Nur170 exam 1

A client who tests positive for a mutation in the BRCA1 gene allele asks a nurse to be present when she discloses this information to her adult daughter. How should the nurse respond?

. This conversation may be difficult for both of you; I will be there to provide support

A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best?

0.45% normal saline

A client has developed malignant hyperthermia. The client weighs 136 pounds. What is the safe dose range for one dose of dantrolene sodium (Dantrium)? (Enter your answer using whole numbers, separated by a hyphen with no spaces.) _____ mg

124-186 mg The dose of dantrolene is 2 to 3 mg/kg. The client weighs 62 kg, so the safe dose range is 124 to 186 mg

The circulating nurse reviews the days schedule and notes clients who are at higher risk of anesthetic overdose and other anesthesia-related complications. Which clients does this include? (Select all that apply.)

A 75-year-old client scheduled for an elective procedure Client who drinks a 6-pack of beer each day Client with a serum creatinine of 3.8 mg/dL Young male client with a RYR1 gene mutation

A client in the operating room has developed malignant hyperthermia. The clients potassium is 6.5 mEq/L. What action by the nurse takes priority?

Administer 10 units of regular insulin

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.)

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

A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming procedure. What action by the nurse is best?

Ask the client to describe current feelings

A client is having a bone marrow biopsy and is extremely anxious. What action by the nurse is best?

Assess client fears and coping mechanisms.

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

Assess other indicators of oxygenation.

A student nurse learns that the spleen has several functions. What functions do they include? (Select all that apply.)

Breaks down hemoglobin Destroys old or defective red blood cells (RBCs) Stores platelets not circulating

A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate?

Be sure to wash the area where you will have surgery very thoroughly

A client is in stage 2 of general anesthesia. What action by the nurse is most important?

Being prepared to suction the airway

An older client asks the nurse why people my age have weaker immune systems than younger people. What responses by the nurse are best? (Select all that apply.)

Bone marrow produces fewer blood cells. You have lower levels of plasma proteins in the blood.

A nurse teaches clients about patterns of inheritance for genetic disorders among adults. Which disorders have an autosomal dominant pattern of inheritance? (Select all that apply.)

Breast cancer Huntington disease Marfan syndrome

An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment?

Change in behavior

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.)

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

A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.)

Check that consent is on the chart. Ensure the client has an armband on. Have the client help mark the surgical site. Allow the client to use the toilet before giving sedation.

A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client should the nurse see first?

Client who reports shortness of breath

A nurse is caring for four clients. After reviewing todays laboratory results, which client should the nurse see first?

Client with a prothrombin time (PT) of 28 seconds

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

Client with a respiratory rate of 6 breaths/min

The health care provider tells the nurse that a client is to be started on a platelet inhibitor. About what drug does the nurse plan to teach the client?

Clopidogrel (Plavix)

A health care provider prescribes genetic testing for a client who has a family history of colorectal cancer. Which action should the nurse take before scheduling the client for the procedure?

Confirm that informed consent was obtained and placed on the clients chart.

A student nurse asks why older adults are at higher risk for complications after surgery. What reasons does the registered nurse give? (Select all that apply.)

Decreased cardiac output Decreased oxygenation Frequent nocturia Mobility alterations

A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best?

Demonstrate how to splint the incision

A nurse cares for an adult client who has received genetic testing. The clients mother asks to receive the results of her daughters genetic tests. Which action should the nurse take?

Direct the mother to speak with the client and support the clients decision to share or not share the results.

A nurse cares for a client who recently completed genetic testing that revealed that she has a BRCA1 gene mutation. Which actions should the nurse take next? (Select all that apply.)

Discuss potential risks for other members of her family. Assist the client to make a plan for prevention and risk reduction. Assess the clients response to the test results

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.)

Disposing of dressings properly Performing proper hand hygiene Removing and replacing wet dressings

A client is having robotic surgery. The circulating nurse observes the instruments being inserted, then the surgeon appears to break scrub when going to the console and sitting down. What action by the nurse is best?

Document the time the robotic portion of the procedure begins

A student nurse observing in the operating room notes that the functions of the Certified Registered Nurse First Assistant (CRNFA) include which activities? (Select all that apply.)

