed a patients original surgical dressing 2 days after surgery and is discharging the patient home with daily dressing changes. which actions will the nurse take for this patients discharge teaching? select all A. ask the patients family or significant other to observe the dressing change b. ask the UAP to get dressing supplies for the patient c. instruct that the drainage will appear serosanguineous d. instruct the patient to go to the ER for problems related to dressing changes e. have the case manager arrange for home health nurse to ensure that dressing changes are done and there are no complications or infection f. teach the patient and family the signs and symptoms of infection

A B E F

Which are interventions for the med surg nurse to use in preventing hypoxemia for post op patients? select all A. monitor the patients oxygen saturation B. position the patient supine C. encourage the patient to cough and breathe deeply D. get the patient ambulating as soon as possible E. instruct the patient to use incentive F. remind the patient to use incentive spirometry every hour while awake

A C D F

A client reports severe pain 2 days after surgery. which initial action should the nurse take after assessing the character of the pain? a. encourage rest b. obtain the vital signs c. administer the prn analgesic d. document the clients pain response

B

A nurse in the PACU observes that after an abdominal cholecystectomy a client has serosangineous drainage on the abdominal dressing. What is the next nursing action? a. change the dressing b. reinforce the dressing c. replace the tape with montgomery ties d. support the incision with an abdominal binder

B

In the PACU the nurse assesses that a patient is bleeding profusely from an abdominal incision. What is the nurses best first action? A. notify the surgeon B. apply pressure to the wound dressing C. instruct the UAP to get additional dressing supplies D. request and draw a CBC

B

The morning after a patients lower leg surgery the nurse notes that the dressing is wet from drainage. The surgeon has not yet been in to see the patient on rounds what does the nurse do about the dressing? A. removes the dressing and puts on a dry sterile dressing B. reinforces the dressing material on top of the existing dressing C. applies dry sterile dressing material directly to the wound and then retapes the originally dressing D. does nothing to the dressing but calls the surgeon to evaluate the patient immediately

B

The nurse is responsible for the care of a post op patient with thoracotomy which action should the nurse delegate to the UAP? A. instructing the patient to alternate rest and activity periods b. encouraging, monitoring, and recording nutritional intake c. monitoring cardiorespiratory response to activity d. planning activities for periods when the patient has the most energy

B

The nurse is teaching incisional care to a patient who is being discharged after abdominal surgery. Which priority instruction must the nurse include? A. do not rub or touch the incision site B. practice proper handwashing C. clean the incision site two times a day with soap and water D. splint the incision site as often as needed for comfort

B

What is the primary purpose of a PACU? A. follow-through on the surgeons postoperative orders B. ongoing critical evaluation and stabilization of the patient C. prevention of lengthened hospital stay D. arousal of patient following the use of conscious sedation

B

four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. paralytic ileus is suspected what does the nurse conclude is the most likely cause of the ileus? a. decreased blood supply b. impaired neural functioning c. perforation of the bowel wall d. obstruction of the bowel lumen

B

the post op patient has a penrose drain in place. which action does the nurse take to prevent skin irritation, wound contamination, and infection? a. keeps a sterile safety pin in place at the end of the drain b. places absorbent pads under and around the exposed drain c. uses minimal tape when tape is needed use hypoallergenic tape d. shortens the drain by pulling it out a short distance and trimming off the excess external portion

B

The nurse on the med-surg unit is caring for a post op patient. Which assessment criteria indicate to the nurse that the patient is experiencing respiratory difficulty? Select all A. the patients oxygen saturation drops from 98 to 94% B. the patient is using accessory muscles to breathe C. the patient makes high pitched crowing sound when breathing D. the patients blood pressure drops from 120/80 to 110/78 E. the patients respiratory rate is 29 F. the patients urine output drops from 50 mL to 30 mL

B C E

A patient who is 2 days post op for abdominal surgery states "i coughed and heard something pop" the nurses immediate assessment reveals an opened incision with a portion of large intestine protruding which statements apply to this clinical situation? Select all A. incision dehiscence has occured B. this is an emergency C. the wound must be kept moist with normal saline soaked sterile dressings D. this is an urgent situation E. incision evisceration has occurred F. a NG tube may be ordered to decompress the stomach

B C E F

When assessing the hydration status of an older post op patient where must the nurse assess for tenting of the skin? select all A. on the back of the hand B. on the forehead C. on the forearm D. on the sternum E. on the abdomen F. on the thigh

B D

which are criteria used by the health care team to determine when a patient is ready to be discharged from the PACU? select all A. recovery rating of 7-10 on rating scale b. stable vital signs with normal body temp c. ability to swallow but remains NPO for at least 4 hours d. intact cough and swallow reflexes e. adequate urine output f. return of gag reflex

