Adult Health #3
A nurse on the postoperative inpatient unit receives a hand-off report on four clients using patient-controlled analgesia (PCA) pumps. Which client should the nurse see first?
Client with a respiratory rate of 8 breaths/min
What actions by the circulating nurse are important to promote client comfort? (Select all that apply.)
Correct positioning Introducing ones self Remaining present Providing warmth
. A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.)
Phase I care may last for several days in some clients. Phase II ends when the client is stable and awake. Vital signs may be taken only once a day in phase III.
A hospitalized client uses a transdermal fentanyl (Duragesic) patch for chronic pain. What action by the nurse is most important for client safety?
Remove the old patch when applying the new one.
12. A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best?
c. Give the client a bedpan or urinal to use.
A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first?
Perform hand hygiene and apply gloves.
A nurse is caring for a postoperative client who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort?
Assist the client into a position of comfort.
A client with a broken arm has had ice placed on it for 20 minutes. A short time after the ice was removed, the client reports that the effect has worn off and requests pain medication, which cannot be given yet. What actions by the nurse are most appropriate? (Select all that apply.)
Educate the client on cold therapy. Repeat the ice application Teach the client relaxation techniques.
The nursing student observing in the perioperative area notes the unique functions of the circulating nurse, which include which roles? (Select all that apply.)
Ensuring the clients safety Monitoring traffic in the room
A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the clients bed. The clients blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the nurse is best?
Lower the head of the bed.
Ten hours after surgery, a postoperative client reports that the antiembolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best?
To prevent blood clots you need them a few more hours.
11. A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority for this client?
Metoclopramide (Reglan)
A faculty member explains to students the process by which pain is perceived by the client. Which processes does the faculty member include in the discussion? (Select all that apply.)
Modulation Sensory perception Transduction Transmission
A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered at high risk? (Select all that apply.)
Morbidly obese client Client who underwent a prolonged surgical procedure Client with severe heart failure Wheelchair-bound client
A nursing student is studying pain sources. Which statements accurately describe different types of pain? (Select all that apply.)
Neuropathic pain sometimes accompanies amputation . Deep somatic pain is pain arising from bone and connective tissues Somatic pain originates from skin and subcutaneous tissues Visceral pain is often diffuse and poorly localized.
A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care?
Older adult who lives at home despite some memory loss
A student nurse asks why several clients are getting more than one type of pain medication instead of very high doses of one medication. What response by the registered nurse is best?
Pain is so complex it takes different approaches to control it.
A postoperative client has an epidural infusion of morphine and bupivacaine (Marcaine). What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
Perform a bladder scan if the client is unable to void after 4 hours Remind the client to use the incentive spirometer every hour Take and record the clients vital signs per agency protocol.
A comprehensive pain assessment includes the items listed in the question plus the clients opinion on a functional goal, such as what pain rating would be acceptable to him or her. Asking about addiction is not warranted in an initial pain assessment. Asking about spiritual meanings for pain may give the nurse important information, but getting the basics first is more important. Asking about pain tolerance may give the client the idea that pain tolerance is being judged.
Sit down, ask one question at a time, and allow the client to answer.
An older adult has been transferred to the postoperative inpatient unit after surgery. The family is concerned that the client is not waking up quickly and states She needs to get back to her old self! What response by the nurse is best?
Sometimes older people take longer to wake up.
A nurse is preparing to give a client ketorolac (Toradol) intravenously for pain. Which assessment findings would lead the nurse to consult with the provider?
Urine output of 20 mL/2 hr
A nurse is preparing a client for discharge after surgery. The client needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important?
Wash your hands before touching the drain or dressing.
The nurse is assessing a clients pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. What question by the nurse would be best to ask the client for
What pain rating would be acceptable to you?
13. A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta blocker to the client. The student asks why this was needed. What response by the nurse is best?
a. A rapid heart rate requires more effort by the heart.
A client in the operating room has developed malignant hyperthermia. The clients potassium is 6.5 mEq/L. What action by the nurse takes priority?
a. Administer 10 units of regular insulin.
17. A client has been given hydroxyzine (Atarax) in the preoperative holding area. What action by the nurse is most important for this client?
b. Raise the siderails on the bed.
A nurse is caring for four clients receiving pain medication. After the hand-off report, which client should the nurse see first?
Client with a Pasero Scale score of 4
10. A client waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)?
b. Give the client a back rub.
1. A client has arrived in the postoperative unit. What action by the circulating nurse takes priority?
d. Participating in hand-off report
A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate?
Be sure to wash the area where you will have surgery very thoroughly.
The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first?
c. Client with a respiratory rate of 6 breaths/min
A faculty member explains the concepts of addiction, tolerance, and dependence to students. Which information is accurate? (Select all that apply.)
