Prep U/Med Surg 1
Which would be included as a responsibility of the scrub nurse?
Handing instruments to the surgeon and assistants
For individuals known to be dying by virtue of age and/or diagnosis, which sign indicates approaching death?
Increased restlessness
A client is scheduled for a test that requires an NPO status and has been ordered 5% dextrose in water (D5W). The nurse understands which of the following to be the best rationale for this action?
Isotonic solutions maintain body fluid balance.
Which of the following statements describes a teaching plan?
It facilitates reaching goals.
A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. Which of the following is an accurate guideline for IV management that the nurse should consider?
It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order.
A client, who had an above the knee amputation of the left leg related to peripheral vascular disease from uncontrolled diabetes, complains of pain in the left lower extremity. What type of pain is the client experiencing?
Neuropathic pain
A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium concentration is 7.6 mg/dL (1.9 mmol/L). Which physical examination finding is consistent with this electrolyte imbalance?
Presence of Trousseau sign
A client informs the nurse that he "thinks she is getting sick." The chief complaints of the client are low-grade fever, headache, and "has no energy." What stage of the infection does the nurse recognize the client is experiencing?
Prodromal stage
The nurse is preparing to administer a blood transfusion to a client and plans to spend the first 15 minutes of the transfusion with the client observing for what manifestations of an incompatibility transfusion reaction?
Rapid pulse Back pain
On the advice of friends, a patient on a palliative care unit has requested acupuncture. What it is the goal of this form of CAT?
Restoring a healthy flow of energy along the meridians of the body
The decision to order an opioid dosage for an elderly patient that is slightly smaller than the dose of medication prescribed for younger patients is based on the following physiologic reason:
Susceptibility to respiratory system depression is lowered.
The nurse is caring for a client with a stage IV leg ulcer. The nurse is closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that the nurse should notify the physician of immediately?
The client's heart rate is greater than 90 beats/minute.
The nurse is assessing a patient's pain. The patient is tearful, hesitant to move, and grimacing. When asked, the patient rates the pain as a two at this time using a zero-to-ten pain scale. What conclusion would be most accurate?
The nurse should reinforce teaching about the pain scale number system.
A client is taking ginkgo to improve her memory. In the teaching plan regarding this herb, the nurse should include which of the following?
Use caution if taking aspirin.
An older adult client has been diagnosed with Legionella infection. When planning this client's care, the nurse should prioritize which of the following nursing actions?
Vigilant monitoring of respiratory status
The nurse is caring for a client with secondary syphilis. What intervention should the nurse institute when caring for this client?
Wear gloves if contact with lesions is possible
A client with ascites is receiving TPN until the condition clears. IV lipid emulsions would be contraindicated in a client with which condition?
egg allergy
The nurse is providing information about warfarin (Coumadin) to a client who takes herbal products. The nurse states, "Some herbs interfere with the effectiveness of warfarin. Do you take
ginkgo biloba
A home healthcare client who is in a coma requires extended IV fluid therapy. Which peripheral access device would be most appropriate for administering this therapy?
midline catheter
A client insists that one can laugh their way to health. The client devotes 30 minutes per day reading funny stories or jokes and indicates having practiced this ritual for forty years. What type of CAM modality is the client using?
mind-body medicine
The nurse assesses a client to determine if there is increased risk for complications intraoperatively or postoperatively. Which are general risk factors?
nutritional status, age, physical condition, health status
A client is diagnosed with hypocalcemia and the nurse is teaching the client about symptoms. What symptom would the nurse include in the teaching?
tingling sensation in the fingers
Which is the best thing the nurse can do to provide culturally sensitive care?
Accept each client as a unique individual.
A client is in a hospice receiving palliative care for lung cancer which has metastasized to the client's liver and bones. For the past several hours, the client has been experiencing dyspnea. What nursing action is most appropriate?
Administer bronchodilators and corticosteroids, as prescribed.
A patient has a wound that has hemorrhaged. What does the nurse understand is the cause of the patient's increased risk of infection?
Dead space and dead cells provide a culture medium
A hospice nurse is well aware of how difficult it is to deal with others' pain on a daily basis. This nurse should put healthy practices into place to guard against what outcome?
Emotional exhaustion
The daughter of a hospital patient has informed the care team of her desire to have a homeopathic practitioner come to the bedside and administer treatment. The nurse should anticipate that the practitioner will likely:
administer minute amounts of substances that are known to cause symptoms in healthy people.