B D E F

The PACU nurse is assessing a patient transferred in from the OR. Which assessment findings apply to assessment of the cardiovascular system? A. opens eyes on command B. absent dorsalis pedis pulse in left foot C. foley catheter in place with clear yellow drainage D. monitor shows normal sinus rhythm E. states name correctly when asked F. apical pulse 85

B D F

The nurse is caring for an obese post op client who underwent surgery for bowel resection. As the client is moving in bed, he comments "something popped open." upon examination the nurse notes wound evisceration. place the steps in order for handling this complication a. cover the intestine with sterile moistened gauze b. stay calm and stay with the client c. check the vital signs, especially blood pressure and pulse d. have a colleague gather sterile supplies and contact the provider e. put the client into semi fowler position with knees slightly flexed f. prepare the client for surgery as ordered.

B E C D A F

A 49 year old patient is in the PACU following a frontal craniotomy for repair of a ruptured cerebral anuerysm. The nurses assesses that the patients eyes open on verbal stimulation, pupils are equal and reactive to light, diameter is 3 mm, The patients hand grasps are equal and strong. The patient is able to state name correctly. The patient has had one episode of nausea and vomiting. Incision edges are dry and approximated with sutures. Lung sounds are slightly diminished on auscultation and the nurse observes the patient using abdominal accessory muscles to breathe. Which body systems has the nurse assessed? Select all A. cardiovascular B. GI C. neurologic D. integumentary E. respiratory F. renal/urinary

BC D E

If a patient experiences a wound dehiscence, which description best characterizes what is happening with the wound? A. purulent drainage is present at incision site because of infection B. extreme pain is present at incision site C. a partial or complete separation of outer layers is present at incision site. D. The inner and outer layers of the incision are separated.

C

The PACU nurse is caring for a post op patient. The patients oxygen saturation drops from 98% to 88% what is the nurses priority action? A. call the anesthesia provider B. call the surgeon C. call the rapid response team D. call the respiratory therapist

C

The medical surgical nurse is caring for a post op patient whose lab values reveal an increase in band cells. What is the nurses best interpretation of this value? A. the patient may need a transfusion B. the patient is using up clotting factors C. the patient is developing an infection D. the patients result is expected postop

C

The nurse transfers a patient to the PACU with an incision and drainage of an abscess in the right groin under general anesthesia. BP is 80/47 HR 117 in sinus tachycardia RR is 28 and o2 is 93% at 3 L per nasal cannula temp is 101.3. The jackson-pratt drain has 70 mL of cream colored output. Normal saline is infusing at 150 mL. The surgeon orders a bolus of 500 mL IV normal saline over 1 hour, 2 sets of blood cultures, and culture drainage from the jackson pratt drain. The patients history includes vulvar cancer with a needle biopsy of the right groin, hypertension treated with lisinopril 5 mg PO daily, and no known drug allergies. The patient is designated as a full code. Using the situation, background, assessment, recommendation charting format, which information should be included in assessment? A. nurse transfers patient to the PACU with an incision and drainage of an abscess in the right groin with general anesthesia B. surgeon sends orders to bolus the patient with 500 mL normal saline over an hour, draw 2 sets of blood cultures, and send a culture of drainage from jackson pratt drain C. BP is 80/47 HR 117 sinus tachycardia RR 28 pulse oximetry 93% on o2 at 3 L nasal cannula temp 101.3 jackson pratt drain with 70 mL cream colored output D. patient had a right groin abscess. Hx of vulvar cancer. Needle biopsy of right groin completed 1 week ago. Hx of hypertension treated with lisinopril 5 mg. No known drug allergies. Full code.

C

The patient is recovering in a PACU environment that advances the patient quickly from phase I care level to a phase II care level, preparing for discharge at home. What type of surgery is this patient most likely having? A. elective surgery B. emergency surgery C. same-day surgery D. urgent surgery

C

The post op care of a morbidly obese client is being planned. which task best uses the expertise of the LPN/LVN under the supervision of the RN team leader? a. obtaining an oversized blood pressure cuff and a large sized bed b. setting up reinforced trapeze bar c. assisting in the planning of toileting, turning, and ambulation d. assigning tasks to UAP and other ancillary staff

C

What is the priority nursing intervention for a client during the immediate post op period? A. monitoring vital signs b. observing hemorrhage c. maintaining a patent airway d. recording the intake and output

C

in the immediate post op period after a gastrectomy the clients NG tube is draining a light red liquid. for how long should the nurse expect this type of drainage? a. 1-2 hours b. 3-4 hours c. 10-12 hours d. 24-48 hours

C

the nurse is assessing a post op patients GI system what is the best indicator that peristaltic activity has resumed? A. presence of bowel sounds B. patient states he is hungry C. passing of flatus or stool D. presence of abdominal cramping

