Med Surg ch 14,15,16,17

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

Correct response: d. Evisceration Explanation: Evisceration is a surgical emergency. A hernia is a weakness in the abdominal wall. Dehiscence refers to the partial or complete separation of wound edges. Erythema refers to the redness of tissue.

What finding by the nurse may indicate that the client has chronic hypoxia? a. Crackles b. Peripheral edema c. Clubbing of the fingers d. Cyanosis

Correct response: Clubbing of the fingers Explanation: Clubbing of the fingers is a change in the normal nail bed. It appears as sponginess of the nail bed and loss of the nail bed angle. It is a sign of lung disease that is found in patients with chronic hypoxic conditions, chronic lung infections, or malignancies of the lung. Cyanosis can be a very late indicator of hypoxia, but it is not a reliable sign of hypoxia. The other signs listed may represent only a temporary hypoxia.

Granulation tissue is not visible and scar formation is minimal. Many postoperative wounds are covered with a dry sterile dressing. a. First intention b. Second intention c. Third intention d. Fourth intention

a. First intention

Nursing students are reviewing information about agents used for anesthesia. The students demonstrate understanding when they identify which of the following as an inhalation anesthetic? a. Halothane b. Fentanyl c. Succinylcholine d. Propofol

Correct response: a. Halothane Explanation: Halothane is an example of an inhalation anesthetic. Fentanyl, succinylcholine, and propofol are commonly used intravenous agents for anesthesia.

A fractured skull would be classified under which category of surgery based on urgency? a. Elective b. Required c. Urgent d. Emergent

Correct response: Emergent Explanation: Emergent surgery occurs when the client requires immediate attention. An elective surgery is classified as a surgery that the client should have. A required surgery means that the client needs to have surgery. An urgent surgery occurs when the client requires prompt attention.

A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern? a. Kussmaul respirations b. Cheyne-Stokes c. Biot's respirations d. Apnea

Correct response: Kussmaul respirations Explanation: Kussmaul respirations are seen in patients with diabetic ketoacidosis. In Cheyne-Stokes respiration, rate and depth increase, then decrease until apnea occurs. Biot's respiration is characterized by periods of normal breathing (3 to 4 breaths) followed by a varying period of apnea (usually 10 to 60 seconds).

A nurse is witnessing a client sign the consent form for surgery. After signing the consent form, the client starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate? a. Answer the client's questions. b. Request that the surgeon come and answer the questions. Place the consent form in the client's medical record. Notify the nurse manager of the client's questions.

Correct response: Request that the surgeon come and answer the questions. Explanation: It is the physician's responsibility to provide information pertaining to risks and benefits of surgery. It is not the responsibility of the nurse or nurse manager to discuss risks and benefits. The consent form should not be placed in the medical record until all of the client's questions are answered fully.

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 been lying on his side for 2 hours with the drain positioned upward. b. The client has a nasogastric (NG) tube in place that drained 400 ml. 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.

Correct response: The Hemovac drain isn't compressed; instead it's fully expanded. Explanation: The Hemovac must be compressed to establish suction. If the Hemovac is allowed to fully expand, suction is no longer present, causing the drain to malfunction. The client who requires major abdominal surgery typically produces abdominal drainage despite the client's position. An NG tube drains stomach contents, not incisional contents. Therefore, the NG tube drainage of 400 ml is normal in this client and is not related to the absence of Hemovac drainage. Dry drainage on the dressing indicates leakage from the incision; it isn't related to the Hemovac drainage.

Which statement by the client indicates further teaching about epidural anesthesia is necessary? a. "I will become unconscious." b. "I will lose the ability to move my legs." c. "I will be able to hear the surgeon during the surgery." d. "A needle will deliver the anesthetic into the area around my spinal cord."

Correct response: a. "I will become unconscious." Explanation: The client receiving epidural anesthesia will remain conscious during the procedure.

What is the blood glucose level goal for a diabetic client who will be having a surgical procedure? a. 80 to 110 mg/dL b. 150 to 240 mg/dL c. 250 to 300 mg/dL d. 300 to 350 mg/dL

Correct response: a. 80 to 110 mg/dL Explanation: Although the surgical risk in the client with controlled diabetes is no greater than in the client without diabetes, strict glycemic control (80 to 110 mg/dL) leads to better outcomes. Frequent monitoring of blood glucose levels is important before, during, and after surgery.

