Med surg exam 1

A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take?

Allow the client to wear the ring and cover it with tape.

A client who had abdominal surgery 4 days ago reports that "something gave way" when he sneezed. The nurse observes a wound evisceration. Which nursing action is the first priority?

Applying a sterile, moist dressing

A client is undergoing a lumbar puncture. The nurse educates the client about surgical positioning. Which statement by the nurse is appropriate?

"You will be lying on your side with your knees to your chest."

For the client who is taking aspirin, it is important to stop taking this medication at least how many day(s) before surgery?

7

What is the blood glucose level goal for a diabetic client who will be having a surgical procedure?

80 to 110 mg/dL

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?

Ineffective thermoregulation

A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented?

Circulating nurse

What medication should the nurse prepare to administer in the event the client has malignant hyperthermia?

Dantrolene sodium

A 70-year-old patient who is to undergo surgery arrives at the operating room (OR). The nurse, when reviewing the patient's medical record, understands that this patient will require a lower dose of anesthetic agent because of which of the following?

Decreased lean tissue mass

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.

Listening to music Watching television Changing position

A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first?

Moisten sterile gauze with sterile normal saline and place on the protruding organ.

A nurse is caring for a client with a chest tube connected to a dry suction water seal drainage system. The nurse notes 2 cm of water and intermittent bubbling in the water seal chamber. Which action will the nurse take?

Document the findings.

You are caring for a 79-year-old man who has returned to the Medical-Surgical unit following abdominal surgery. Your patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. You explain that refusing to wear external pneumatic compression stockings places him at significant risk for what?

Pulmonary embolism

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?

Use diaphragmatic breathing.

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?

experiences pain within tolerable limits.

During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication?

malignant hyperthermia

The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order?

ondansetron

A client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to:

place saline-soaked sterile dressings on the wound

Which nursing statement would best decrease a client's anxiety before an emergency operative procedure?

"Let me explain to you what will happen next."

Which statement by the client indicates further teaching about epidural anesthesia is necessary?

"I will become unconscious."

A nurse is teaching a client about pain management after surgery. Which client statement indicates the teaching was effective?

"I will support my incision with my hands when I cough and do my deep breathing exercises."

A patient was admitted 2 hours ago to the postsurgical unit from PACU following a Hartmann's resection (bowel surgery). During the nurse's most recent assessment of the patient, significant bleeding was noted on the patient's abdominal dressing, which was previously dry and intact. What action should the nurse perform first?

Apply a sterile gauze and hold it in place while applying moderate pressure.

A client undergoing coronary artery bypass surgery is subjected to intentional hypothermia. The client is ready for rewarming procedures. Which action by the nurse is appropriate?

Apply a warm air blanket, gradually increasing body temperature.

What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities?

Coordinating the surgical team

When practicing perioperative care, the nurse monitors clients for what symptoms that are indicative of malignant hyperthermia? Select all that apply.

Cyanosis Muscle rigidity Diaphoresis Irregular heart rate

Which health care profession has the ultimate responsibility to provide appropriate information regarding a nonemergent surgery?

Physician

The anesthesiologist will use moderate (conscious) sedation during the client's surgical procedure. The circulating nurse will expect the client to:

Respond verbally during the procedure

A 79-year-old man is scheduled for surgical repair of an inguinal hernia. In light of this patient's age, the nurse will prioritize nursing interventions aimed at preventing:

Skin breakdown

Which clinical manifestation is often the earliest sign of malignant hyperthermia?

Tachycardia (heart rate >150 beats per minute)

The OR personnel responsible for maintaining the safety of the client and the surgical environment is the:

The OR personnel responsible for maintaining the safety of the client and the surgical environment is the: