nursing 300 test 1

normal creatinine level

0.6-1.2

NPO

12 hours before surgery(give or take) prevents aspiration during surgery

normal sodium level

135-145

normal hemoglobin levels

W:12-16 M:14-18

fluid levels are influenced by

age gender weight

hypernatremia causes

dehydration enteral feeding with no water flushes diarrhea burns

dressing and grooming

gown, hair cap

hypochloremia management

correct underlying cause

hyperchloremia managment

correct underlying issue

As the nurse assists the postoperative client out of bed, the client reports having gas pains in the abdomen. To reduce this discomfort, what should the nurse do?

encourage the patient to ambulate

hypochloremia assessments

i/o abgs electrolytes LOC muscle strength and movement

hyponatremia assessment

i/o daily weight neuro checks monitor labs

hypokalemia assessment

i/o kidney function cardiac monitoring musculoskeletal respiratory GI

hypocalcemia causes

inadequate calcium intake acute pancreatitis medications decrease in vit d high phosphorous levels

post op pain control

most severe 24-48 hours postop opioid medications treat pain early use same scale, establish goal, observe behaviors oral pain meds when oral intake is tolerate, iv for breakthru pain assess and treat side effects

normal potassium level

3.5-5.0

normal hematocrit levels

36-48

When conducting the preoperative preparations, the nurse determines that the client does not speak English, and the nurse does not speak the client's language. The surgeon needs to obtain the client's informed consent. What is the best way for the nurse to obtain the client's informed consent?

Call the Spanish interpreter to translate the surgeon's explanation of the procedure, risks, and alternatives to obtain the client's consent and to answer the client's questions.

A client in a general hospital is to undergo surgery in 2 days and is experiencing moderate anxiety about the procedure and its outcome. What should the nurse do to help the client reduce anxiety?

Explain the surgical procedure to the client and what happens before and after surgery.

hypophosphatemia assessment

GI function muscle weakness cardiac and resp function

variables affecting surgical outcomes

age, nutritional status, lifestyle choices, chronic medical conditions, medications

hypernatremia manifestations

big and bloated skin:red and rosy, edema, low grade fever polydipsia (thirst) late serious signs:swollen dry tongue, nausea and vomiting, increased muscle tone

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's

blood pressure

sodium main functions

blood pressure blood volume ph balance

hyperphosphatemia assessment

bones blood heart

A client with chronic kidney disease (CKD) has a blood urea nitrogen (BUN) of 100 mg/dL, serum creatinine of 6.5 mg/dL, potassium of 6.1 mEq/L, and lethargy. What is the priority nursing assessment?

cardiac rhythm

what causes hypervolemia

caused by: fluid overload, heart failure, renal failure, cirrhosis, excessive salt intake

After abdominal surgery, a client is reluctant to turn in bed. The nurse should:

explain importance of turning to patient

main function of potassium

heart and muscle

intraoperative phase

holding room: skin prep, IV fluids/medications positioning patient to prevent injury/ensure safety

regional anesthesia

loss of sensations to region without loss of consciousness blocks specific nerve or group of nerves admin via spinal block, epidural or peripheral nerve block

how do lungs help w fluid regulation

remove 400mL of water per day thru expiration

The nurse administered morphine IV to a client after a cholecystectomy one hour ago. The nurse should contact the healthcare provider based on what assessment finding?

respiratory rate 8 breaths/min

management of hyperkalemia

restriction diet and K meds medications as ordered: kayexalate, calcium gluconate (immediately for heart), sodium bicarb, reg insulin, diuretic (loop), dialysis

what is hypervolemia what are some characteristics

retention of sodium and water in ECF moon face edema moist cough crackles distended jugular bounding pulses no appetite

how does pituitary gland regulate fluids

stores anti-diuretic hormone (ADH) regulates volume and osmolarity

hypercalcemia manifestations

swollen and slow constipation bone pain renal calculi decreased DTR severe muscle weakness

hypermagnesemia assessment

vitals cardiac and resp status DTR neuro checks

The expected outcome of withholding food and fluids from a client who will receive general anesthesia is to help prevent:

vomiting and potential aspiration during surgery

postop day 2&3 infection

water: remove cath? cauti? iv site, UTI

The registered nurse (RN) is assigned a client with stomach cancer, who has just returned from a subtotal gastrectomy. Which nursing interventions would be delegated to either a licensed practical/vocational nurse (LPN/VN) or a nursing assistant/unregistered healthcare worker (UHW)? Select all that apply.