Dressing the surgical wound Suctioning the surgical site Suturing the surgical wound

A client is having a bone marrow biopsy today. What action by the nurse takes priority?

Ensure valid consent is on the chart.

A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing? (Select all that apply.)

Infection Serious cardiac events Thromboembolism

The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate?

Inform the surgeon that the sterile field has been broken

A client is receiving rivaroxaban (Xarelto) and asks the nurse to explain how it works. What response by the nurse is best?

It inhibits thrombin.

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

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

A client has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important?

Place the client on a cardiac monitor and pulse oximeter

A hospitalized client has a platelet count of 58,000/mm3. What action by the nurse is best?

Place the client on safety precautions.

A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met?

There is no redness, warmth, or drainage at the insertion site

A nurse is monitoring a client after moderate sedation. The nurse documents the clients Ramsay Sedation Scale (RSS) score at 3. What action by the nurse is best?

Document findings and continue to monitor

The nursing student observing in the perioperative area notes the unique functions of the circulating nurse, which include which roles? (Select all that apply.)

Ensuring the clients safety Monitoring traffic in the room

A nursing student wants to know why clients with chronic obstructive pulmonary disease tend to be polycythemic. What response by the nurse instructor is best?

It compensates for tissue hypoxia caused by lung disease.

A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best?

It helps prevent ulcers from the stress of the surgery

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

Participating in hand-off report

A client has a serum ferritin level of 8 ng/mL and microcytic red blood cells. What action by the nurse is best?

Perform a Hemoccult test on the clients stools.

A nursing student learns that many drugs can impair the immune system. Which drugs does this include? (Select all that apply.)

Amphotericin B (Fungizone) Ibuprofen (Motrin) Nitrofurantoin (Macrobid)

A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best?

Assess the client for anxiety

A client is having surgery. The circulating nurse notes the clients oxygen saturation is 90% and the heart rate is 110 beats/min. What action by the nurse is best?

Assess the clients end-tidal carbon dioxide level

A nurse is assessing a dark-skinned client for pallor. What action is best?

Assess the conjunctiva of the eye.

A client is having shoulder surgery with regional anesthesia. What actions by the nurse are most important to enhance client safety related to this anesthesia? (Select all that apply.)

Assessing distal circulation to the operative arm after positioning Padding the clients shoulder and arm on the operating table

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?

Assist the client into a position of comfort.

A student nurse is caring for clients on the postoperative unit. The student asks the registered nurse why malnutrition can lead to poor surgical outcomes. What responses by the nurse are best? (Select all that apply.)

A malnourished client will have fragile skin Many drugs are bound to protein in the body. Protein stores are needed for wound healing. Weakness and fatigue are common in malnutrition.

A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta blocker to the client. The student asks why this was needed. What response by the nurse is best?

A rapid heart rate requires more effort by the heart

A client presents to the emergency department in sickle cell crisis. What intervention by the nurse takes priority?

Administer oxygen.

A nurse cares for a client who has a specific mutation in the a1AT (alpha1-antitrypsin) gene. Which action should the nurse take?

Advise the client to limit exposure to secondhand smoke and other respiratory irritants.

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

Airway

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.)

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

A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort? (Select all that apply.)

Allow the client to assume a position of comfort. Allow the clients family to remain at the bedside. Provide warm blankets or cool washcloths as desired. Pull the curtains around the bed to provide privacy.

A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client?

Allow the client to keep hearing aids in until anesthesia begins

The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best?

Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met

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

Auscultate lung sounds

A nurse cares for a client of Asian descent who is prescribed warfarin (Coumadin). What action should the nurse perform first?

Confirm the prescription starts warfarin at a lower-than-normal dose

The circulating nurse and preoperative nurse are reviewing the chart of a client scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority?

Consent for MIS procedure only

A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best?

Consult the surgeon about a postoperative dietitian referral

What actions by the circulating nurse are important to promote client comfort? (Select all that apply.)

Correct positioning Introducing ones self Providing warmth Remaining present

A nurse caring for a client with sickle cell disease (SCD) reviews the clients laboratory work. Which finding should the nurse report to the provider?

Creatinine: 2.9 mg/dL

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best?

Do not have the client sign the consent and call the surgeon

A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate?

Explain the rationale for giving the medicine now

A client is scheduled for a below-the-knee amputation. The circulating nurse ensures the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate?