Which would be included as a responsibility of the scrub nurse? a. Obtaining and opening wrapped sterile equipment b. Keeping all records and adjusting lights c. Handing instruments to the surgeon and assistants d. Coordinating activities of other personnel

Correct response: c. Handing instruments to the surgeon and assistants Explanation: The responsibilities of a scrub nurse are to assist the surgical team by handing instruments to the surgeon and assistants, preparing sutures, receiving specimens for laboratory examination, and counting sponges and needles. Responsibilities of a circulating nurse include obtaining and opening wrapped sterile equipment and supplies before and during surgery, keeping records, adjusting lights, and coordinating activities of other personnel.

Which stage of anesthesia is referred to as surgical anesthesia? a. I b. II c. III d. IV

Correct response: c. III Explanation: Stage III may be maintained for hours with proper administration of the anesthetic. Stage I is beginning anesthesia, where the client breathes in the anesthetic mixture and experiences warmth, dizziness, and a feeling of detachment. Stage II is the excitement stage, which may be characterized by struggling, singing, laughing, or crying. Stage IV is a state of medullary depression and is reached when too much anesthesia has been administered.

The nurse recognizes that written informed consent is required for insertion of a(n): a. Nasogastric tube. b. Urinary catheter. c. Peripherally-inserted central catheter. d. Oral airway.

Correct response: c. Peripherally-inserted central catheter. Explanation: Nonsurgical invasive procedures, such as insertion of a peripherally-inserted central catheter, that carry more than a slight risk to the client require written informed consent.

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

Correct response: c. Pink to red and soft, noting that it bleeds easily Explanation: Second-intention healing (granulation) occurs in infected wounds or in wounds in which the edges have not been approximated. Gradually, the necrotic material disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue. Healing is complete when skin cells grow over these granulations.

The nurse is caring for a postoperative client with a Hemovac. The Hemovac is expanded and contains approximately 25 cc of serosanguineous drainage. The best nursing action would be to: a. Assess the client's wound and apply a pressure dressing. b. Notify the surgeon that the Hemovac is not functioning. c. Remove the Hemovac because it is expanded. d. Empty and measure the drainage and compress the Hemovac.

Correct response: d. Empty and measure the drainage and compress the Hemovac. Explanation: A Hemovac needs to be recompressed periodically, because it operates with the use of gentle, constant suction. The amount of drainage is not excessive.

xA physician has ordered that a client with suspected lung cancer undergo magnetic resonance imaging (MRI). The nurse explains the benefits of this study to the client. What is the reason the client with suspected lung cancer would undergo magnetic resonance imaging (MRI)? a. Tumor densities can be seen with radiolucent images. b. Narrow-beam x-ray can scan successive lung layers. c. Lung blood flow can be viewed after a radiopaque agent is injected. d. MRI can view soft tissues and can help stage cancers.

Correct response: d. MRI can view soft tissues and can help stage cancers. Explanation: MRI uses magnetic fields and radiofrequency signals to produce a detailed diagnostic image. MRI can visualize soft tissues, characterize nodules, and help stage carcinomas. The other options describe different studies.

Or primary closure, refers to the healing of a wound in which the edges are closely re-approximated. In this type of wound healing, union or restoration of continuity occurs directly with minimal granulation tissue and scar formation. a. First intention b. Granulation c. Second intention d. Third intention

a. First intention

Which of the following is a duty of the registered nurse first assistant? Select all that apply. a. Handling tissue b. Suturing c. Maintaining hemostasis d. Providing exposure at the operative field e. Specimen management

a. Handling tissue b. Suturing c. Maintaining hemostasis d. Providing exposure at the operative field

What is the primary function of the larynx? a. Producing sound b. Protecting the lower airway from foreign objects c. Facilitating coughing d. Preventing infection

a. Producing sound

Which of the following actions by the nurse is appropriate? a. Touching the edges of an open sterile package b. Touching sterile items with a clean-gloved hand c. Reaching over the sterile field d. Discarding an object that comes in contact with the 1-inch border

correct response: d.Discarding an object that comes in contact with the 1-inch border Explanation: The 1-inch border of a sterile field is considered unsterile.

Delayed primary wound healing after 4-6 days. This occurs when the process of secondary intention is intentionally interrupted and the wound is mechanically closed. This usually occurs after granulation tissue has formed a. First intention b. Granulation c. Second intention d. Third intention

d. Third intention

Monitored anesthesia care differs from moderate sedation in that monitored anesthesia care: a. is used as an adjunct to spinal anesthesia. b. may result in the administration of general anesthesia. c. is a type of regional anesthesia. d. requires the introduction of an anesthetic agent into the epidural space.

