CH 19 Practice Questions

A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition? A) The client is displaying early signs of shock. B) The client is showing signs of an anesthesia reaction. C) The client is showing signs of a medication reaction. D) The client is displaying late signs of shock.

A

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis? A) Ineffective thermoregulation B) Acute incisional pain C) Ineffective airway clearance D) Decreased cardiac output

A

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action? A) Position the client to maintain a patent airway. B) Monitor vital signs for early detection of shock. C) Administer antiemetics to prevent nausea and vomiting. D) Assess the incisional dressing to detect hemorrhage.

A

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? A) <30 mL B) Between 100 and 200 mL C) >200 mL D) Between 75 and 100 mL

A

What measurement should the nurse report to the physician in the immediate postoperative period? A) A systolic blood pressure lower than 90 mm Hg B) Respirations between 20 and 25 breaths/min C) A temperature reading between 97°F and 98°F D) A hemoglobin of 13.6

A

Which term refers to the protrusion of abdominal organs through the surgical incision? A) Evisceration B) Hernia C) Dehiscence D) Erythema

A

A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention? A) Educating the client on safe bed-to-chair transfer procedures B) Assessing WBC count, temperature, and wound appearance C) Obtaining dietary consultation for improved wound healing D) Administering pain medications within 1 hour of the client's request

B

A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for? A) Contractures B) Wound dehiscence C) Hypotension D) Phlebitis

B

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? A) Monitoring vital signs every 15 minutes B) Reinforcing the dressing or applying pressure if bleeding is frank C) Elevating the head of the bed D) Encouraging the client to breathe deeply

B

Which findings would be indicative of a nursing diagnosis of decreased cardiac output? A) bradycardia; urinary output < 30 ml; confusion B) tachycardia; hemoglobin 10.9 gm/dL; BP 88/56 C) urinary output > 60 ml; BP 90/60; tachypnea D) confusion; tachypnea; hemoglobin 14.2 gm/dL

B

The client asks the nurse about ways to control pain other than taking pain medication. Which strategy should the nurse include when responding to the client? Select all that apply. A) An epidural infusion B) Listening to music C) An On-Q pump D) Changing position E) Watching television

B D E

A patient who underwent abdominal surgery 3 hours ago has started to hemorrhage. The nurse would classify this type of hemorrhage has which of the following? A) Primary B) Secondary C) Intermediary D) Tertiary

C

A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage? A) The client has a nasogastric (NG) tube in place that drained 400 ml. B) The client has been lying on his side for 2 hours with the drain positioned upward. C) The Hemovac drain isn't compressed; instead it's fully expanded. D) There is a moderate amount of dry drainage on the outside of the dressing.

C

The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by: A) Third intention B) Granulation C) First intention D) Second intention

C

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue? A) Pink to red and soft, noting that it bleeds easily B) Pale yet able to blanch with digital pressure C) White with long, thin areas of scar tissue D) Necrotic and hard

A

A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound A) dehisced. B) pustulated. C) hemorrhaged. D) eviscerated.

A

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding? A) Evisceration B) Hernia C) Erythema D) Dehiscence

A

The nurse is concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus? A) Abdominal distention B) Increased abdominal girth C) Abdominal tightness D) Absence of peristalsis

D

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function? A) Upper endoscopy B) Complete blood count C) Chest x-ray D) Central venous pressure

D

The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan? A) Family members can be involved in the administration of pain medications with patient-controlled analgesia. B) There are no advantages of patient-controlled analgesia over a PRN dosing schedule. C) The client can self-administer oral pain medication as needed with patient-controlled analgesia. D) Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia.

D