• Document intake and output in the electronic medical record. • Reinforce tape over an abdominal incision. • Provide report for the next shift.

When administering IV replacement of 5% dextrose in water with potassium chloride, what should the nurse do first?

• Evaluate laboratory results for electrolytes.

The nurse is assigned to care for five clients. Which could be assigned by the nurse to the unlicensed assistive personnel (UAP)? Select all that apply.

• a client post-operative appendectomy with BP 110/80 mm Hg, pulse 84 bpm • a client scheduled for cataract surgery with BP 134/78 mm Hg, pulse 70 bpm

For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which assessment findings would alert the nurse to suspect hypermagnesemia?

• decreased deep tendon reflexes

skin

CHG baths, prevents infection

hyperchloremia causes

hypernatermia bicarb loss meabolic acidosis

hyperphosphatemia causes

low calcium renal failure diabetic ketoacidosis metabolic resp acidosis

diffusion

natural tendency of substance to move from area of higher to lower concentration

hypermagnesemia causes

renal failure diabetic ketoacidosis

how does adrenal gland regulate fluids

secretes aldosterone increase or decrease urinartion

how does skin help w fluid regulation

sensible perspiration (0-100 ml/day) insensible perspiration (fever burns etc) 600ml/day

hypocalcemia management

slow iv calcium vit d diet meds exercise

A nurse is reviewing a client's laboratory test results. Which electrolyte is the major cation controlling a client's extracellular fluid (ECF) osmolality?

sodium

hyperkalemia s/s

>5.0 tight and contracted hypotension bradycardia Vfib or cardiac standstill diarrhea hyperactive bowel sounds paralysis in extremities increased deep tendon reflexes profound muscle weakness MEDICAL EMERGENCY bc of cardiac effect

Which symptom is an early indication that the client's serum potassium level is below normal?

muscle weakness in legs

potassium is excreted thru

kidneys

isotonic

sodium and water leaving in same proportions treat with isotonic solution

When the nurse asks the client who is having abdominal surgery today if the client understands the procedure, the client replies, "No, not really; I talked about several different things with my surgeon, and I'm just not sure." What should the nurse do next?

notify the surgeon of the lack of understanding

normal platelet levels

140-440

normal bands level

3-5

pH of blood

7.35-7.45

normal glucose level

70-100

Which finding is an example of a variance in the critical pathway of a client 3 days after an above-the-knee amputation?

• Temperature of 102° F (38.9°C)

A client with an I.V. of normal saline at 150 mL/hour reports dyspnea and restlessness. What is the priority nursing action?

asses lung sounds

hypomagnesemia assessments

assess cardiac function DTR swallowing*

chloride main functions

blood volume blood pressure ph balance always follows sodium and does what sodium does

prostheses and belongings

dentures out, jewelry off, contacts out, lock it up

hypernatremia managment

hypotonic or isotonic non saline

normal INR level

less than 1.2 cumadin specific

hyperchloremia assessment

monitor vials ABGs (arterial blood gasses) i/o

hypercalcemia assessment

bowels pain weakness mobility

sanguineous drainage

bright red, indicates active bleed

hypermagnesemia manifestations

calm and quiet hypotension bradycardia hyporeflexia (decreased dtr) shallow respirations hypoactive bowel sounds

volume expansion

can be hypo hyper or isotonic treat w diuretics

1 L of fluid is

2lb weight gain

normal aPTT level

30-40 sec heparin specific

Normal WBC count

4000-11000 abnormal= stress, inflammation, infection

hupophosphatemia management

prevention

postop day 1&2 infection

wind- respiratory infections IS and cough and deep breathe

The nurse is reviewing laboratory data for a client with pancreatic cancer. Which finding does the nurse prioritize as requiring notification of the healthcare provider?