Correct response: b. may result in the administration of general anesthesia. Explanation: Monitored anesthesia care may require the anesthesiologist to convert to general anesthesia.

The nurse expects informed consent to be obtained for insertion of: a. An indwelling urinary catheter b. An intravenous catheter c. A gastrostomy tube d. A nasogastric tube

Correct response: c. A gastrostomy tube Explanation: Informed consent is required for invasive procedures that require sedation and are associated with more than usual risk to the client.

The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes increased serosanguinous drainage, wound edges not approximated, and a ¼-inch (6 mm) gap at the lower end of the incision. The nurse concludes which of the following conditions exists? a. Dehiscence b. Evisceration c. Hemorrhage d. Normal healing by primary intention.

Correct response: Dehiscence Explanation: Dehiscence is a disruption of the incision.

Your client is scheduled for a bronchoscopy to visualize the larynx, trachea, and bronchi. What precautions would you recommend to the client before the procedure? a. Abstain from food for at least 6 hours before the procedure. b. Avoid sedatives or narcotics as they depress the vagus nerve. c. Avoid atropines as they dry the secretions. d. Practice holding the breath for short periods.

Correct response: a. Abstain from food for at least 6 hours before the procedure. Explanation: For at least 6 hours before bronchoscopy, the client must abstain from food or drink to decrease the risk of aspiration. Risk is increased because the client receives local anesthesia, which suppresses the reflexes to swallow, cough, and gag. The client receives medications before the procedure. Typically, atropine is given to dry secretions and a sedative or narcotic is given to depress the vagus nerve. The client may need to hold his or her breath for short periods during lung scans and for bronchoscopy.

The nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action? a. Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax b. Asking the client to say "one, two, three" while the nurse auscultates the lungs c. Instructing the client to take a deep breath and hold it while the diaphragm is percussed d. Placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply

Correct response: a. Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax Explanation: While the nurse is assessing for tactile fremitus, the client is asked to repeat "ninety-nine" or "one, two, three," or "eee, eee, eee" as the nurse's hands move down the client's thorax. Vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand(s) are moved in sequence down the thorax, and corresponding areas of the thorax are compared. Asking the client to say "one, two, three" while auscultating the lungs is not the proper technique to assess for tactile fremitus. The nurse assesses for anterior respiratory excursion by placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply. The nurse assesses for diaphragmatic excursion by instructing the client to take a deep breath and hold it while the diaphragm is percussed.

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? a. First intention b. Second intention c. Third intention d. Fourth intention

Correct response: a. First intention Explanation: When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal. Many postoperative wounds are covered with a dry sterile dressing. Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been well approximated. Third-intention healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two apposing granulation surfaces. Fourth-intention is not a type of wound healing.

As a circulating nurse, what task are you solely responsible for? a. Keeping records. b. Estimating the client's blood loss. c. Handing instruments to the surgeon. d. Counting sponges and needles.

Correct response: a. Keeping records. Explanation: The circulating nurse wears OR attire but not a sterile gown. Responsibilities include obtaining and opening wrapped sterile equipment and supplies before and during surgery, keeping records, adjusting lights, receiving specimens for laboratory examination, and coordinating activities of other personnel, such as the pathologist and radiology technician. It is the responsibility of the scrub nurse to hand instruments to the surgeon and count sponges and needles. It is the responsibility of the surgeon to estimate blood loss.

What complication is the nurse aware of that is associated with deep venous thrombosis? a. Pulmonary embolism b. Immobility because of calf pain c. Marked tenderness over the anteromedial surface of the thigh d. Swelling of the entire leg owing to edema

Correct response: a. Pulmonary embolism Explanation: Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism (Rothrock, 2010).

Which of the following consequences may result if tranquilizers are withdrawn suddenly? a. Seizures b. Cardiovascular collapse c. Hypotension d. Respiratory depression

Correct response: a. Seizures Explanation: Abrupt withdrawal of tranquilizers may result in anxiety, tension, and even seizures if withdrawn suddenly. Abrupt withdrawal of steroids may precipitate cardiovascular collapse. Monoamine oxidase inhibitors increase the hypotensive effects of anesthetics. Thiazide diuretics may cause excessive respiratory depression during anesthesia due to an associated electrolyte imbalance.

The nurse is aware that the amino acid, arginine, a. Stimulates T-cell response b. Is essential for antibody formation c. Is involved in capillary formation d. Is important for normal blood clotting

Correct response: a. Stimulates T-cell response Explanation: Arginine is necessary for collagen synthesis and deposition, increases wound strength, and stimulates T-cell response.

A patient's lung volumes and capacities were assessed to help determine the cause of a respiratory problem. Which of the following findings are indicative of chronic obstructive pulmonary disease (COPD)? a. Vital capacity of 3,000 mL b. Expiratory reserve volume of 1,100 mL c. Residual volume of 1,200 mL d. Functional residual capacity of 2,300 mL

Correct response: a. Vital capacity of 3,000 mL Explanation: Vital capacity is reduced in COPD because of air trapping. The other choices are all normal findings. Refer to Table 8-2 in the text.

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. Elevating the head of the bed b. Reinforcing the dressing or applying pressure if bleeding is frank c. Monitoring vital signs every 15 minutes d. Encouraging the client to breathe deeply

Correct response: b. Reinforcing the dressing or applying pressure if bleeding is frank Explanation: The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the client to breathe deeply will not help manage and minimize hemorrhage and shock. Monitoring vital signs every 15 minutes is an appropriate nursing intervention but will not minimize hemorrhage and shock; it will just help to determine the extent and progression of the problem.

The nurse recognizes the client has reached stage III of general anesthesia when the client: a. lies quietly on the table b. displays agitation due to noise c. shouts, talks, or sings d. exhibits shallow respirations and a weak, thready pulse

Correct response: a. lies quietly on the table Explanation: Understanding the stages of anesthesia is necessary for nurses because of the emotional support that the client may need. Stage III or surgical anesthesia is reached when the patient is unconscious and lies quietly on the table. The pupils are small but constrict when exposed to light. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed. Clients in stage I of anesthesia may have a ringing, roaring, or buzzing in the ears and, although still conscious, may sense an inability to move the extremities easily. These sensations can result in agitation. Stage II of anesthesia is characterized variously by struggling, shouting, talking, singing, laughing, or crying, and is often avoided if IV anesthetic agents are given smoothly and quickly. Stage IV is reached if too much anesthesia is given. Respirations become shallow, the pulse is weak and thready, and the pupils become widely dilated and no longer constrict when exposed to light. Cyanosis develops and, without prompt intervention, death rapidly follows. If this stage develops, the anesthetic agent is discontinued immediately and respiratory and circulatory support is initiated to prevent death.

During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication? a. malignant hyperthermia b. hypothermia c. infection d. fluid volume excess

Correct response: a. malignant hyperthermia Explanation: Malignant hyperthermia is an inherited disorder that occurs when body temperature, muscle metabolism, and heat production increase rapidly, progressively, and uncontrollably in response to stress and some anesthetic agents. If the client's temperature begins to rise rapidly, anesthesia is discontinued, and the OR team implements measures to correct physiologic problems, such as fever or dysrhythmias. Hypothermia is a lower than expected body temperature. Signs of infection would not present during the procedure. Increased body temperature would not indicate fluid volume excess.

The nurse auscultates lung sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as a. pleural friction rub. b. sonorous wheezes. c. sibilant wheezes. d. crackles.

Correct response: a. pleural friction rub. Explanation: A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid. Crackles are soft, high-pitched, discontinuous popping sounds that occur during inspiration. Sonorous wheezes are deep, low-pitched rumbling sounds heard primarily during expiration. Sibilant wheezes are continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration.

The nurse auscultates the lung sounds of a client during a routine assessment. The sounds produced are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as a. pleural friction rub. b. crackles. c. sonorous wheezes. d. sibilant wheezes.

Correct response: a. pleural friction rub. Explanation: A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid. Crackles are soft, high-pitched, discontinuous popping sounds that occur during inspiration. Sonorous wheezes are deep, low-pitched rumbling sounds heard primarily during expiration. Sibilant wheezes are continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration.

The nursing instructor is teaching students about the respiratory system. The instructor knows the teaching has been effective when a student makes which statement? a. "Ventilation is the process of gas exchange." b. "Ventilation is the movement of air in and out of the respiratory tract." c. "Ventilation is the process of getting oxygen to the cells." d. "Ventilation is the exchange of gases in the lung."

