MedSurg Final Review

A nurse is caring for a patient who has had a total hip replacement. The nurse is reviewing education prior to discharge. Which of the clients statements would indicate to the nurse that the client requires further teaching A) I'll need to keep several pillows between my legs at night B) I need to remember not to cross my legs. It is such a habit C) The OT is showing me how to use a sock puller to help me get dressed D) I will need my husband to assist me in getting off the low toilet seat at home

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The OR nurse is setting up a water-seal chest drainage system for a client who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? A) 20 cm H20 B) 15 cm H20 C) 10 cm H20 D) 5 cm H20

A) 20 cm H20

What is the nurses best first action when a client who has had a craniotomy develops periorbital edema and ecchymosis A) Immediately notify the surgeon B) Apply cold compresses C) Check pupillary response D) Perform a focused neurological assessment

B) Apply cold compresses

Which of the following assessment findings would indicate an effect of hypothermia in an elderly post-op patient A) Hypotension B) Bradyacrdia C) tachycardia D) Rapid, shallow respirations

B) Bradycardia

A nurse assesses a patient who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.) A) Production of pink sputum B) Sudden onset of shortness of breath C) Tracheal deviation D) Drainage greater than 70 mL/hr E) Pain at insertion site F) Disconnection at Y site

B) Sudden onset of shortness of breath C) Tracheal deviation D) Drainage greater than 70 mL/hr F) Disconnection at Y site

The Surgical Care Improvement Project (SCIP) goals focus on A) Hemorrhage B) Thromboembolism C) Infection D) Serious cardiac events E) Stroke

B) Thromboembolism C) Infection D) Serious cardiac events

Pre-op assessment revealed that the patient's HR is 115. The surgeon ordered a beta blocker. Which of the following is the correct rational for this A) Patient might have undiagnosed heart condition B) When the HR goes up, the BP does too C) Anesthesia has bad effects if the patient is tachycardic D) A rapid HR requires more effort by the heart

D) A rapid HR requires more effort by the heart

A post-op patient is receiving dopamine for tx of shock. Which of the following assessment findings necessitate that the nurse contact the PCP immediately A) BP 98/68 B) Pedal pulse 1+/4+ bilateral C) Urine output 32mL/hr D) Report of chest heaviness

D) Report of chest heaviness (myocardial ischemia possible adverse effect of dopamine)

While assessing a client who has had knee replacement surgery, the nurse notes that the client has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this client? A) Unilateral Neglect Related to Hematoma B) Disturbed Kinesthetic Sensory Perception C) Risk for Infection D) Risk for Ineffective Peripheral Tissue Perfusion

D) Risk for Ineffective Peripheral Tissue Perfusion

A nurse is developing a plan of care for a client who is 12 hours post op following colon resection. Which of the following intervention should the nurse include in the plan to reduce respiratory complications A) Use incentive spirometer every 4 hours while awake B) Initiate ambulation after discontinuing the NG tube C) Maintain supine position with abdominal binder D) Splint then incision to support coughing every 1 to 2 hours

D) Splint then incision to support coughing every 1 to 2 hours

Following CABG surgery, a client's body temp is below 96.8 what measures should the nurse take to re-warm the client A) Infuse warm IV fluids B) Do not re-warm because cold cardioplegia is protective C) Place the client in warm fluid bath D) Use lights and thermal blanket to slowly warm teh client

D) Use lights and thermal blanket to slowly warm the client

The nurse is caring for a client post operative day 4 following a kidney transplant. When assessing for potential signs and symptoms of rejection, what assessment should the nurse prioritize A) Assessment of the quality of the clients urine output B) Assess incision C) Assess client's abdominal girth D) Assess for flank or abdominal pain

A) Assessment of the quality of the clients urine output

A client is scheduled for a total hip replacement and the surgeon has explained the risks of blood loss associated with orthopedic surgery. The risk of blood loss is the indication for which of the following actions? A) Autologous blood donation B) Use of a cardiopulmonary bypass machine C) Prophylactic blood transfusion D) Postoperative blood salvage

A) Autologous blood donation

The nurse is caring for a client who is being admitted for the removal of an intracranial mass. Which of the following diagnostic procedures might be included in this client's admission orders? Select all that apply. A) Cerebral angiography B) Transcranial Doppler flow study C) MRI D) Cranial radiography E) Electromyelography (EMG)

A) Cerebral angiography B) Transcranial Doppler flow study C) MRI

The nurse is caring for a patient who has just returned to the postsurgical unit following renal surgery. When assessing the client's output from surgical drains, the nurse should assess what parameters? Select all that apply. A) Color of the output B) pH of the output C) Quantity of output D) Visible characteristics of the output E) Odor of the output

A) Color of the output C) Quantity of output D) Visible characteristics of the output E) Odor of the output

A nurse is assessing a client who is post op and find the clients abdominal incision has eviscerated. Which of the following actions should the nurse take A) Cover the wound with a sterile saline soaked dressing B) Place the client in high Fowlers position C) Auscultate all quadrants of the abdomen for a bowel sounds D) Gently re-insert the protruding pouch