• potassium: 2.2 mEq/L (2.2 mmol/L)

Which outcome is expected for a client who has undergone surgical repair of an inguinal hernia?

The client will verbalize understanding of instructions to avoid lifting for 2 to 6 weeks after surgery.

A 7-year-old has had an appendectomy on November 12. He has had pain for the last 24 hours. There is a prescription to administer acetaminophen with codeine every 3 to 4 hours as needed. The nurse is beginning the shift, and the child is requesting pain medication. The nurse reviews the chart below for pain history. Based on the information in the medical record, what should the nurse do next?

administer meds

hypomagnesemia causes

alc withdrawal * nasogastric suction diarrhea tube feeding diabetic ketoacidosis

preop phase

all care before entering OR nursing goals- inform and educate, reduce anxiety, decrease risk of complications assessment: health history, preop tests and labs, client education, consent

hypochloremia causes

alteration in acid base balance

hyponatermia management

based on why neurologic symptoms edema

phosphorus functions

bone and teeth formation helo regulate calcium calcium high=phos low calcium low=phos high

calcium funcions

bones blood (clotting) heart transmits nerve impulses inverse relation to phosophorous

assessment of hyperkalemia

cardiac muscle weakness labs

surgical team

circulating nurse: manages OR conditions, verifies consent is complete, monitors aseptic practices scrub nurse: preps hand scrub, sets up sterile tables, preps sutures and special equipment, counts all products nurse 1st assistant: handles tissues, provides exposure site, sutures, maintain hemostasis

serous drainage

clear watery plasma

post op phase

completion of procedure thru transfer or discharge takes place in PACU nursing care focused on ensuring stability or patient keep family informed of status or changes ABCs frequent vitals, focused assesment, pain control

osmolarity

concentration of solutes

hyponatremia causes

depressed and deflated seizures and coma tachycardia and weak thready pulses respiratory arrest* diarrhea diuretics GI suctioning heart failure cirrhosis excessive water intake

The nurse is caring for an infant with severe diarrhea that has lasted 3 days. The child has poor skin turgor and dry mucous membranes. What is the priority nursing diagnosis for the nurse to use when planning care for this child?

fluid volume deficit

preop medications

give 30-60 min before given for comfort and control common side effects increases effectiveness of anesthetic safety concers: dont get out of bed, stay w patient, quiet, fall risk

The nurse is assessing a client who is restless and agitated, has dry mucous membranes, and has intense thirst. The nurse should assess the client further for which electrolyte imbalance?

hypernatrimia

types of drains

penrose JP hemovac wound vac abscess drain ttube NG tube always assess and interventions

hypernatremia assessments

i/o vital signs neurological (confused, altered LOC bc brain dehydrated) fluid intake

causes of hypovolemia

inadequate intake vomiting diarrhea GI suctioning hemorrhage third spacing diabetes

informed consent

includes procedure and outcomes, risks, pt needs to have a clear understanding and repeat in own words

hypervolemia labs

labs: BUN increased urine sodium increased pulmonary congestion

management of hypokalemia

oral replacement IV replacement diet

When admitting an elderly client for nausea and vomiting that has lasted for 3 days, the nurse should assess for which clinical findings?

poor skin turgor

hypophosphatemia causes

protein calorie malnutrition

manifestations of hypovolemia

rapid weight loss decreased skin turgor oliguria (less than 30 ml/hr) concentrated urine postural hypotension tachycardia cool clammy skin dry mucous membranes altered LOC

how do kidneys regulate fluids

regulates vol and osmolarity regulate electrolyte in ECF regulate PH in ECF excretion of metabolic waste and toxic substances 170L of plasma filtered per day 1.5L of urine excrete per day

filtration

separation of liquid from undissolved particles floating in it

A client is placed on hypocalcemia precautions after removal of the parathyroid gland for cancer. The nurse should observe the client for which symptoms? Select all that apply.