Correct response: b. "Ventilation is the movement of air in and out of the respiratory tract." Explanation: Ventilation is the part of the respiration process that involves physical movement of air in and out of the respiratory tract. Respiration, not ventilation, encompasses the entire process of exchange of oxygen and CO2 between atmospheric air and the blood and between the blood and the cells.

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. Granulation b. First intention c. Second intention d. Third intention

Correct response: b. First intention Explanation: First-intention healing is characterized by a closed incision with little tissue reaction and the absence of signs and symptoms of infection.

An elderly client is preparing to undergo surgery. The nurse participates in preoperative care knowing that which of the following is the underlying principle that guides preoperative assessment, surgical care, and postoperative care for older adults? a. Aging processes reduce the chances that surgery will be successful for these clients. b. Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients. c. Neurologic and musculoskeletal complications are the leading cause of postoperative morbidity and mortality for older adults. d. All older people face similar risks when undergoing surgeries.

Correct response: b. Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients. Explanation: The underlying principle that guides preoperative assessment, surgical care, and postoperative care is that elderly clients have less physiologic reserve (the ability of an organ to return to normal after a disturbance in its equilibrium) than younger clients. The hazards of surgery for the elderly are proportional to the number and severity of coexisting health problems and the nature and duration of the operative procedure. Respiratory and cardiac complications are the leading causes of postoperative morbidity and mortality in older adults.

A patient who has received general anesthesia has reached stage II. Which of the following would the nurse expect the patient to exhibit? a. Dizziness and a feeling of detachment b. Pupillary dilation and rapid pulse c. Unconsciousness and regular respirations d. Weak, thready pulse and cyanosis

Correct response: b. Pupillary dilation and rapid pulse Explanation: During stage II, or the excitement stage, of general anesthesia, the pupils dilate and the pulse rate is rapid. During stage I, warmth, dizziness, and a feeling of detachment may be experienced. During stage III, the patient is unconscious, respirations are regular, and the pulse rate and volume are normal. During stage IV, respirations become shallow, the pulse is weak and thready, the pupils become widely dilated, and cyanosis develops.

An unconscious patient with normal pulse and respirations would be considered to be in what stage of general anesthesia? a. Beginning anesthesia b. Excitement c. Surgical anesthesia d. Medullary depression

Correct response: c. Surgical anesthesia Explanation: Surgical anesthesia is reached by administration of anesthetic vapor or gas and supported by IV agents as necessary. The patient is unconscious and lies quietly on the table. The pupils are small but contract when exposed to light. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed. In beginning anesthesia, as the patient breathes in the anesthetic mixture, warmth, dizziness, and a feeling of detachment may be experienced. The patient may have a ringing, roaring, or buzzing in the ears and, although still conscious, may sense an inability to move the extremities easily. The excitement stage, characterized variously by struggling, shouting, talking, singing, laughing, or crying, is often avoided if IV anesthetic agents are administered smoothly and quickly. The pupils dilate, but they contract if exposed to light; the pulse rate is rapid, and respirations may be irregular. Medullary depression is reached if too much anesthesia has been administered. Respirations become shallow, the pulse is weak and thready, and the pupils become widely dilated and no longer contract when exposed to light.

The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment? a. The nursing assistant is assisting the client to a semi-Fowler's position. b. The nursing assistant is assisting the client to the side of the bed to use a urinal. c. The nursing assistant is pouring a glass of water to wet the client's mouth. d. The nursing assistant is asking a question requiring a verbal response.

Correct response: c. The nursing assistant is pouring a glass of water to wet the client's mouth. Explanation: When completing a procedure which sends a scope down the throat, the gag reflex is anesthetized to reduce discomfort. Upon returning to the nursing unit, the gag reflex must be assessed before providing any food or fluids to the client. The client may need assistance following the procedure for activity and ambulation but this is not restricted in the post procedure period.

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. The client can self-administer oral pain medication as needed with patient-controlled analgesia. b. Family members can be involved in the administration of pain medications with patient-controlled analgesia. c. Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. d. There are no advantages of patient-controlled analgesia over a PRN dosing schedule.

Correct response: c. Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. Explanation: Advantages of patient-controlled analgesia include participation of the client in care, elimination of delayed administration of analgesics, and maintenance of therapeutic drug levels. The client must have the cognitive and physical abilities to self-dose.