Addiction is a chronic physiologic disease process.Tolerance is a normal response to regular opioid use Tolerance is said to occur when opioid effects decrease.
A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority?
Airway
A nurse is admitting an older client for surgery to the inpatient surgical unit. The client relates a prior history of acute confusion after a previous operation. What interventions does the nurse include on the clients plan of care to minimize the potential for this occurring? (Select all that apply.)
Allow family and friends to visit as the client desires. Ask the client about coping techniques frequently used. Instruct the nursing assistant to ensure the client is bathed Provide the client with uninterrupted periods of sleep.
A client has received an opioid analgesic for pain. The nurse assesses that the client has a Pasero Scale score of 3 and a respiratory rate of 7 shallow breaths/min. The clients oxygen saturation is 87%. What action should the nurse perform first?
Attempt to arouse the client.
A client is being discharged from the hospital after surgery on hydrocodone and acetaminophen (Lorcet). What discharge instruction is most important for this client?
Check any over-the-counter medications for acetaminophen.
A student nurse learns that there are physical consequences to unrelieved pain. Which factors are included in this problem? (Select all that apply.)
Decreased immune response Development of chronic pain Increased gastrointestinal (GI) motility Possible immobility Slower healing
A nurse is assessing pain on a confused older client who has difficulty with verbal expression. What pain assessment tool would the nurse choose for this assessment?
FACES Pain Scale-Revised
A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which IV-push medication and dose does the nurse prepare to administer?
Flumazenil (Romazicon) 0.2 to 1 mg
A nurse is caring for a client on an epidural patient-controlled analgesia (PCA) pump. What action by the nurse is most important to ensure client safety?
Have another nurse double-check the pump settings.
A nurse is caring for several clients prior to surgery. Which medications taken by the clients require the nurse to consult with the physician about their administration? (Select all that apply.)
Metformin (Glucophage) Phenytoin (Dilantin) Pilocarpine hydrochloride (Isopto Carpine) Warfarin (Coumadin)
A client has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important?
Place the client on a cardiac monitor and pulse oximeter.
A registered nurse (RN) and nursing student are caring for a client who is receiving pain medication via patient-controlled analgesia (PCA). What action by the student requires the RN to intervene?
Presses the button when the client cannot reach it
A client on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations of 24 breaths/min. The client denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection. What should the nurse assess next?
Psychosocial status
An older client who lives alone is being discharged on opioid analgesics. What action by the nurse is most important?
Request a home safety assessment.
A client who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. What intervention for pain management does the nurse include in the clients care plan?
Round-the-clock analgesia with PRN analgesics
A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN?
Securing the drains safety pin to the sheets
. A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team?
Use of multiple herbs and supplements
2. A nursing instructor is teaching students about different surgical procedures and their classifications. Which examples does the instructor include? (Select all that apply.)
Liver biopsy: diagnostic Total shoulder replacement: restorative
1. A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing? (Select all that apply.)
Infection Serious cardiac events Thromboembolism
An emergency department (ED) manager wishes to start offering clients nonpharmacologic pain control methodologies as an adjunct to medication. Which strategy would be most successful with this client population?
Listening to music on a headset
The circulating nurse reviews the days schedule and notes clients who are at higher risk of anesthetic overdose and other anesthesia-related complications. Which clients does this include? (Select all that apply.)
A 75-year-old client scheduled for an elective procedure Client who drinks a 6-pack of beer each day Client with a serum creatinine of 3.8 mg/dL Young male client with a RYR1 gene mutation
A student nurse is caring for clients on the postoperative unit. The student asks the registered nurse why malnutrition can lead to poor surgical outcomes. What responses by the nurse are best? (Select all that apply.)
A malnourished client will have fragile skin. Many drugs are bound to protein in the body. Many drugs are bound to protein in the body Weakness and fatigue are common in malnutrition.
A client is put on twice-daily acetaminophen (Tylenol) for osteoarthritis. What finding in the clients health history would lead the nurse to consult with the provider over the choice of medication?
Drinking 3 to 5 beers a day
An older adult has diabetic neuropathy and often reports unbearable foot pain. About which medication would the nurse plan to educate the client?
Duloxetine (Cymbalta)
A hospitalized client has a history of depression for which sertraline (Zoloft) is prescribed. The client also has a morphine allergy and a history of alcoholism. After surgery, several opioid analgesics are prescribed. Which one would the nurse choose?
Hydromorphone (Dilaudid)
A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort? (Select all that apply.)
Allow the client to assume a position of comfort. Allow the clients family to remain at the bedside. Provide warm blankets or cool washcloths as desired. Pull the curtains around the bed to provide privacy.
A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort interventions can the nurse provide? (Select all that apply.)
Apply stimulation to the contralateral leg Assess the clients willingness to try meditation Elevate the clients operative leg and apply ice Reduce the noise level in the clients environment
A postoperative client is reluctant to participate in physical therapy. What action by the nurse is best?