• numbness • tingling • muscle twitching and spasms

The nurse is caring for a 3-year-old child with acute kidney injury. Which laboratory finding should the nurse immediately report to the healthcare provider?

• potassium level of 6.5 mEq/L (6.5 mmol/L)

hypervolemia interventions

interventions: admin diuretics, sodium restrictions, fluid restrictions, hemodialysis. teach diet. prevent

serosanguinous drainage

pale red water mix of serous and sanguinous

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of their body. The client is in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?

• a urine output consistently above 40 ml/hour (40 mL/hour)

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?

Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer

The nurse has reinforced a pressure dressing on a client who is postoperative mastectomy and notes there is considerable sanguineous drainage in the hemovac. Which assessments should the nurse report to the physician? Select all that apply.

• blood pressure 86/50 mm Hg; pulse weak and thready at 120 bpm • fever of 102 degrees F, no urine output for 2 hours

A client is 2 hours postoperative after an appendectomy. The nurse recognizes a priority is to teach the client potential pulmonary postoperative complications. What action by the client demonstrates understanding of the teaching?

• diaphragmatic breathing and use of incentive spirometry 4-8 times an hour while awake

A client is diagnosed with left-sided heart failure. Which treatment should the nurse anticipate being prescribed to reduce this client's excess fluid?

diuretics

other post op nursing care

activity: purpose, restrictions, safety nutrision: promote ehaling, specific foods pain control: pharmacologic, nonpharm client edu: s/s infection, wound care, complications, when to call, restrictions, followup care

general anesthesia

acts on CNS causes loss of conciousness, sensation reflexes pain perception and memory pt cannot: be aroused or maintain own airway/breathing given inhaled or IV given by anesthesiologist of CRNA meds given to reverse effects at end

hypervolemia assessments

assess: i/o, weight daily, lung sounds, edema

hypocalcemia assessment

bones weak blood bleeding precautions beats dysrythmia

A client who is 12 hours post total thyroidectomy reports tingling around the mouth. Which assessment is the priority?

calcium level

magnesium fuctions

calming effect on muscle heart uterus DTR calcium and vit d absorption

A client with Addison's disease has fluid and electrolyte loss due to inadequate fluid intake and to fluid loss secondary to inadequate adrenal hormone secretion. As the client's oral intake increases, which fluids would be most appropriate?

chicken broth and juice

A nurse is caring for a client who just had an appendectomy. The client is receiving opioid analgesics routinely for pain. The nurse should focus the follow-up assessment on which complication?

constipation

time out

correct patient, procedure, and site informed consent signed identify any concerns

hypomagnesemia managment

diet oral meds slow iv admin

hypermagnesemia managment

discontinue all mag administer antiacids admin loop diretic if renal function allows dialysis

Upon waking up in the postanesthesia care unit and seeing a drain with bright red fluid in it exiting from his total hip incision, a client asks the nurse, "Is this the way it's supposed to be?" What should the nurse tell the client?

drainage is what needs to be drained out for healing

moderate sedation

drug induced depression of consciousness pt can: maintain airway, respond to verbal commands, faster recovery combination of sedative and opioid can be administered by RN continuous monitoring of vitals ECG O2 responsiveness

A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed assistive personnel (UAP) to report which clinical manifestation of this laboratory report?

elevated temp

epidural anesthesia

epidural: injection into epidural space (thoracic or lumbar), low dose blocks sensory pathway only, high dose blocks motor&sensory can cause hypotension decreased incidence of heart attack can be continuous or 1 hr injection larger needle use increases risk of complications if dura is punctured punctured dura leads to collapse of cardiac system

A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, jugular vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client?

excess fluid volume

On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?

hypocalcemia

A physician orders a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?