When a client with a history of chronic alcoholism is admitted to the hospital for surgery, the nurse anticipates that the client may show signs of alcohol withdrawal delirium during which time period? a. Immediately upon admission b. Upon awakening in the postanesthesia care unit c. Up to 72 hours after alcohol withdrawal d. Up to 24 hours after alcohol withdrawal

Correct response: c. Up to 72 hours after alcohol withdrawal Explanation: Alcohol withdrawal delirium is associated with a significant mortality rate when it occurs postoperatively. Onset of symptoms depends on when alcohol was last consumed. Twenty-four hours is too short a time frame to consider alcohol withdrawal delirium as no longer a threat to a chronic alcoholic.

The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what? a. Requirement of intermittent catheterization b. Calculus formation c. Urine retention d. Urinary infection

Correct response: c. Urine retention Explanation: Voiding frequent, small amounts of urine indicates retention of urine with elimination of overflow. The nurse should assess the volume of first voided urine to determine adequacy of output. If the client fails to void within 8 hours of surgery, the nurse should consult with the physician regarding instituting intermittent catheterization until voluntary voiding returns and is not required in this case. Frequent and small amounts of urine voiding does not indicate urinary infection nor does it indicate the formation of a calculus.

A nurse understands that a safe but low level of oxygen saturation provides for adequate tissue saturation while allowing no reserve for situations that threaten ventilation. What is a safe but low oxygen saturation level for a patient? a. 40% b. 75% c. 80% d. 95%

Correct response: d. 95% Explanation: Normal SpO2 values are more than 95%. Values less than 90% indicate that the tissues are not receiving enough oxygen, in which case further evaluation is needed.

A client arrives at the physician's office stating dyspnea; a productive cough for thick, green sputum; respirations of 28 breaths/minute, and a temperature of 102.8° F. The nurse auscultates the lung fields, which reveal poor air exchange in the right middle lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this anticipated diagnosis, which sound, heard over the chest wall when percussing, is anticipated? a. Tympanic b. Resonant c. Hyperresonant d. Dull

Correct response: d. Dull Explanation: A dull percussed sound, heard over the chest wall, is indicative of little or no air movement in that area of the lung. Lung consolidation such as in pneumonia or fluid accumulation produces the dull sound. A tympanic sound is a high-pitched sound commonly heard over the stomach or bowel. A resonant sound is noted over normal lung tissue. A hyper resonant sound is an abnormal lower pitched sound that occurs when free air exists in disease processes such as pneumothorax. Reference:

Unless contraindicated, how should the nurse position an unconscious client? a. Flat on the back, without elevation of the head, to facilitate frequent turning and minimize pulmonary complications b. In semi-Fowler's position, to promote respiratory function and reduce the incidence of orthostatic hypotension when the patient can eventually stand c. In Fowler's position, which most closely simulates a sitting position, thus facilitating respiratory as well as gastrointestinal functioning d. On the side with a pillow at the patient's back and the chin extended, to minimize the dangers of aspiration

Correct response: d. On the side with a pillow at the patient's back and the chin extended, to minimize the dangers of aspiration Explanation: The head of the bed is elevated 15 to 30 degrees unless contraindicated, and the patient is closely monitored to maintain the airway as well as to minimize the risk of aspiration. If vomiting occurs, the patient is turned to the side to prevent aspiration and the vomitus is collected in the emesis basin.

A patient describes his chest pain as knife-like on inspiration. Which of the following is the most likely diagnosis? a. Bacterial pneumonia b. Bronchogenic carcinoma c. A lung infection d. Pleurisy

Correct response: d. Pleurisy Explanation: Pleuritic pain from irritation of the parietal pleura is sharp and seems to "catch" on inspiration. Some patients describe the pain as being "stabbed by a knife." Chest pain associated with the other conditions may be dull, aching, and persistent.

A postanesthesia care unit (PACU) nurse is preparing to discharge a client home following ankle surgery. The client keeps staring at the ceiling while being given discharge instructions. What action by the nurse is appropriate? a. Ask the client, "Do you understand?" b. Continuously repeat the instructions until the client restates them. c. Give the written instructions to the client's 16-year-old child. d. Review the instructions with the client and an accompanying adult.

Correct response: d. Review the instructions with the client and an accompanying adult. Explanation: The effects of anesthesia may impair a client's memory or concentration. It is important that the discharge instructions are covered with the client and an accompanying adult. Giving the instructions to a 16-year-old is not appropriate. Repeating the instructions until the client restates them does not ensure that the client will remember them, because anesthesia can impair memory. Asking whether the client understands the instructions only elicits an yes or no answer; it does not give insight into whether the client comprehends the instructions.

