Pre-op NCLEX

-As the nurse is preparing a patient for surgery, the patient refuses to remove a wedding ring. Which of the following is the most appropriate action by the nurse?" A. Note the presence of the ring in the nurse's notes of the chart. B. Insist the patient remove the ring. C. Explain that the hospital will not be responsible for the ring. D. Tape the ring securely to the finger."

". Explain that the hospital will not be responsible for the ring. It is customary policy to tape a patient's wedding band to the finger and make a notation on the preoperative checklist that the ring is taped in place."

"Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? "1. Complete the preoperative checklist. 2. Assess the client's preoperative vital signs. 3. Teach the client about coughing and deep breathing. 4. Assist the client to remove clothing and jewelry.

"1. The nurse should complete this form because it requires analysis, which cannot be delegated to the UAP. 2. Nurses cannot delegate assessment. 3. THe nurse cannot delegate teaching to a UAP. 4. The UAP can remove clothing and jewelry."

"While completing the preoperative assessment, the male client tells the nurse that heis allergic to codeine. Which intervention should the nurse implement first? "1.Apply an allergy bracelet on the client's wrist. 2.Label the client's allergies on the front of the chart. 3.Ask the client what happens when he takes the drug. 4.Document the allergy on the medication administration record

"1. This is an important step for the nurse toimplement, but it is not the first intervention. 2.This must be done, but it is not the first inter- vention. CORRECT 3. The nurse should first assess the eventsthat occurred when the client took thismedication because many clients think that a side effect, such as nausea, is an allergicreaction. 4.This information must be put on the medica-tion administration record (MAR), but it is notthe first intervention"

A client is admitted to the hospital for surgical repair of a detached retina in the right eye. In planning care for this patient postoperatively, the nurse should encourage the patient to do which of the following? "1. Perform self-care activities. 2. Maintain patches over both eyes. 3. Limit movement of both eyes. 4. Refrain from excessive talking."

"1. activity restrictions depend on location an size of tear. 2. only affected eye covered 3. CORRECT - bed rest with eye patch or shield 4. no restriction"

The nurse is completing an admission assessment for a client admitted to the medical unit with a diagnosis of Acute Alcohol Intoxication. When asked to describe his drinking pattern and amount, the client states, "I only drink when I am under a lot of stress." The client's response indicates what defense mechanism? 1. Regression 2. Denial 3. Projection 4. Rationalization"

"4. Rationalization. Rationale: 1. Denial. Denial is used to protect a client from reality, especially unpleasant events in life. The client is not denying alcohol use. 2. Rationalization. Substituting acceptable reasons or explanations for real or actual problems that motivate a client's behavior is rationalization. The client is rationalizing his drinking by justifying why he needs to drink. 3. Projection. Attributing one's own unacceptable thoughts, feelings, or impulses to another person is projection. This client is describing his behavior as reasonable under the circumstances. 4. Regression. Returning to comfortable behavior that was used at an earlier point in one's life is regression. For example, a child who has been toilet-trained suddenly starts bedwetting following the parents' separation."

A hospitalized client with a history of alcohol abuse tells a nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been dischagred. The clientis scheduled for an inportant diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. The appropriate nursing action is to: "A. Call the nursing supervisor B. Call security to block all exit areas. C. Restrain the client until the physician can be reached. D. Tell the client that the client cannot return to this hospital again if the client leaves now."

"A. Call the nursing supervisor A nurse can be charged with false imprisonment if a client is made to believe wrongfully that he or she cannot leave the hospital. Most health care facilities have documents that the client is asked to sign relating to the client's respinsibilities when the client leaves against medical advice. The client should be asked to sign this document before leaving. The nuse should request that the client wait to speak to the physician before leaving, but if the client refuses to do so the nurse cannot hold the client against the clients will.

1. How does palliative surgery differ from any other type of surgery? "The main purpose is cosmetic in nature rather than functional repair or comfort. B. There are fewer risks associated with palliative surgery than with any other type of surgery. C. The outcomes of palliative surgery cannot be ensured to produce the desired effect or restoration of functional ability. D. Palliative surgery is performed to provide temporary relief of distressing symptoms rather than to cure a problem or condition."

"ANS: D The purpose of palliative surgery is to improve the client's quality of life by reducing or eliminating distressing symptoms. It does not cure a health problem and, often, does not prolong life. Although the exact outcomes of palliative surgery cannot be ensured, neither can the outcomes of any other type of surgery."

A home health nurse visits a client at home and determine that the client is dependent on drugs. Whcih of the following assesment questions would assist the nurse to provide appropriate nursing care? 1. ""Why did you get started on these drugs?"" 2. ""How much do you use and what effect does it have on you?"" 3. ""How long did you think you could take these drugs without someone finding out?"" 4. The nurse does not ask anyquestions for fear that the client is in denial and will throw the nurse out of the home."