C

the patient who received moderate sedation with midazolam appears to be overly sedated and has respiratory depression. Which drug does the nurse prepare to administer to this patient? A. lorazepam b. naloxone c. flumazenil d. butorphanol tartrate

C

Which signs/symptoms are considered postoperative complications? Select all A. sedation B. pain at the surgical site C. pulmonary embolism D. hypothermia E. wound evisceration F. postoperative ileus

C D E F

a nurse in the surgical ICU is caring for a client with a large surgical incision. what medication does the nurse anticipate will be prescribed for this client? a. vitamin a b. cyanocobalamin c. phytonadione d. ascorbic acid

D

a patient arrives in the PACU and the nurse notes respiratory rate of 10 with sternal retractions. The report from the anesthesia provider indicates that the patient received fentanyl during surgery. What is the nurses best first action? A. monitor the patient for effects of anesthetic for at least 1 hour B. closely monitor vital signs and pulse oximetry readings until the patient is responsive C. administer oxygen as ordered, monitoring pulse oximetry D. maintain an open airway through positioning and suction if needed

D

a post op client is diagnosed having atelectasis which nursing assessment supports this diagnosis? a. productive cough b. clubbing of fingernails c. crackles at the height of inhalation d. diminished breath sounds on auscultation

D

A nurse is applying a dressing to a clients surgical wound using sterile technique. While engaging in this activity the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. what physical principle is applicable for causing the sterile field to become contaminated? a. dialysis b. osmosis c. diffusion d. capillarity

D

A nurse is caring or a postop client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? A. postural drainage b. cupping the chest c. nasotracheal suctioning d. frequent changes of position

D

A patient develops respiratory distress after having a left total hip replacement. The patient develops labored breathing, and a pulse oximetry reading is 83% on 2 L oxygen via nasal cannula. Which intervention is appropriate for the nurse to delegate to the UAP? A. assess change in the patients respiratory status B. order necessary medications to be administered C. insert oral airway to maintain open airway D. check the patients vital signs

D

After abdominal surgery a client reports pain what action should the nurse take first? a. reposition the client b. obtain the clients vital signs c. administer the prescribed analgesic d. determine the characteristics of the pain

D

In what position should the nurse place a client recovering from general anesthesia? A. supine b. side-lying c. high-fowler d. trendelenburg

D

The health care team determines a patients readiness for discharge from the PACU by noting a postanesthesia recovery score of at least 10. After determining that all criteria have been met, the patient is discharged to the hospital unit or home. Review the patient profile after 1 hour in the PACU listed below. Which patient should the nurse expect to be discharged from the PACU first? A. 10 year old female tonsillectomy general anesthesia duration of surgery 30 minutes immediate response to voice alert to place and person able to move all extremities respirations even deep rate of 20 VS are within normal limits IV solution is D5RL has voided on bedpan eating ice chips complaining of sore throat B. 55 year old male repair of fractured lower left leg general anesthesia duration of surgery 1 hour 30 minutes drowsy but responds to voice nausea and vomiting twice in PACU no urge to void at this time IV infusing D5NS pedal pulses noted in both LE VS temp 98.6 pulse 130 RR 24 BP 124/76 C. 24 year old male reconstruction of facial scar general anesthesia duration of surgery 2 hours sleeping groans to voice command. VS are within normal limits respirations 10 no urge to void IV of D5RL infusing complains of pain in surgical area D. 42 year old female colonoscopy IV conscious sedation awake and alert up to bathroom to void IV discontinued resting quietly in chair VS are within normal limits

D

Which description illustrates the beginning of the postoperative period? A. completion of the surgical procedure and arousal of the patient from anesthesia in the OR B. providing care before, during, and after surgery C. Closure of the patient's surgical incision with sutures D. Completion of the surgical procedure and transfer of the patient to the PACU

D

Which intervention for post surgical care of a patient is correct? A. when positioning the patient use the knee gatch of the bed to bend the knees and relieve pressure B. gently massage the lower legs and calves to promote venous return to the heart C. encourage bedrest for 3 days after surgery to prevent complications D. teach the patient to splint the surgical wound for support and comfort when getting out of bed

D

when assessing an obese client a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low fowler position with the knees slightly bent and encourages the client to lie still. what is the next nursing action? a. obtain vital signs b. notify the health care provider c. reinsert the protruding organs using aseptic technique d. cover the would with a sterile towel moistened with normal saline

D

while caring for a client with a portable wound drainage system a nurse observes the collection container is half full and empties it. what is the next nursing intervention? a. encircle the drainage on the dressing b. irrigate the suction tube with sterile water c. clean the drainage port with an alcohol wipe d. compress the container before closing the port

D