A) Cover the wound with a sterile saline soaked dressing

In immediate postop period following a right hip prosthesis what heath education should the nurse emphasize A) Don't bring knees close together B) Try to lie as still as possible for the next few days C) Try to avoid bending your knees until next week D) Keep your legs higher than your chest whenever you can

A) Don't bring knees close together

A nurse is developing teaching plan for a client who has an ileostomy and will require stoma care. Which of the following information should the nurse include A) Empty the pouch when it is 1/2 to 1/3 full B) Hold pressure on the skin barrier for 10 to 15 seconds to secure the seal C) Clean the peristomal skin 4 times a day D) Take enteric coated medication only

A) Empty the pouch when it is 1/2 to 1/3 full

The nurse is caring for a client with increasing intercranial pressure following a stroke. Which evidence-based nursing actions are indicated for the client (SATA) A) Hyper oxygenate the client before and after suctioning B) Avoid sudden or extreme hip or neck flexion C) Provide oxygen to maintain SaO2 95% or greater D) Maintain the client in a supine position at all times E) Avoid clustering care nursing activities and procedures F) Provide environmental stimulation to improve cognition G) Position the client supine H) Maintain HOB elevated at 30 to 45° I) Position client and prone position J) Maintain bed and trandelenburd position

A) Hyper oxygenate the client before and after suctioning B) Avoid sudden or extreme hip or neck flexion C) Provide oxygen to maintain SaO2 95% or greater E) Avoid clustering care nursing activities and procedures H) Maintain HOB elevated at 30 to 45°

What the critical care nurse assessed for postoperative bleeding and a client who just had CABG surgery A) Measure mediastinal and pleural chest tube drainage at least once an hour and report drainage over 200 mL/hr to the surgeon B) Measure mediastinal and pleural chest tube drainage at least once a shift and report drainage amount over 50 mL/hr to the surgeon C) Assess the sternal dressing for bleeding Q4 hours, then reinforce with sterile gauze as needed and report the approximate amount of bleeding to the surgeon D) Assess the vein donor site Q4 hours and report the amount of serous drainage as well as pain to the surgeon

A) Measure mediastinal and pleural chest tube drainage at least once an hour and report drainage over 200 mL/hr to the surgeon Drainage should not exceed over 200mL/hr for the first 4-6hrs- should be clear in a few days

What is the nurses it's actually really caring for a client after craniotomy and finding a dressing is saturated and the Hemovac drainage is 100 mL over eight hours A) Notify the surgeon immediately B) Reinforce the dressing with sterile gauze C) Record the Hemovac drainage on the intake and output sheet D) Check the drainage on the dressing for a halo effect

A) Notify the surgeon immediately (report anything over 50mL/hr)

A cardiac surgery clients new onset of signs and symptoms suggestive of cardiac tamponade. As a member of the interdisciplinary team what is the nurse is most appropriate action A) Prepare to assist with pericardiocentesis B) Position the client in prone position C) Administer metoprolol as prescribed D) Administer a bolus of normal saline as prescribed

A) Prepare to assist with pericardiocentesis (will remove the fluid)

Nurse admitted a client who is scheduled for thoracic resection. Which study will be performed to determine weather the planned resection will leave sufficient functioning lung tissue A) Pulmonary function studies B) Arterial blood gas C) Exercise tolerance test D) Chest x-ray

A) Pulmonary function studies

Nurse is preparing to administer an osmotic diuretic IV to a client with increased intercranial pressure. Which of the following should the nurse identify as the purpose of this medication A) Reduce edema of the brain B) Provide fluid hydration C) Increase cell size in the brain D) Expand extracellular fluid volume

A) Reduce edema of the brain

Which of the following assessment findings would indicate that a post-op patient is meeting the PACU DC criteria A) Return of gag, cough, and swallow reflex B) BP within 30 points of preanesthetic level C) No overt bleeding D) Oxygen saturation greater than or equal to 95% on room air E) Ability to move 2 extremities

A) Return of gag, cough, and swallow reflex C) No overt bleeding D) Oxygen saturation greater than or equal to 95% on room air

While assessing the client, the nurse observes constant bubbling in the water-seal chamber of the client's closed chest-drainage system. What should the nurse conclude? A) System has an air leak B) Client has pneumothorax C) System is functioning properly D) Chest tube is obstructed

A) System has an air leak

A nurse cares for a patient who had a ileostomy two weeks ago. The patient states "the stool in my pouch is still liquid" how were the nurse respond A) The stool will always be liquid with ileostomy B) Eating additional fiber will bulk up your stool and decrease diarrhea C) Your stool will become a firmer over the next couple of weeks D) This is abnormal. I will contact your healthcare provider

A) The stool will always be liquid with ileostomy

Which vital sign changes in the client with hypovolemic shock indicate to the nurse that teh therapy is effective A) Urine output increases from 5 mL/hr to the 25mL/hr B) pulse pressure decreases from 35mmHg to 28 mmHg C) RR increases from 22breaths/min to 26breaths/min D) Core body temp increases from 98.2 to 98.8

A) Urine output increases from 5 mL/hr to the 25mL/hr (indicates adequate renal perfusion)

A client in the ICU has had an endotracheal tube in place for 3 weeks. The health care provider has ordered that a tracheostomy tube be placed. The client's family wants to know why the endotracheal tube cannot be left in place. What would be the nurse's best response? A) When an endotracheal tube is left in too long it can damage the lining of the windpipe." B) "The physician may feel that mechanical ventilation will have to be used long-term." C) "Long-term use of an endotracheal tube diminishes the normal breathing reflex." D) "It is much harder to breathe through an endotracheal tube than a tracheostomy."