"Answer two is the correct answer. Whenever the nurse carries out an assesement for a client who is dependent on drugs it is best for the nurse to attempt to elicity information by being nonjudginmental and direct. Option I is incorrect because it is judgemental. Option 3 is incorrect because it is judgemental which is non therapeutic. Option four is incorrect because it indicates pssivity on the nurse's part and uyses rationalization to avoid the therapeutic invervention."

"The physician has ordered preoperative atropine for a client undergoing surgery. Which of the following provides the best rationale for the use of this medication? "A. It induces general calmness and sleepiness B. It reduces oral and pulmonary secretions and prevents laryngeospasms C. It is used to reduce anxiety and ease anesthetic induction. D. It reduces gastric fluid volume and gastric acidity."

"B. Anticholinergics, such as atropine, scopolamine, and glycopyrrolate (Robinul), reduce oral and pulmonary secretions and prevent laryngospasm."

While performing preoperative teaching, the patient asks when she needs to stop drinking water before the surgery. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, the nurse tells the patient that: "A. She must be NPO after breakfast. B. She needs to be NPO after midnight. C. She can drink clear liquids up to 2 hours before surgery. D. She can drink clear liquids up until she is taken to the OR.

"C. She can drink clear liquids up to 2 hours before surgery. Practice guidelines for preoperative fasting state the minimum fasting period for clear liquids is 2 hours. Evidenced-based practice no longer supports the long-standing practice of requiring patients to be NPO after midnight."

"A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opiod analgesics that have been administered. The nurse should take which appropriate action in the care of this client? "1.Obtain a court order for the surgery 2.Send the client to surgery without the consent form being signed. 3.Have the hospital chaplain sign the consent form. 4.Obtain a telephone consent from a family member, following agency policy"

"Correct Answer: 4 Rationale: Every effort should be made to obtain consent from a responsible family member to perform the surgery if a client is unable to sign the consent form."

"When preparing a client for surgery, which intervention should the nurse implement first? "1.Check the permit for the spouse's signature. 2.Take and document intake and output. 3.Administer the "on call" sedative. 4.Complete the preoperative checklist."

"Correct answer: 4 Rationale: 1. The client's signature, not the spouse's, shouldbe on the surgical permit. 2.This would be information that would be im-portant if abnormal, but it is not the first inter- vention. 3."On call" sedations should be administeredafter the surgical checklist is completed. 4.Completing the preoperative checklist hasthe highest priority to ensure that all detailsare completed without omissions"

A priority nursing intervention to assist a preoperative patient in coping with fear of pain would be to: "a) Inform the patient that pain medication will be available b) teach the patient to use guided imagery to help manage pain. c) Describe the type of pain expected with the patient's partcular surgery. d) Explain the pain management plan, including the use of a pain intensity scale."

"Correct answer: d Rationale: If a patient has fear of pain and discomfort during and after surgery, the nurse should reassure the patient that drugs are available for anesthesia and analgesia during surgery. The nurse should teach the patient to ask for medications after surgery when pain is present and assure him or her that taking these medications will not contribute to an addiction. Instruct the patient on the use of some form of pain intensity scale (e.g., 0-10, FACES) and to request pain medication before the pain becomes severe"

"To prevent airway obstruction in the postoperative patient who is unconscious or semiconscious, the nurse: "A. encourages deep breathing. B. elevates the head of the bed. C. administers oxygen per mask. D. positions the patient in a side-lying position.

"D. ""positions the patient in a side-lying position."" is the correct answer. An unconscious or semiconscious patient should be placed in a lateral position to protect the airway from obstruction by the tongue. Deep breathing and elevation of the head of the bed are implemented to facilitate gas exchange when the patient is responsive. Oxygen administration is often used, but the patient must first have a patent airway."

A patient is to recieve ranitidine (Zantac) preoperatively. He tells the nurse that he took his esomeprazole (Nexium) today (as ordered). The nurse explains taht these medications will. a.) calm the patient and relieve his anxiety b.) provide sedation and amnesia before surgery c.) prevent aspiration of stomach contents into his lungs d.) work to decrease stomach acids and help avoid nausea after surgery

"D.) work to decrease stomach acids and help avoid nausea after surgery Rationale: Ranitidine (Zantac) is a histamine (H2) receptor antagonist, and esomeprazole (Nexium) is a proton pump inhibitor. These drugs decrease stomach acid and postoperative nausea."

"While witnessing a preoperative consent, the nurse learns that the client does not understand the risks of the surgery. The nurse's best action is to: "Notify the surgeon Notify the surgical unit Notify the anesthetist Notify the client's family"

"Notify the surgeon Rationale: The primary responsibility for informed consent lies with the attending surgeon, not the interdisciplinary team."

