Unit 1 Adult Health

A patient tells you as you prepare to start his IV line for surgery that he has hard veins to find and that people always miss his veins. The best response by the nurse is what?

I sense that you are worried about being stuck repeatedly for an IV. I will ask someone to help me if i miss

Postoperative care for a patient who has had a craniotomy is typically handled in which PACU unit

ICU

An example of an acceptable time out is:

Name, birthday, and procedure including site

The nurse understands the immediate post op assessment upon admission to the PACU includes which of the following

Neurological assessment, blood pressure, site drainage

Which pain management approach is best for Mrs J?

Nsaids and opioid medications, cold application to the back, supported ambulation and distraction

The nurse should be prepared to administer what IV solution to someone that has injuries sustained in a motor vehicle accident?

0.9% normal saline

A patient is ordered to receive a blood transfusion because of anemia. What is the recommended minimum gauge of the IV catheter to adminster blood?

20 gauge

A patient is admitted with osteomyelitis and is going to require 3-4 weeks of IV antibiotics. Which IVAD is most appropriate for this patient?

20 gauge midline catheter

In order to deliver 0.9 NS at 125 mL/hr, the nurse has selected an infusion set with a drop factor of 15 gtts/mL. What is the correct drop rate required to deliver this volume?

31 gtts/min. 125 mL/ 1 hr * 1 hr/ 60 min * 15 gtt/1 mL

Which of the following patients presents the greatest risk for a negative response to anesthesia?

A 29 y.o. female with a history of stage 2 acute renal failure

What clinical manifestations can the nurse use to indicate the level of Mrs. J's pain on the AM assessment?

A subjective report of 6/10 pain, shallow guarded breathing, short terse resonses to questions, nurse reports she had poor overnight sleep and reduced participation in supported ambulation, facial grimacing and observed rubbing of lower back and legs by patient

In assessing a patient's pain, the nurse asks the patient, "What makes the pain worse?" Which aspect of pain is the nurse determining?

Aggravating factors

On assessing jason's central line, the nurse notes that the luer lock on one of the lumens is not tight and recognizes that this places him at risk for what complication?

Air embolism

Which statement is true about the complicated nature of managing pain medication in the immediate postanesthesia patient?

All patients respond to pain in different ways, potentially requiring different medications

The preoperative nurse receives her patient posting for the day. There are four 0800 cases in the hospital's OR. Which patient is a priority based on extent of preoperative care needed?

An 80 year old male scheduled for a bowel resection with history of DVTs, chronic hypertension and smoking

What interventions can the nurse implement to prevent surgical site infections?

Appropriate surgical site hair removal before surgery, maintaining glycemic control, maintain body temp. proper maintenance of sterile field

You are preparing a patient for surgery and have asked her to verify her information on her patient identification band. She tells you that the birth date is incorrect on her ID band. Most appropriate action at this time is what?

Ask admissions office to please send a corrected ID band

Maria expresses her anxiety about her procedure and anesthesia to her nurse. The most appropriate response is:

Assure her that her fears are normal and encourage her to use her consultation time with the surgeon and anesthesiologist to address her concerns

The nurse anticipates which fluid movement when administering an isotonic IV fluid to a patient

Causes no or equal movement of fluid into or out of cells

Shortly later, mr. wells becomes restless and his heart rate goes up to 100. As the nurse assesses him, the priority assessment should include which interventions?

Check dressing and drains for bleeding, check breathing and o2 sat, check pain and comfort level, check BP and fluid volume status

The PACU nurse understands the first priority for patients upon admission to the PACU is which?

Checking vital signs and neurological status

Which statement is true regarding discharge instructions?

Discharge teaching should always be done with the patient and a family member present

The nurse identifies which vein as the most appropriate for placement of a peripheral IVAD to begin infusion therapy?