The surgical client has been intubated and general anesthesia has been administered. The client exhibits cyanosis, shallow respirations, and a weak, thready pulse. The nurse recognizes that the client is in which stage of general anesthesia? a. Stage I b. Stage II c. Stage III d. Stage IV

Correct response: d. Stage IV Explanation: Stage IV: medullary depression is characterized by shallow respirations, a weak, thready pulse, dilated pupils that do not react to light, and cyanosis.

The nurse is caring for the client in the preoperative period and documenting rationale for a palliative surgical procedure. Which rationale is appropriate? a. The physician needs additional information to plan medical treatment. b. The client wishes to improve body structures and elects a procedure. c. The physician is repairing a deformity from birth or disease process. d. The client and physician are focusing on symptom relief not a cure.

Correct response: d. The client and physician are focusing on symptom relief not a cure. Explanation: The nurse realizes a palliative surgical procedure is focused on the relief of symptoms or enhancement of function without a cure. Diagnostic surgical procedures provide additional information for medical diagnosis and treatment. Cosmetic surgery procedures are elective, with the purpose of improving body appearance. Reconstructive surgery corrects a deformity.

A client is preparing for a surgical procedure is taking corticosteroids for Crohn's disease. What is most important for the nurse to monitor during the operative experience with the client? a. obstruction b. surgical site infection c. hypoglycemia d. adrenal insufficiency

Correct response: d. adrenal insufficiency Explanation: Clients who have received corticosteroids are at risk for adrenal insufficiency. They are not at greater risk for obstruction, infection, or hypoglycemia during the operative experience.

A client develops malignant hyperthermia. What client symptom would the nurse most likely observe as the first indicator of the disorder? a. body temperature increase of 1 °C to 2 °C (2 °F to 4 °F) b. tetanus-like jaw movements c. generalized muscle rigidity d. heart rate over 150 beats per minute

Correct response: d. heart rate over 150 beats per minute Explanation: With malignant hyperthermia, tachycardia with a heart rate greater than 150 beats per minute is often the earliest sign because of an increase in end-tidal carbon dioxide. Generalized muscle rigidity and tetanus-like movement occurs often in the jaw are not the first signs for health care providers to note with malignant hyperthermia. The rise in body temperature is a late sign that develops rapidly.

A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client? a. experiences pain within tolerable limits. b. exhibits wound healing without complications. c. resumes usual urinary elimination pattern. d. maintains adequate fluid status.

Correct response: experiences pain within tolerable limits. Explanation: Because pain can contribute to postoperative delirium, adequate pain control without oversedation is essential. Nursing assessment of mental status and of all physiologic factors influencing mental status helps the nurse plan for care because delirium may be the initial or only indicator of infection, fluid and electrolyte imbalance, or deterioration of respiratory or hemodynamic status in the older adult client.

A client is receiving general anesthesia. The nurse anesthetist starts to administer the anesthesia. The client begins giggling and kicking her legs. What stage of anesthesia would the nurse document related to the findings? a. I b. II c. III d. IV

b. II Explanation: Stage II is the excitement stage, which is characterized by struggling, shouting, and laughing. Stage I is the beginning of anesthesia, during which the client breathes in the anesthetic mixture and feelings of warmth, dizziness, and detachment occur. Stage III is surgical anesthesia characterized by unconsciousness and quietness. Surgical anesthesia is achieved by continued administration of anesthetic vapor and gas. Stage IV is medullary depression.

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which term should the nurse document? a. Crackles b. Pleural friction rub c. Rhonchi d. Bronchial

c. rhonchi

__________ is a partial or total separation of previously approximated wound edges, due to a failure of proper wound healing. a. Erythema b. Hernia c. Dehiscence d. Evisceration

c. Dehiscence

A wound will be left open (rather than being stitched together) and left to heal by itself, filling in and closing up naturally. It will mean you need regular dressings to the area for up to six weeks, but the time to full healing depends on the size, depth and site of the wound. a. First intention b. Granulation c. Second intention d. Third intention

c. Second intention

Secondary suture is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two apposing granulation surfaces. Fourth-intention is not a type of wound healing. a. First intention healing b. Second intention healing c. Third intention healing d. Fourth intention healing

c. Third intention healing