"A pre-operative nurse prepares a client for surgery, which nursing interventions should be included in the plan of care? Mark all that apply." "a. Maintain NPO status to prevent aspiration. b. Verify the client's signature on the consent prior to surgery. c. Remove dentures and contact lenses prior to surgery. d. Check the client's allergy and blood bands for accuracy. e. Verify the client's mobility in all extremities prior to surgery."

"Rationale: Maintaining nothing by mouth prevents the client from aspirating food particles into the lungs during and after surgery. Because of legal requirements, the surgical consent must be signed prior to surgery to verify the client's acknowledgement of the content on the consent. Dentures, hairpins, glasses, and contacts may interfere with client safety, or compromise the sterile field. Allergy, blood, and identification bands should all be checked prior to surgery to prevent medication errors, blood bank errors, and to facilitate proper identification of the client. Verifying the client's mobility in all extremities prior to surgery is part of the physical assessment, but not a necessary action prior to surgery. Nursing Process: Intervention Client Need: Management of Care Cognitive Level: Application Objective: Provide appropriate nursing care for the client in the preoperative, intraoperative, and postoperative phases of surgery. Strategy: Apply knowledge of the nursing process to the clinical scenario to select the correct interventions."

The nurse must obtain surgical consent forms for the following clients who are sched-uled for surgery. Which client would not be able to consent to surgery? "1.The 65-year-old client who cannot read or write.2.The 30-year-old client who does not understand English.3.The 16-year-old client who has a fractured ankle. 4.The 80-year-old client who is not oriented to the day."

"The 65-year-old client who cannot read canmark an "X" on the form and is legally able tosign a surgical permit as long as the clientunderstands the benefits, alternatives, and allpotential complications of the surgery.2.The client who does not speak English can andshould have information given and questionsanswered in the client's native language. 3.A 16-year-old client is not legally able togive permission for surgery unless theadolescent is given an emancipated statusby a judge. This information was not given in the stem. 4.A client is able to give permission unless deter-mined incompetent. Not knowing the day of the week is not significant"

"When completing the assessment for the client in the day surgery unit, the client states,"I am really afraid of having this surgery. I'm afraid of what they will find." Which state-ment would be the best therapeutic response by the nurse? "1."Don't worry about your surgery. It is safe." 2."Tell me why you're worried about your surgery." 3."Tell me about your fears of having this surgery." 4."I understand how you feel. Surgery is frightening.""

"The correct answer is 3. 1.This statement is giving false reassurance. 2.This statement is requesting an explanation. 3. This statement focuses on the emotion that the client identified and is therapeutic. 4.This statement belittles the client's fear, andno person understands how another personfeels"

"A patient who is dependent on barbiturates is scheduled for surgery following an automobile accident. The nurse recognizes that this patient "a. may need less pain medication during the postoperative period. b. should be provided with taper doses of barbiturates following surgery. c. may have an immediate onset of withdrawal symptoms when given anesthetic and analgesic agents. d. has a low risk for physical withdrawal symptoms but is likely to experience craving and drug-seeking behavior during the post-operative period."

"answer: b Rationale: withdrawal from sedative hypnotics can be very serious.After 24 hours, the patient may experience delirium, seizures, and respiratory and cardiac arrest, and withdrawal from high doses requires close monitoring in an inpatient setting. Long-acting agents such as diazepam (Valium), chlordiazepoxide (Librium), clonazepam (Klonopin), or phenobarbital may be substituted for the abused drug and gradually tapered after stabilization. Mild to moderate symptoms can persist for 2 to 3 weeks after a 3- to 5-day period of acute symptoms."

"A nurse is developing a POC for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? "1. Have the client void immediately before going into surgery 2. Avoid oral hygiene and rinsing with mouthwash. 3. Verify that the client has not eaten for the last 24 hours. 4. Report immediately any slight increase in blood pressure or pulse."

. Have the client void immediately before going into surgery The nurse would assist client to void immediately before surgery so that the bladder will be empty. A slight increase in blood pressure and pulse is common during the preoperative period and usually the result of anxiety. The client usually has a restriction of food and fluids for 6-8 hours before surgery instead of 24.

The nurse requests a client to sign the surgical consent form for an emergency appen-dectomy. Which statement by the client indicates that further teaching is needed? 1. "I will be glad when this is over so that I can go home."2."I will not be able to eat or drink anything prior to my surgery."3."I need to practice relaxing by listening to my favorite music."4."I will need to get up and walk as soon as possible."

1. "I will be glad when this is over so that I can go home"1. When recuperating from emergency sur-gery, the client will be in the hospital for afew days. This is not a day-surgery proce-dure. The client needs more teaching. 2.Clients are NPO (nothing by mouth) prior tosurgery to prevent aspiration during and afteranesthesia.3.Listening to music and other relaxing tech-niques can be used to alleviate anxiety and pain.4.Clients are encouraged to get out of bed assoon as possible and progress until a return todaily activity is achieved."