hypokalemia

delayed complications: DVT and PE

immobility contributes to stasis of blood flow inflammation and tissue damage from surgery promote cot formation clots break free from veins in lower extremities and become lodged in pulm veins (PE) Risks: immobility, smoking, BC, increased platelets, surgery, family hx, lack of edu, dehydration Assessment: resp changes, low o2, tachycardia, anxious feeling, SOB, chest pain, doppler (DVT), redness warmth pain edema, med hx, mobility level, labs- INR aPTT Interventions:scds, ted hose, walking, ROM, hydration, nutition, medication-heparin (aPTT levels), pain meds, Evaluation:RT, pain assessment, skin assesment, labs, doppler, reassess education/understanding

A client is to have a below-the-knee amputation. Prior to the surgery, what should the circulating nurse in the operating room do?

initiate time out

spinal anesthesia

injected into subarachnoid space effective below injection site autonomic block: vasodialation, hypotention, bradycardia sensory&motor block: can affect diaphragm when block is too high: respiratory complications spinal headache: CSF leaks from puncture site, relieved by lying flat, decreased by using smaller needle, blood block

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?

lactated ringers

how does GI tract regulate fluids

lose 100ml/day w 8 L of fluid circulating daily

what is hypovolemia

loss of ECF volume exceeds intake of fluid water and electrolytes both lost in same proportions

local anesthesia

loss of sensation without loss of consciousness given topically of injection minor procedures

hypotonic

loss of sodium exceeds loos of water treat with isotonic of hypertonic

hypertonic

loss of water exceeds loss of sodium treat with hypotonic fluid

hypokalemia s/s

low and slow flat t waves st depression and prominent u wave decreased DTR muscle cramping flaccid paralysis decreased motility constipation abdominal distension paralytic ileus hypotension and bradycardia

A nurse administers furosemide to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully?

low serum potassium

infection and temp day of surgery

lower temp than normal

hypercalcemia causes

malignancy hyperparathyroidism immobilizaion

The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms?

may be developing hypocalcemia

A client is receiving a bowel preparation of magnesium citrate the evening before a scheduled colonoscopy. Which factor should the nurse consider when providing care for this client?

may require fluid and electrolyte replacement

delayed complications: N&V consitpation and paralytic ileus

medications cause n&v slow peristalsis and lead to immobility increases risk of GI complications preop bowel prep and NPO status delay return of BS passage of gas and BM paralytic ileus is result of absence of peristalsis causing distension n&v and pain risks: pain meds, anesthesia, dehydration, malnutrition (low fiber diet), age Assessment: hypoactive bowel sounds, assess meds (side effects), assess i/o's, last BM, distention, diet, abdominal assessment (palpate, auscultate, peristalsis) Interventions: increase fiber intake, increase fluids, administer mirolax or other stool softener, look at medications to switch or decrease dose, CAT scan/xray, walk, i/o's, enema Evaluation: frequency, color, form, bowel sounds, abdominal appearance, hydration status and diet, medication frequency, ambulate Listen 5 min if no bowel sounds

delayed complications: urinary retention and acute renal failure

medications used during surgery and after decreased sensation prolonged hypotension decreases blood flow to kidneys state of hypovolemia will decrease the amount of urine produced Risks: medications, opioids, anesthesa, age, kidney disease, bladder infection, prostate cancer, trauma, Post Partum Assessment: monitor i/o's, bladder scan (>100mL), UA, distention, health hx Intervention: retrain bladder every 2 hours, straight cath, bladder scan, void within 8 hours of pulling catheter, education Evaluation: increased output, empty bladder on scan, clear UA, decreased/no distention, decreased/no pain Creatinine BUN GFR labs

delayed complications: atelectasis and pneumonia

meds depress resp function immobility limits lung expansion secretions become thicker and drier fluid collects in lungs pain inhibits coughing and deep breather Risks: obesity, immunocomprimised, lack of movement, copd, asthma, heart failure, aspiration, opioid use Assessment: crackles, wheezing, diminished lunch sounds, low O2, low resp rate, labs-wbc, chest xray, sputum, retractions/weak (cough), blood sugars-related to steroids Interventions: incentive spirometer, o2, breathing treatments, suction, increase mobility, antibiotics, steroids, HOB >30, education Evaluation: clear lung sounds, improved vitals, improved mobility, no further infection, education teach back