Dorsal -- the hand. Start in the most distal available and appropriate vein.

what is an important responsibility of Maria's nurse before the procedure

Ensure completion of the preop assessment

During the initial assessment and admission questions, the nurse asks maria for the time of her last oral intake. The patient replies, " I had dinner last night at 8 but i took a few sips of water this morning with my vitamins" The nurses best response is what?

Explain that a sip of water should not be a problem but the vitamins might be. Pass info on to the anesthesiologist

The nurse understands which of the following is true about family support in the PACU setting?

Familys are allowed to visit but not recommended

The nurse understands which is the result of administering hypertonic solutions?

Fluid shifts from the intracellular space into the intravascular space

The nurse recognizes the prevention of which complication as the primary rationale for initiating total parenteral nutrition at a slow rate?

Hyperglycemia. Due to the high amount of dextrose

The nurse understands which actions are essential when providing support to the intraoperative patient and family during the OR experience?

Give updates every 2 hours, explain what to expect from the operative experience

Initially upon admission, mr. wells remains sleepy and hard to arouse. The PACU nurse anticipates an order for which laboratory test?

Glucose level

The nurse should report the following findings from a patient's history as an increased risk for DVTs postoperatively

History of smoking, History of DVTs, Borderline hypertension

What is the best physiological explanation of why Mrs J may be experiencing chronic back pain?

Hyperexcited neurons at the time of injury created new pathologic synaptic connections that persist

The nurse realizes which central access device has the least effect on a person's self-image?

Implanted port

How should assessment findings of blanched cool skin and leaking fluid at a peripheral infusion site be documented?

Infiltration

The nurse understands that a patient undergoing right upper lobe lobectomy requiring general anesthesia will be recovered in which of the following settings?

Inpatient PACU

What is the rationale for using ketorolac as the preferred NSAID to treat Mrs. J?

It targets both prostaglandins and leukotrienes

Which of the following is an airway used to support airway management

LMA and ETT

Which of the following is an example of a local anesthetic?

Lidocaine

The nurse understands PACUs are designed for which of the following

Managing the transition from anesthesia through phase 2 of recovery

Maria is allergic to latex. What is the appropriate action to prevent an allergic reaction in the patient who is having surgery?

Maria should be the first case of the day and only non latex items used

The nurse correlates Mrs. J's clinical presentation to which type of pain?

Mixed acute and chronic pain

To prevent circulatory complications in the immediate postop period for a patient who has had an exploratory laparotomy, which nursing action is of highest priority?

Monitoring vital signs every hour until stable

The nurse recognizes that the incidence of pain is greatest in which patient population?

Older patients who are institutionalized

The nurse incorporates which content in the teaching plan for the patient receiving coumadin?

Over the counter NSAIDs may increase the anticoagulation effect of coumadin

The nurse recognizes which patient may need infusion therapy?

Patient who sustained trauma presenting to the emergency department. Patient with cancer receiving parenteral chemotherapy.

When planning discharge education for a 65 year old male who is having a hip replacement, it is appropriate for the nurse to consider what?

Patients resources at home for completing ADLs, stairs in the home, transportation access, number of bathrooms in the home

The nurse recognizes multiple units of packed RBCs are received for blood loss after a motor vehicle accident did not contain clotting factors and anticipates which blood component may be required?

Plasma

Into which port of his triple lumen CVAD can the nurse infuse the next dose of antibiotics?

Port where PCA is attached, port that is saline locked or port with NS infusing

The nurse recognizes that education for patients receiving infusion therapy should include which information?

Precautions for preventing infection, signs and symptoms to report, purpose of infusion therapy.

The nurse understands surgical attire is worn to :

Prevent transmission of microorganisms between the patient and the team

Proper informed consent includes the following:

Procedure name, reason for surgery, consent to administer blood products, alternatives to surgery

The trendelenburg position is used for which type of procedures

Procedures on the lower abdomen and pelvis

What is a common IV anesthetic

Propofol

The nurse correlates which findings to the pathophysiology of chronic malignant pain?