The nurse is discharging a client from an inpatient alcohol treatment unit. Which of the following statements by the client's wife indicates to the nurse that the family is coping adaptively? "1. ""My husband will do well as long as I keep him engaged in activities he likes. "" 2. ""My focus is learning how to live my life."" 3. ""I am so glad that our problems are behind us."" 4. ""I'll make sure that the children don't give my husband any problems."""

2. ""My focus is learning how to live my life."""1. ""My husband..."" - wife is accepting responsibility, codependent behavior 2. ""My focus..."" - (CORRECT): wife is working to change codepended patterns 3. ""I am so glad..."" - unrealistic; discharge is not the final step of treatment 4. ""I'll make sure..."" - wife is accepting responsibility, codependent behavior"

The nurse has just finished explaining the necessity of coughing and deep breathing following surgery to a perioperative client. Which of the following responses by the client would indicate his understanding and acceptance of what he has been taught? "1. ""I thought that spirometry thing was supposed to do the job."" 2. ""When I do the coughing and deep breathing, I reduce my chances of getting pneumonia."" 3. ""It really hurts too much to do that. Deep breathing and coughing are impossible."" 4. ""I guess I'll try to remember to take a couple of deep breaths once and a while.""

2. ""When I do the coughing and deep breathing, I reduce my chances of getting pneumonia.Deep-breathing exercises are encouraged. These exercises help remove mucus, which can form and remain in the lungs due to the effects of general anesthetic and analgesics. Deep breathing increases lung expansion and prevents the accumulation of secretions. It helps prevent pneumonia and atelectasis, which may result from stagnation of fluid in the lungs.

A patient is to have elective surgery. The RN should plan with the patient to schedule the surgery: 1. If the patient wished to have the procedure done. 2. At the patient's convenience 3. Within the next 2 wteeks. 4. Within the next 2 days.

2. AT THE PATIENT'S CONVENIENCE.Rationale: Since this is an elective surgery it will be scheduled at the patient's convenience when the surgeon is available. There is not a time constraint on elective procedures.

A nurse is reviewing a physician's order sheet for a preoperative client that states that the client must be NPO after midnight. The nurse would telephone the physician to clarify whether which of the following medications should be given to the client and not withheld? 1) Ferrous sulfate. 2) Prednisone (Deltasone) . 3) Cyclobenzaprine (Flexeril). 4) Conjugated estrogen (Premarin).

2: Prednisone (Deltasone)Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withtand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated strogen is used for hormone replacement therapy in postmenopausal women. These three meds can be withheld before surgery without consequences.

"Which of the laboratory result would require immediate intervention by the nurse for the client scheduled for surgery? "1. Calcium 9.2 mg/dL 2. Bleeding time 2min 3. Hemoglobin 15 g/dL 4. Potassium 2.4 mEq/L

4: Potassium 2.4 mEq/L "1. This laboratory value is within normal limits 2. This laboratory value is within normal limits 3. This laboratory value is within normal limits 4. This potassium levels is low and should be reported to the health care provider because potassium is important for muscle function, including the cardiac muscle"

"The nurse is assessing a client who has a current history of alcohol dependence for signs of major withdrawal. What findings would the nurse expect to find?" "1. Tachycardia, severe diaphoresis 2. Hypotension, bradycardia 3. Cold, clammy skin, decreased body temperature 4. Anxiety and increased appetite

Answer 1: "1. Hypotension, bradycardia. Symptoms associated with major withdrawal, also known as delirium tremens (DTs), are not low blood pressure and a slow heartbeat, but hypertension and tachycardia. 2. Cold, clammy skin, decreased body temperature. Severe diaphoresis and elevated body temperature are physical symptoms of impending DTs (delirium tremens). 3. Tachycardia, severe diaphoresis. Tachycardia and severe diaphoresis are associated with major withdrawal from alcohol. 4. Anxiety and increased appetite. Clients experiencing a minor withdrawal from alcohol may experience anxiety and gastrointestinal-related symptoms such as nausea, vomiting, and anorexia."

"Preoperatively, the nurse develops a plan to prepare a 7-month-old infant psychologically for a scheduled herniorrhaphy the next day. Which of the following should the nurse expect to implement to accomplish this goal? 1. Explaining the preoperative and postoperative procedures to the mother. 2. Having the mother stay with the infant. 3. Making sure the infant's favorite toy is available. 4. Allowing the infant to play with surgical equipment.

Answer 2, 2. The best way to prepare a 7-month-old infant psychologically for surgery is to have the primary caretaker stay with the child. Infants in the second 6 months of life commonly develop separation anxiety. Therefore, the priority in this case is to support the child by having the parent present. Teaching the mother what to expect may decrease her anxiety; this is important because infants sense anxiety and distress in parents, but the priority in this case is to have the parent present. Actual play and acting out life experiences are appropriate for preschool-age children. Allowing an infant to play with surgical equipment would be inappropriate and dangerous.

A nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal. Which of the following would alert the nurse to the potential for withdrawal delirium? "1. Hypotension, ataxia, hunger 2. Stupor, agitation, muscualr rigidity 3. Hypotension, coarse hand tremors, agitaition 4. Hypertension, changes in LOC, hallucinations

Answer 4, Syptoms associated with withdrawal delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions.

"A client taking the drug disulfiram (Antabuse) is admitted to the ER. Which clinical manifestations are most indicative of recent alcohol ingestion? "A. Vomiting, heart rate 120, chest pain B. Nausea, mild headache, bradycardia C. Respirations 16, heart rate 62, diarrhea D. Temp 101°F, tachycardia, respirations 20"

Answer A is correct. Vomiting, a heart rate of 120, and chest pain are symptoms of drinking alcohol while taking Antabuse. Additional symptoms include severe headache, nausea, ardiac collapse, respiratory collapse, convulsions, and death. Answers B, C, and D contain incomplete or inaccurate clinical signs of the combination of alcohol and Antabuse.

"An order is written to start an IV on a 74-year-old client who is getting ready to go to the operating room for a total hip replacement. What gauge of catheter would best meet the needs of this client? "A) 18 B) 20 C) 21 butterfly D) 25"

Answer A. Clients going to the operating room ideally should have an 18- gauge catheter. This is large enough to handle blood products safely and to allow rapid administration of large amounts of fluid if indicated during the perioperative period. An 18-gauge catheter is recommended. A 20-gauge catheter is a second choice. A 21-gauge needle is too small and a butterfly too unstable for a client going to surgery. A 25-gauge needle is too small.

The nurse is aware that the client requires clarification of preoperative instructions when the client says "a. ""It is OK to drink some juice in the morning."" b. ""I should remove all jewelry before surgery. c. ""I should shower the night before with this soap I was give d. ""I will have an IV put in before surgery."""

Answer A. The client repeats correct information, except that juice is not allowed the morning of surgery. B. All jewelry should be remove C. Patient will be given specific soap to wash with night before D. IV will help adminster meds during surgery

The physician has ordered sequential compression devices (SCDs) for a client going to surgery. The best rationale for use of SCDs is to: A) keep the legs warm B) Promote venous return (C) Maintain balanced fluid volume D) Induce Relaxation

Answer B, Clients who are undergoing surgery may benefit from a sequential compression device (SCD) to promote venous return from the legs. SCDs inflate and deflate plastic sleeves wrapped around the legs to promote venous flow.

"A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? "A. "The tube will drain fluid from your chest." B. "The tube will remove excess air from your chest." C. "The tube controls the amount of air that enters your chest." D. The tube will seal the hole in your lung.""

Answer B. The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.

"Which of the following preoperative patients likely faces the greatest risk of bleeding as a result of their medication? "a. A woman who takes metoprolol (Lopressor) for the treatment of hypertension b. a man whose type 1 diabetes is controlled with insulin injections four times daily c. a man who is taking copidogrel (Plavix) after the placement of a coronary artery stent d. a man who recently started taking finasteride (Proscar) for the treatment of benign prostatic hyperplasia"

Answer C: Any drug that inhibits platelet aggregation, such as clopidogrel (Plavix), represents a bleeding risk. Insulin, metoprolol (Lopressor), and finasteride (Proscar) are less likely to contribute to a risk for bleeding.

During preparation for bowel surgery, a male client receives an antibiotic to reduce intestinal bacteria. Antibiotic therapy may interfere with synthesis of which vitamin and may lead to hypoprothrombinemia? "a. vitamin A b. vitamin D c. vitamin E d. vitamin K

Answer D. Intestinal bacteria synthesize such nutritional substances as vitamin K, thiamine, riboflavin, vitamin B12, folic acid, biotin, and nicotinic acid. Therefore, antibiotic therapy may interfere with synthesis of these substances, including vitamin K. Intestinal bacteria don't synthesize vitamins A, D, or E.

"Which of the following is the primary reason for accurately recording the patient's current medications during a preoperative assessment? "A. Some medications may alter the patient's perceptions about surgery. B. Many anesthetics alter renal and hepatic function, causing toxicity of other drugs. C. Some medications may interact with anesthetics, altering the potency and effect of the drugs. D. Routine medications are withheld the day of surgery, requiring dosage and schedule adjustments after surgery."

Answer, C, Drug interactions may occur between prescribed medications and anesthetic agents used during surgery. For this reason, it is important to take a careful medication history and check that they have been communicated to the anesthesia care provider.

Lydia is scheduled for elective splenectomy. Before the clients goes to surgery, the nurse in charge final assessment would be: "a. signed consent b. vital signs c. name band d. empty bladder"

B, VS: An elective procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs are the final check that must be completed before the client leaves the room so that continuity of care and assessment is provided for.