A client reports occasional numbness in the fingers and lips. Which of the following dietary choices should the nurse encourage the client eat?

milk products

hypophosphatemia manifestations

moans groans and stones consitpation decreased DTR severe mucle weakness decrease HR and respiratory rate increased blood pressure

active transport

movement of molecules across a membrane low to high concentration in direction against concentration gradient

osmosis

movement of water caused by concentration gradient low to high

A client who has been taking furosemide has a serum potassium level of 3.2 mEq/L. Which assessment findings by the nurse would confirm an electrolyte imbalance?

muscle weakness and weak thready pulse

hyperchloremia manifestations

nearly same as high sodium n&v swollen dry tongue confusion

hypochloremia manifestatiosn

nearly same as low sodium excessive diarrhea vomiting sweating fever (only dif)

adjunct to general anesthesia

opioids used to maintain anesthesia. analgesia during surgery, improve post op pain, can combine diff opioids can depress respers ie: fentynal morphine hydromorphone antedote: narcan benzos induce and maintain anesthesia, large doses produce unconsciousness, amnesic effect, supplemental sedation potentiates effects of opiods, resp depression, hypotension, no analgesic propertics ie: midazolam, diazepam antidote: flumazoril

hypomagnesemia manifestations

opposite of calm and quiet tachycardic v fib hyperflexia abnormal eye movement diarrhea

assessments for hypovolemia

oral fluids IV fluids, lactated ringers, isotonic rate and volume based on volume loss and hemodynamics

During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and

phosphorus

delayed complications: infection and non healing wounds

preexisting conditions increase risk of complications strains on suture lines can reopen the surgical wound: dehiscence evisceration: bowel protrudes thru open wound delayed treatment, traumatic injuries and previously infected wounds at higher risk Infection Risk: wound, foley, Iv lines, nutritional status, high glucose, immunosuppressive med, low WBC, poor hygiene, increase hospital stay, lifestyle, age, chronic illness, length of surgery, dehiscence, evisceration, diabetes, Assessment: cbc-wbc, vitals-high temp, pain, redness swelling drainage, odor, skin in tact, diet, Interventions: hand hygiene, preop antibiotic, dressing changes and wound care, balanced diet, educate, foley care early removal, Evaluation: improvement of area, LOC, vitals, WBC, pain level Delayed wound healing: Risk: diabetes, nutrition, positioning, LOC, smoker, age, attitude/mentality, lack of edu, lack of resources, mobility, Assessment: size, color, skin, labs, mobility, drainage Interventions: turning, dressing change, wound care consult, hygiene, wound vac, hydration Evaluation: decreased pain, decreased drainage, decreased size, improved labs

purulent drainge

thick yellow green tan brown

hyperphophatemia management

treat underlying cause

hypercalcemia management

treat underlying cause increase mobility encourage fluids encourage fiber calcitonin dialysis

hyperphosphatemia manifestations

trousseasus sign chvosteks sign dirrhea weak bone blood and beats

hypocalcemia manifestations

trousseaus sign (hand cramp) chvosteks sign (facial nerve) diarrhea circumoral tingling (around mouth)

A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation?

urine output of 30mL/hr

post op nursing care

vitals every 5-15 min, hypothermia respers: depth, rate, effort, O2 stats cardiac: pulse rate and strength, hypotension neuro: LOC motor/sensation complications: hypoxia, hemorrhage hypovolemia control symptoms: pain, n&v discharge pacu: stable vs, orientedx4, pulmonary and cardiac function, spo2 above 90, symptoms controlled

A client is admitted on the day of surgery for an arthroscopy of the left knee. Which nursing activities should be completed prior to administering anesthesia to the client to avoid wrong-site surgery? Select all that apply.

