MED SURGE Exam 1 (iggy) Ch 16

3. A nurse is admitting an older client for surgery to the inpatient surgical unit. The client relates a prior history of acute confusion after a previous operation. What interventions does the nurse include on the clients plan of care to minimize the potential for this occurring? (Select all that apply.)

a. Allow family and friends to visit as the client desires. b. Ask the client about coping techniques frequently used. c. Instruct the nursing assistant to ensure the client is bathed. e. Provide the client with uninterrupted periods of sleep.

7. A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority?

Airway

5. A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort interventions can the nurse provide? (Select all that apply.)

a. Apply stimulation to the contralateral leg.b. Assess the clients willingness to try meditation.c. Elevate the clients operative leg and apply ice.d. Reduce the noise level in the clients environment.

3. A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%. What action by the nurse is most appropriate?

a. Assess other indicators of oxygenation.

4. A postoperative client is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the client? (Select all that apply.)

a. Check all over-the-counter medications for acetaminophen.b. Do not take more pills each day than you are prescribed. c. Eat a diet that is high in fiber and drink lots of water. e. You shouldnt drive while you are taking this medication.

8. A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which IV-push medication and dose does the nurse prepare to administer?

a. Flumazenil (Romazicon) 0.2 to 1 mg

9. A nurse is caring for a postoperative client who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort?

b. Assist the client into a position of comfort.

6. A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important?

b. Auscultate lung sounds.

6. A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.)

b. Disposing of dressings properly d. Performing proper hand hygiene e. Removing and replacing wet dressings

2. A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.)

b. Hemoglobin: 7.8 mg/dL c. pH: 7.68 d. Potassium: 2.9 mEq/L

12. A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first?

b. Perform hand hygiene and apply gloves.

1. A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.)

b. Phase I care may last for several days in some clients. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III.

2. The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first?

c. Client with a respiratory rate of 6 breaths/min

5. A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the clients bed. The clients blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the nurse is best?

c. Lower the head of the bed.

14. A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN?

c. Securing the drains safety pin to the sheets

1. A client has arrived in the postoperative unit. What action by the circulating nurse takes priority?

d. Participating in hand-off report

13. A client on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations of 24 breaths/min. The client denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection. What should the nurse assess next?

d. Psychosocial status

11. An older adult has been transferred to the postoperative inpatient unit after surgery. The family is concerned that the client is not waking up quickly and states She needs to get back to her old self! What response by the nurse is best?

d. Sometimes older people take longer to wake up.

4. Ten hours after surgery, a postoperative client reports that the antiembolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best?

d. To prevent blood clots you need them a few more hours.

10. A nurse is preparing a client for discharge after surgery. The client needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important?

d. Wash your hands before touching the drain or dressing.