Which client statement demonstrates positive progress toward recovery from substance abuse? A) "I have completed detox and therefore am in control of my drug use." B) "I will faithfully attend Narcotic Anonymous (NA) when I can't control my carvings." C) "As a church deacon, my focus will now be on spiritual renewal." D) "Taking those pills got out of control. It cost me my job, marriage, and children."

Correct Answer: D --- clients who takes responsibility for the consequences of substance abuse/dependence is making positive progress toward recovery. This client would most likely be in the working phase of the counseling process in which acceptance of the fact that substance abuse causes problems occurs.

"Mary received AtropineSO4 as a pre-medication 30 minutes ago and is now complaining of dry mouth and her PR is higher, than before the medication was administered. "A. The patient is having an allergic reaction to the drug. B. The patient needs a higher dose of this drug C. This is normal side-effect of AtSO4 D. The patient is anxious about upcoming surgery"

C Atropine lowers body fluid in throat and mouth pre-surgery

5.) Which of the following nursing actionsshould be given highest priority whenadmitting the patient into the operatingroom? A.) Level of consciousness B.) Vital signs C.) Patient identification and correctoperative consent D.) Positioning and skin preparation

C.) Patient identification and correctoperative consent

"A client is to have NPO for at least 12 hrs before surgery that same day. A nurse learns the client has half a glass of orange juice 3hr prior to admission. The nurse should... "A: Report the incident to the nursing supervisor. B: Inform the surgery department. C: Notify the anesthesiologist. D: Reschedule the surgery."

C: Notify the anesthesiologist. Restriction of fluids and food is designed to minimize the potential risk of aspiration and to decrease the risk of postoperative nausea and vomiting. A client who has not followed this instruction may have surgery delayed of cancelled.

A 20 year old female client who tried lysergic acid diethylamide (LSD) as a teen tells the nurse that she has had bad dreams that make her want to kill herself. Which is the explanation for this occurence? A. These occurences are referred to as hold-over reactions to the drugs. B. These are flashbacks to a time of a "bad trip". C. The drug is still in the body and causing these reactions. D. The client is suicidal and should be on one-to-one precautions.

CORRECT ANSWER: BA. These reactons are called "flashbacks" B. Flashback reactions occur after the use of hallucinogens in which the client relives a bad episode that occurred while using the drug. C. The drug is gone from the body, but the mind-altering effects can occur at any time in the form of memory flashbacks. D. The client stated that the dreams are causing her distress. She is asking for help with the dreams, not planning her suicide.

"An 85-year-old woman with a hip fracture is scheduled for surgery. She has Alzheimer's disease and is only oriented to her name. Which of the following should the nurse look for on the informed consent? "a. The patient's mark witnessed by the surgeon. b. The patient's explanation of the operative procedure. c. A signature of a person who has legal guardianship of the patient. d. The surgeon's note stating that the surgery was explained to the patient.

Correct answer is c"Rationale: If the patient is mentally incompetent to sign the permit for surgery, then written permission may be given by a legally appointed representative or responsible family member.

A nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal. Which of the following would alert the nurse to the potential for withdrawal delirium? 1. Hypotension, ataxia, hunger 2. Stupor, agitation, muscular rigidity, 3. hypotension, coarse hand tremors, aitation 4. hypertension, changes in level of consciousness, hallucinations

Correct answer=4. Rationale: Symptoms associated with withdrawal delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions.

The nurse would expect a cocaine overdose in a patient who is experiencing a. craving, restlessness, irritability b. agitation, cardiac dysrhythmia, and seizures c. diarrhea, nausea and vomiting, and confusion d. slow, shallow respirations, hyporeflexia and blurred vision" "a. craving, restlessness, irritability

Correct, B = agitation, cardiac dysrhythmia and seizures "a. Acute overdose of cocaine does not include cravings as a symptom b. Cocaine is a stimulant and will result in psychological, cardiac and neurological problems c. Cocaine typically does not have adverse GI effects d. These are symptoms of alcohol overdose."

According to psychological theorists, personality traits associated with drug abuse include: 1. difficulty dealing with intimacy 2. poor impulse control 3. low self-esteem 4. narcisstic behavior 5. introverted personality

Correct: 3, 4, 2, 1"Rationale: 1. Low self-esteem. Clients have a diminished sense of self-worth and value. Alcohol can numb these feelings and clients perceives themselves as more social, more relaxed, and enjoying life more. 2. Difficulty dealing with intimacy. The client may feel inadequate, insecure, and have low self-esteem. Personal intimacy threatens the alcoholic's sense of self. Alcohol is thought to be an avenue to alleviate anxiety and feelings of inadequacy. 3. Introverted personality: Behavioral traits associated with substance abuse include overt extroversion, not introversion. 4. Poor impulse control. The need for immediate gratification can drive alcohol and drug abuse, which is perceived by the client as a path to feel good immediately. 5. Narcissistic behaviors. The narcissistic person tends to feel unique or superior to others and is in control of the situation, including behaviors involving substance consumption. Cognitive Level: Application Client Need: Psychological Integrity Nursing Process: Assessment Learning Outcome: Discuss the major theoretic explanations for substance-related disorders."