Ask the client about pain goals and if they are being met.
A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia. The client scores a zero. What action by the nurse is best?
Assess physiologic indicators and vital signs.
A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best?
Assess the client for anxiety.
A client is having shoulder surgery with regional anesthesia. What actions by the nurse are most important to enhance client safety related to this anesthesia? (Select all that apply.)
Assessing distal circulation to the operative arm after positioning Padding the clients shoulder and arm on the operating table
A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important?
Auscultate lung sounds.
A nurse on the postoperative unit administers many opioid analgesics. What actions by the nurse are best to prevent unwanted sedation as a complication of these medications? (Select all that apply.)
Avoid using other medications that cause sedation. Give the lowest dose that produces good control Identify clients at high risk for unwanted sedation Use an oximeter to monitor clients receiving analgesia.
A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. What response by the experienced nurse is best?
Being able to sleep doesnt mean pain doesnt exist.
The nurse receives a hand-off report. One client is described as a drug seeker who is obsessed with even tiny changes in physical condition and is on the light constantly asking for more pain medication. When assessing this clients pain, what statement or question by the nurse is most appropriate?
Help me understand how pain is affecting you right now.
A postoperative client is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the client? (Select all that apply.)
Check all over-the-counter medications for acetaminophen Do not take more pills each day than you are prescribed Eat a diet that is high in fiber and drink lots of water You shouldnt drive while you are taking this medication.
A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.)
Check that consent is on the chart. Ensure the client has an armband on. Have the client help mark the surgical site Allow the client to use the toilet before giving sedation.
A nurse on the medical-surgical unit has received a hand-off report. Which client should the nurse see first?
Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale
A student asks the nurse what is the best way to assess a clients pain. Which response by the nurse is best?
Clients self-report
A client reports a great deal of pain following a fairly minor operation. The surgeon leaves a prescription for the nurse to administer a placebo instead of pain medication. What actions by the nurse are most appropriate? (Select all that apply.)
Consult with the prescriber and voice objections. Notify the nurse manager of the physicians request.
A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.)
Hemoglobin: 7.8 mg/dL pH: 7.68 Potassium: 2.9 mEq/L
The nurse in the surgery clinic is discussing an upcoming surgical procedure with a client. What information provided by the nurse is most appropriate for the clients long-term outcome?
Discuss acceptable pain control after your operation with the surgeon.
A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.)
Disposing of dressings properly Performing proper hand hygiene Removing and replacing wet dressings
A student nurse observing in the operating room notes that the functions of the Certified Registered Nurse First Assistant (CRNFA) include which activities? (Select all that apply.)
Dressing the surgical wound Suctioning the surgical site Suturing the surgical wound
A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client?
a. Allow the client to keep hearing aids in until anesthesia begins.
16. A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming procedure. What action by the nurse is best?
a. Ask the client to describe current feelings.
A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%. What action by the nurse is most appropriate?
a. Assess other indicators of oxygenation.
6. A client is having surgery. The circulating nurse notes the clients oxygen saturation is 90% and the heart rate is 110 beats/min. What action by the nurse is best?
a. Assess the clients end-tidal carbon dioxide level.
14. The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best?
a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met.
An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment?
a. Change in behavior
15. A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best?
a. Consult the surgeon about a postoperative dietitian referral.
18. A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate?
a. Explain the rationale for giving the medicine now.
A client is scheduled for a below-the-knee amputation. The circulating nurse ensures the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate?
a. Facilitate marking the site with the client and surgeon.
6. An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best?
b. Do not have the client sign the consent and call the surgeon.
A client is having robotic surgery. The circulating nurse observes the instruments being inserted, then the surgeon appears to break scrub when going to the console and sitting down. What action by the nurse is best?
b. Document the time the robotic portion of the procedure begins.
5. A client is in stage 2 of general anesthesia. What action by the nurse is most important?
b. Being prepared to suction the airway
The circulating nurse and preoperative nurse are reviewing the chart of a client scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority?
b. Consent for MIS procedure only
A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best?
b. Demonstrate how to splint the incision.
19. A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best?
b. It helps prevent ulcers from the stress of the surgery.
A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met?
b. There is no redness, warmth, or drainage at the insertion site.
7. A nurse is monitoring a client after moderate sedation. The nurse documents the clients Ramsay Sedation Scale (RSS) score at 3. What action by the nurse is best?
c. Document findings and continue to monitor.
1. The circulating nurse is plugging in a piece of equipment and notes that the cord is frayed. What action by the nurse is best?
c. Get another piece of equipment.
4. The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate?
c. Inform the surgeon that the sterile field has been broken.
A circulating nurse wishes to provide emotional support to a client who was just transferred to the operating room. What action by the nurse would be best?
d. Remain with the client.