Facilitate marking the site with the client and surgeon

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

Flumazenil (Romazicon) 0.2 to 1 mg

A client has Crohns disease. What type of anemia is this client most at risk for developing?

Folic acid deficiency

A nurse consults a genetic counselor for a client whose mother has Huntington disease and is considering genetic testing. The client states, I know I want this test. Why do I need to see a counselor? How should the nurse respond?

Genetic testing can be a stressful experience. Counseling can provide support and education throughout the process.

The circulating nurse is plugging in a piece of equipment and notes that the cord is frayed. What action by the nurse is best?

Get another piece of equipment

A client waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)?

Give the client a back rub

A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best?

Give the client a bedpan or urinal to use

A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking. When the client requests pain medication, what action by the nurse is best?

Give the client pain medication if it is time for another dose.

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.)

Hemoglobin: 7.8 mg/dL pH: 7.68 Potassium: 2.9 mEq/L

A nurse completes pedigree charts for clients at a community health center. Which diagnosis should the nurse refer for carrier genetic testing? (Select all that apply.)

Hemophilia Sickle cell disease Cystic fibrosis

A client is typed and crossmatched for a unit of blood. Which statement by the nurse indicates a need for further genetic education?

If the clients blood type is AB, then the client is homozygous for that trait.

A nurse cares for a client who has a genetic mutation that increases the risk for colon cancer. The client states that he does not want any family to know about this result. How should the nurse respond?

It is not required that you tell anyone about this result. However, your siblings and children may also be at risk for colon cancer and this information might help them.

A nursing instructor is teaching students about different surgical procedures and their classifications. Which examples does the instructor include? (Select all that apply.)

Liver biopsy: diagnostic Total shoulder replacement: restorative

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?

Lower the head of the bed.

A nurse is caring for several clients prior to surgery. Which medications taken by the clients require the nurse to consult with the physician about their administration? (Select all that apply.)

Metformin (Glucophage) Phenytoin (Dilantin) Pilocarpine hydrochloride (Isopto Carpine) Warfarin (Coumadin)

A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority for this client?

Metoclopramide (Reglan)

A nurse obtains health histories when admitting clients to a medical-surgical unit. With which client should the nurse discuss predisposition genetic testing?

Middle-aged woman whose mother died at age 48 of breast cancer

A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered at high risk? (Select all that apply.)

Morbidly obese client Client who underwent a prolonged surgical procedure Client with severe heart failure Wheelchair-bound client

A nurse works in a gerontology clinic. What age-related changes cause the nurse to alter standard assessment techniques from those used for younger adults? (Select all that apply.)

Nail beds may be thickened or discolored. Progressive loss of hair occurs with age. Skin becomes dry as the client ages.

A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care?

Older adult who lives at home despite some memory loss

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?

Perform hand hygiene and apply gloves.

A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team?

Potassium: 2.9 mEq/L

A nurse cares for a pregnant client who has a family history of sickle cell disease. The client is unsure if she wants to participate in genetic testing. What action should the nurse take?

Provide information about the risks and benefits of genetic testing

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?

Psychosocial status

A client has been given hydroxyzine (Atarax) in the preoperative holding area. What action by the nurse is most important for this client?

Raise the siderails on the bed

A circulating nurse wishes to provide emotional support to a client who was just transferred to the operating room. What action by the nurse would be best?

Remain with the client

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?

Securing the drains safety pin to the sheets

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?

Sometimes older people take longer to wake up

A client is having a radioisotopic imaging scan. What action by the nurse is most important?

Teach the client about the procedure.

A nurse is educating a client about genetic screening. The client asks why red-green color blindness, an X-linked recessive disorder noted in some of her family members, is expressed more frequently in males than females. How should the nurse respond?

The incidence of X-linked recessive disorders is higher in males because they do not have a second X chromosome to balance expression of the gene

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?

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

A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team?

Use of multiple herbs and supplements

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?

Wash your hands before touching the drain or dressing.

A nurse cares for a client who recently completed genetic testing and received a negative result. The client states, I feel guilty because so many of my family members are carriers of this disease and I am not. How should the nurse respond?

We usually encourage clients to participate in counseling after receiving test results. Can I arrange this for you?