A nurse is conducting preoperative teaching with a client about the use of incentive spirometer. The nurse should include which piece of information in discussions with the client? A. Inhale as rapidly as possible. B. Keep a loose seal between the lips and mouth piece. C. After maximum inspiration, hold teh breath for 15 seconds and exhale. D. The best results are achieved when sitting up or with the head of the bed elevated 45-90 degrees.

D is correct, must be in high fowler's position for optimal lung expansion. The mouthpiece should be covered tightly and breath holds for 5 seconds.

"The wife of the client diagnosed with chronic alcoholism tells the nurse, ""I have to call his work just about every Monday to let them know he is ill or he will lose his job."" Which would be the nurse's best response? "A. ""I'm sure that this must be hard for you. Tell me about your concerns."" B. ""You are afraid he will lose his source of income."" C. ""Why would you call in for your husband? Can't he do this?"" D. ""Are you aware that when you do this your are enabling him?""

D. ""Are you aware that when you do this your are enabling him?"" "A and B. These are therapeutic responses. The spouse is not expressing feelings but is stating a fact. The nurse should address the problem. C. The spouse is not required to give an explanation to the nurse. D. The spouse's behavior is enabling the client to continue to drink until he cannot function."

The nurse assesses a preoperative client. Which question should the nurse ask the client, to help determine the client's risk for developing malignant hyperthermia in the periperative period? A. Have you ever had heat exhaustion or heat stroke? B. What is the normal range for you body temperature? C. Do you or any of your family members have frequent infections? D. Do you or any of your family members have problems with anesthesia?

D. Do you or any of your family members have problems with anesthesia? Malignat hyperthermia is a genetic disorder in which a combination of anesthetic agents triggers uncontrolled skeletal muscle contractions that lead to a potentially fatal hyperthermia. Questioning the client about family history of general anesthesia problems reveal this as a risk for the client. Options A, B, and C are unrelated to this surgical complication.

A patient is scheduled for a laparoscopic cholecystectomy at an ambulatory surgery center. What do you expect? "A. Curative surgery for cancer of the pancreas. B. Palliative surgery for a resection of a tumor. C. Surgery with small incisions for removal of the liver. D. Removal of the gallbladder using a minimally invasive technique.

D: Most surgical procedures are being performed as ambulatory surgery (also called same-day or outpatient surgery). Many of these operations use minimally invasive techniques (e.g., laparoscopic techniques). Cholecystectomy is removal of the gallbladder.

"A 65 year old man has been admitted to the hospital for spinal stenosis surgery. When does the discharge training and planning begin for this patient? "A: Following surgery B: Upon admit C: Within 48 hours of discharge D: Preoperative discussion"

Discharge planning for any surgery begins upon admit.

"The client presents in the emergency room with constricted pupils, slurred speech, drowsiness, and respirations of 8/min. The person who accompanied the client to the emergency room reports the client had taken an unknown quantity of meperidine (Demerol) tablets 30 minutes earlier. Which medication should the nurse anticipate giving the client?" "Methadone Phenytoin (Dilantin) Naloxone (Narcan) Diazepam (Valium)

Naloxone (Narcan)

During the preoperative interview the nurse obtains information about the client's medication history. Which of the following is not necessary to record about the client? 1) Current use of medications, herbs, and vitamins. 2) Over the counter medication use in the last 6 weeks. 3) Steroid use in the last year. 4) Use of all drugs taken in the last 18 months.

The nurse does not need to ask about all drugs used in the last 18 months unless the client is still taking them. The nurse does need to know all drugs the client is currently taking, including herbs and vitamins, over the counter medications such as aspirin taken in the past 6 weeks, the amount of alcohol consumed, and illegal use of drugs, because these can interfere with the anesthetic and analgesic agents. Steroid use is of concern because it can suppress the adrenal cortex for up to 1 year, and supplemental steroids may need to be administered in times of stress such as surgery.

"35. The nurse provides a referral to Alcoholics Anonymous to a client who describes a 20-year history of alcohol abuse. The primary function of this group is to: "a. Encourage the use of a 12-step program. b. Help members maintain sobriety. c. Provide fellowship among members. d. Teach positive coping mechanisms."

The primary purpose of Alcoholics Anonymous is to help members achieve and maintain sobriety. Although each of the remaining answer choices may be an outcome of attendance at Alcoholics Anonymous, the primary purpose is directed toward sobriety of members.

"Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks the nurse to get up to go to the bathroom to urinate. Which of the following is the most appropriate action for the nurse to take? "A.) Assist patient to bathroom and stay next to door to assist patient back to bed when done. B. Allow patient to go to the bathroom since the onset of the medication will be more than 5 minutes. C. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety. D. Ask patient to hold the urine for a short period of time since a urinary catheter will be placed in the operating room."

The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance.

A nurse has just reassessed the condition of a postoperative patient admitted to the surgical unit 1 hour ago. The nurse plans to monitor which of the following parameters most carefully during the next hour? 1. urinary output of 20 ml/hr 2. Temperature of 37.6 Celsius 3. Blood Pressure of 100/70 mmhg 4. Serous drainage of the surgical dressing

Urine output should be maintained at a minimum of 30 ml/hr for an adult. An output of less than 30ml/hr for each consecutive 2 hours should be reported to a physician.

A nurse is developing a plan of care for a client scheduled for surgery The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Have the client void immediately before going into surgery 2. Avoid oral hygiene and rinsign with mouthwash 3. Verify that the client has not eaten for the last 24 hours 4. Report immediately any slight increase in blood pressure or pulse.

answer #1The nurse would assist the client to void immediately before surgery so that the bladder will be empty. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety. The client usually has a restriction of food and fluids for 6 to 8 hours before surgery instead of 24 hours. Oral hygeine is allowed, but the client should not swallow any water.

"A preoperative client expresses anxiety to a nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? "a) ""If its any help, everyone is nervous before surgery"" b) ""I will be happy to explain the entire surgical procedure to you"" c) ""Can you share with me what you've been told about your surgery?"" d) ""Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate"""

c) ""Can you share with me what you've been told about your surgery?""Explanations should begin with the info the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assit the client in handling anxiety and fear for a smooth preoperative experience. Clients who are clam and emotionally prepared for surgery withstand anesthesia better and experience fewer postop complications. Options a, b, and d will produce anxiety in the patient.

"A pre-operative nurse prepares a client for surgery, which nursing interventions should be included in the plan of care? Mark all that apply. "a. Maintain NPO status to prevent aspiration. b. Verify the client's signature on the consent prior to surgery. c. Remove dentures and contact lenses prior to surgery. d. Check the client's allergy and blood bands for accuracy. e. Verify the client's mobility in all extremities prior to surgery.

correct answers: a,b,c,d"Maintaining NPO prevents the client from aspirating food particles into the lungs during and after surgery. Because of legal requirements, the surgical consent must be signed prior to surgery to verify the client's acknowledgement of the content on the consent. Dentures, hairpins, glasses, and contacts may interfere with client safety, or compromise the sterile field. Allergy, blood, and identification bands should all be checked prior to surgery to prevent medication errors, blood bank errors, and to facilitate proper identification of the client. Verifying the client's mobility in all extremities prior to surgery is part of the physical assessment, but not a necessary action prior to surgery.

A nurse is preparing a plan of care for a client who is a Jehovah's Witness. The client has been told that the surgery is necessary. The nurse considers the client's religious preferences in developing the plan of care and documents that: a) faith healing is practiced primarily b) medication administration is not allowed c) surgery is prohibited in this religious group d) the administration of blood and blood products is forbidden"

d) the administration of blood and blood products is forbidden Among Jehovah's Witnesses, surgery is not prohibited, but the administration of blood and blood products is forbidden. Faith healing is forbidden in this religious group. Administration of medication is an acceptable practice, except if the medication is derived from blood products.

"While assessing a patient preoperatively, the nurse notices a history of latex allergy. Which of the following would be an appropriate intervention? "a. Notify the surgeon so that the case can be canceled b. Give the patient antihistamines to prevent anaphylactic shock c. Question the patient about how his or her latex allergy developed d. Notify the operating room staff so that latex-free supplies will be used

d. Notify the operating room staff so that latex-free supplies will be used Rationale: Latex precaution protocols should be used for patients identified as having a positive latex allergy test result or a history of signs and symptoms related to latex exposure. Many health care facilities have created latex-free product carts that can be used for patients with latex allergies.

A 77-year-old client with a history of COPD has undergone a hernia repair. Which of the following expected outcomes should be the priority focus for the nurse? " a.The client ambulates 10 feet with assistance. b.The client tolerates a clear liquid diet. c.The client rates his pain as 2 to 3 on a 10-point scale. d.The client has normal auscultated breath sounds"

d: client has normal breath sounds, is the the biggest priority after major surgery

the client just had surgery to create an ileostomy. the nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? "1. folate deficiency 2. malabsorption of fat 3. intestinal obstruction 4. fluid and electrolyte imbalance

fluid and electrolyte imbalancea frequent compliction that occurs following ileostomy is fluid and electrolyte imbalance. the client requires constant monitoring of intake and output to prevent this from occurring. losses require replacement by IV infusion until the client can tolerate a diet orally. intestinal obstruction is a less common complication. fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.