• Verify that the surgeon has marked with a permanent marker the correct knee for the surgical site. • Verbally ask the client to state his or her name, surgical site, and procedure. • Verify the correct client with the correct operative site from medical records and diagnostic reports. • Call a "time-out" in the operating room to have the surgeon verify the correct knee before making the incision.

post op day 4&5+ infection

wound: surgical wound infection

normal neutrophil levels

50-70

A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?

Cover the protruding internal organs with sterile gauze, moistened with sterile saline solution.

The nurse is caring for a 5-year-old child who had a hernia repair 1 day ago. The child is vomiting, has a nasogastric (NG) tube to low intermittent suction, and has diarrhea. Which of the following laboratory results would be the immediate priority for the nurse to assess?

potassium level

A client who had transurethral resection of the prostate has dribbling urine after his Foley catheter is removed on the second postoperative day. The nurse notes that the client had 200 mL of urine output in the last 8 hours with a 1,000-mL intake. What should the nurse do first?

assess for bladder distention

A client with acute renal failure has a serum potassium level of 6.5 mEq/L (6.5 mmol/L). The nurse should monitor the client for which potential complication?

cardiac arrest

The nurse is assessing a client's abdominal incision 48 hours after surgery. Which finding indicates that the wound is inflamed?

• Localized warmth over the incisional area.

purpose of surgery

diagnostic- biopsy curative- appendix removal palliative-rid of pain cosmetic-facelift preventative-mole removal for skin cancer

A client is scheduled to have surgery to relieve an intestinal obstruction. Prior to surgery, the nurse should verify that the client has followed which preoperative instructions?

discontinue use of blood thinners

The nurse is taking a nursing history from a client prior to surgery. Which information in the client's history would have a significant impact on the client's recovery postoperatively? The client:

has smoked 1 pack of cigarettes a day for 12 years.

bowel prep

helps with visability

A client with cirrhosis begins to develop ascites. Spironolactone is prescribed to treat the ascites. The nurse should monitor the client closely for which drug-related adverse effect?

hyperkalemia

A client has had an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than 1 week. The nurse should assess the client for which complication?

hypokalemia

A multigravid client thought to be at 14 weeks' gestation reports that she is experiencing such severe morning sickness that she "has not been able to keep anything down for a week." The nurse should assess for signs and symptoms of which condition?

hypokalemia

Which nursing intervention is the highest priority during the first 24 hours postoperatively for the client who had a total laryngectomy due to cancer of the larynx?

keep airway open

The nurse is caring for a client postoperatively who received an inhalation anesthetic during GI surgery. The client complains of being very cold and is shivering. The nurse provides extra blankets. What additional intervention is needed?

provide oxygen as ordered

A nurse completes preoperative teaching for a client scheduled for a cholecystectomy. The client states, "If I lie still and avoid turning, I will avoid pain. Do you think this is a good idea?" What is the nurse's best response?

• "Turn from side to side every 2 hours, and the nurse will administer pain medication to assist in movement."

Which of the following statements heard during shift report identifies an important priority for action?

• A postoperative client's pulse has been increasing, and the blood pressure is decreasing.

A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?

• Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels

The nurse is providing preoperative instructions to a client who is deaf. Which strategy is most effective in assuring that the client understands the information?

• Give the client written material to read, and follow up with time for questions.

A nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do?

• Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.

normal BUN level

6-20

A client has been experiencing abdominal cramps, diarrhea, and concentrated urine for the past 2 days. Which signs would be included in a focused assessment?

• signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes

The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable over the last 24 hours, with most recent temperature 98.6°F (37°C), blood pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16 breaths/minute, and heart rate (HR) 78 bpm, but these signs are now changing. Which set of vital signs indicates that the nurse should contact the health care provider (HCP)?