Rapidly dividing cells. -- Associated with cancer growth, causes severe pain

In preparing an in service about pain management, the nurse includes which finding as the most serious adverse effect of opioids?

Respiratory depression

The nurse caring for a patient in the supine position on the OR table incorporates which nursing diagnosis into the plan of care?

Risk for aspiration

Before administering pain meds to mr wells, the nurses assessments include which of the following?

Sedation level, self report of pain, vital signs

The nurse recommends treatment with transdermal fentanyl for which patient?

Severe pain due to cancer metastasis to bone

Potential adverse effects of Ms D being placed in the supine position for her surgery include?

Skin breakdown, venous pooling in legs, ulnar nerve injury

The nurse recognizes teaching has been effective by which of the following statements?

So that IV line will stay in throughout the procedure?

If a hemolytic transfusion reaction is suspected, what is the nurse's priority action?

Stop the transfusion but maintain the infusion with 0.9 NS

If Ms D indicates there is a family history of problems with anesthesia, it is important to discuss this with the anesthesia provider in order to avoid the use of which MH triggering agent?

Succinylcholine

A five year old patient will be returning home after surgery for a right inguinal hernia repair. Which of the following is an important teaching need before the child and family leave the hospital?

Teach the family how to use the facial pain scale to ensure that the child gets pain medication as needed

Maria's surgeon has asked that TED hose be placed on the patient before surgery as well as sequential compression devices on both legs to the knees. Maria asks the nurse what they will do for her. Which response by the nurse is most appropriate?

They complement each other to prevent blood from backing up into your legs and causing DVT due to you not moving during the surgery

The nurse recognizes the presence of pain, redness, and streak formation at the site of a peripheral IV site as what grade of phlebitis?

Three. 1- redness with or without pain 2- pain with redness and/ or edema 3- pain with redness, streak formation and/ or palpable cord 4- pain with redness, streak, palpable cord and/or purulent drainage

The nurse recognizes that the primary indication for the administration of an opioid medication is which outcome?

To relieve pain

The nurse closely monitors the patient receiving morphine and a TCA for which medication interaction?

Urinary retention

What is the rationale for placing a nontunneled percutaneous central catheter

Used for urgent need for fluid and medication administration

The nurse chooses which pain scale to most effectively assess pain in the older patient with limited vision?

Verbal scale- use descriptive words

The OR nurse is completing a perioperative assessment for a patient who is scheduled for exploratory surgery. Which of the following interventions must be completed prior to going to the OR?

Verify operative consent was signed, assure allergy and ID bands are on, Removal of personal items, determine advance directive is in place, validate completed patient history and physical exam, Determine NPO status

Progression of recovery from a surgical procedure through phase 2 includes which of the following?

Vital signs returning to preoperative state, recovery of reflexes and motor control, patient awake and oriented, patient meeting discharge criteria

What is one airway complication that can occur when the patient is receiving anesthesia care?

aspiration

Upon patient admission to the PACU, the nurse understands the priority intervention is which of the following?

connect patient to the monitor

Prior to the start of Ms D's surgical procedure, all members of the surgical team participate in a time out. Which of the following are components of the time out?

correct procedure, site and equipment

The PACU nurse supports mr wells family by doing which of the following?

inform family when patient arrives to PACU, allow visitation as safety and privacy allows, provide frequent updates.

Because of maria's smoking history, the nurse understands she is at great risk for what?

respiratory depression, increased healing time, DVT

Which of the following is the identified leader of the surgical team?

the surgeon

Extended observation care is provided under what circumstance

the transfer bed is not ready

While Ms D is in the OR, what considerations will be taken to ensure her safety and positive outcome?

time out, maintain sterile technique, continuous patient monitoring, instrument count, sponge count

The initial assessment including attaching the patient to the cardiac monitor should be completed in what time frame after admission to the pacu

within five minutes