• temperature 101.8° F (38.8° C), BP 140/86 mm Hg, HR 94 bpm, RR 24 breaths/min Explanation: This client is exhibiting signs of sepsis, and the nurse should notify the health care provider. The client has three signs indicating sepsis: temperature >101.0°F (38.3°C) (or <96.8°F [36°C]), HR >90 bpm, and RR >20 breaths/min. At least two of these variables are required to diagnose sepsis

A client has a serum calcium level of 7.2 mg/dl (1.8 mmol/L). During the physical examination, the nurse expects to assess

• Trousseau's sign.

A client who is 1 day postoperative is using a morphine patient-controlled analgesia (PCA) pump. The client is confused and disoriented. What is the priority intervention by the nurse?

• Check respiratory rate and depth as well as oxygen saturation levels.

The nurse is working with a licensed practical nurse (LPN) and delegating the taking of vital signs for a preoperative client. Upon review of the chart as the client is leaving for the operating room, the nurse notes that the temperature is 101.1°F (38.4°C) and the pulse is 110 bpm. What are the nurse's initial actions?

• Notify the surgeon and await the surgeon's decision; reinforce with the LPN the importance of reporting abnormal preoperative vital signs.

A client had surgery for a bowel obstruction 4 days ago. The nurse assesses that the client has not passed any flatus, and there are no bowel sounds. Even though the abdomen has become more distended, the client feels little discomfort. In considering the plan of care, what is the most appropriate first step for the nurse to take?

• Obtain an order for nasogastric tube insertion.

The nurse is caring for a client who is post-operative cholecystectomy. When assessing the respiratory status after general anesthesia, which of the following clinical findings would the nurse view as a concern? Select all that apply.

• PAO2 of 76 mm Hg • cyanosis around the mouth and fingertips

A nurse is administering 50 mEq potassium chloride (KCl) in 250 mL 0.9 normal saline (NS) intravenously piggyback (I.V.PB) to a client with hypokalemia. Which action should the nurse take?

• Provide continuous cardiac monitoring during the infusion.

A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication?

• Serum potassium level of [2.6 mEq/L (2.6 mmol/L)}

The surgeon prescribes cefazolin 1 g to be given IV at 0730 when the client's surgery is scheduled at 0800. What is the primary reason to start the antibiotic exactly at 0730?

• The antibiotic is most effective in preventing infection if it is given 30 to 60 minutes before the operative incision is made.

A 250-lb (113-kg) male client is recovering from general anesthesia. The client's vital signs are: pulse, 150 bpm; blood pressure, 90/50 mm Hg; respiratory rate, 28 breaths/min; tympanic temperature, 99.8°F (37.7°C); The client has rigid muscles. How should the nurse interpret these findings?

• The client is in the early stages of malignant hyperthermia; the nurse should obtain emergency medications and notify the anesthesiologist. Explanation: A heart rate of 150 bpm or greater, hypotension, and muscle rigidity are early signs of malignant hyperthermia. The nurse should quickly assemble emergency supplies and personnel because malignant hyperthermia is potentially and rapidly fatal in more than 50% of cases. Rapid, extreme rise in temperature is a late sign. Another factor influencing the analysis is that the client has a large body frame, and having large, bulky muscles is a risk factor for malignant hyperthermia. The client's vital signs are well out of the range of normal; analysis of the data and swift intervention are indicated. Excessive blood loss is unlikely, and the data do not support this conclusion. Although clients do have changes in vital signs when in acute pain, the nurse would expect the client to be hypertensive, not hypotensive.

A client is in the operating room having surgery to replace a hip. Prior to starting the surgery, there is confusion about the view of the hip on the X-ray The surgical team requests a "time out" and stops the surgery. When can surgery continue? Select all that apply.

• The surgeon verifies the correct procedure. • The surgeon verifies correct surgical site. • The surgical team identifies the client using two sources of identification.

The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved?

• The urine output is greater than 35 mL/h.

A nurse is caring for a client with chronic renal failure. The laboratory results indicate hypocalcemia and hyperphosphatemia. When assessing the client, the nurse would be alert for which signs and symptoms? Select all that apply.

• Trousseau's sign • cardiac arrhythmias • fractures