A) When an endotracheal tube is left in too long it can damage the lining of the windpipe."

A nurse is educating a client in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the client and the family that this drainage system is used for? A) removing excess air and fluid B) maintain positive chest wall pressure C) Monitoring pleural fluid osmolarity D) Provide positive intrathoracic pressure

A) removing excess air and fluid

A nurse is caring for a client who has a post operative ileus and an NG tube that has rained 2,500 mL in the past 6 hours. Which of the following electrolyte imbalance should the nurse monitor for A) Elevated sodium level B) Decreased Potassium level C) Elevated magnesium level D) Decreased calcium level

B) Decreased Potassium level

The nurse is caring for a client who is recovering from intracranial surgery. A transsphenoidal approach was used. The nurse understands that this approach is used to perform surgeries on what neurologic structure? A) Pineal gland B) Pituitary gland C) Hypothalamus D) Cerebellum

B) Pituitary gland

A nurse teaches a patient to use a room humidifier after a laryngectomy. Which statement would the nurse include in this patient's teaching? A) "Keep the humidifier filled with water at all times. B) "Make sure you clean the humidifier to prevent infection." C) "Add peppermint oil to the humidifier to relax the airway." D) "Use the humidifier when you sleep, even during daytime naps."

B) "Make sure you clean the humidifier to prevent infection."

nurse cares for a patient who had a partial laryngectomy 10 days ago. The patient states that all food tastes bland. How would the nurse respond? A) "I will consult the speech therapist to ensure you are swallowing properly." B) "This is normal after surgery. What types of food do you like to eat?" C) "I will ask the dietitian to change the consistency of the food in your diet." D) "Replacement of protein, calories, and water is very important after surgery."

B) "This is normal after surgery. What types of food do you like to eat?"

What action does the nurse used to prevent harm by further increasing ICP when an intubated post intercranial surgery client needs to be suction A) Providing 100% oxygen before and after each past of the suction catheter B) Aggressively hyperventilating with 100% oxygen before suctioning C) Performing oral suctioning often but avoiding endotracheal suctioning D) Obtaining an arterial blood gas sample before suctioning the client

B) Aggressively hyperventilating with 100% oxygen before suctioning

The nurse is caring for a patient who is postoperative day 4 following a kidney transplant. When assessing for potential signs and symptoms of rejection, what assessment should the nurse prioritize? A) Assessment of the client's abdominal girth B) Assessment of the quantity of the client's urine output C) Assessment for flank or abdominal pain D) Assessment of the client's incision

B) Assessment of the quantity of the client's urine output

Why will the nurse immediately notify the nephrology healthcare provider if a client develops hypotension and diuresis postoperatively after a kidney transplant A) These problems please the client at risk for hypervolemia and dehydration B) Dehydration with hypotension reduces perfusion and oxygen to the new kidney C) Assessment findings are indicators of a possible serious acute infection D) Increased work by the kidney for diuresis results in excessive buildup of cellular toxins that damage the new kidneys tubules

B) Dehydration with hypotension reduces perfusion and oxygen to the new kidney

A client recently admitted it to the ortho unit following total hip arthroplasty. Client has a close suction device in place, the nurse has determined there was 320 mL output in the first 24 hrs. How should the nurse respond to this assessment A) Inform provider promptly B) Document as expected finding C) Limit client's fluid intake to 2L for the next 24 hrs D) Administer a loop diuretic as prescribed

B) Document as expected finding (drainage of 200-500mL in first 24 hrs is expected)

The clients enteral feedings have been determined to be too concentrated based on the clients development of dumping syndrome what physiologic phenomenon caused the clients complication after enteral feeding A) Increased gastric secretions of HCL and gastrin because of high osmolality of feeds B) Entry of large amounts of water into the small intestines because of osmotic pressure C) Mucosal irritation of the stomach and small intestine by the high concentration of the feed D) Acid base and balance resulting from the high volume of solutes in the feed

B) Entry of large amounts of water into the small intestines because of osmotic pressure

Patient is being discharged home after a large myocardial infarction and subsequent CABG in surgery the patient sternal world has not yet healed. What statement by the patient most indicates a higher risk for developing sepsis after discharge A) All of my friends are planning a party for me B) I hope I can get my water turned back on when I get home C) I am going to have my daughter scoop the liter box D) My grandkids are excited to have me home

B) I hope I can get my water turned back on when I get home

After teaching a patient who is recovering from a colon resection, the nurse assesses the clients understanding. Which statements by the patient indicate a correct understanding on the teaching (SATA) A) I must change the ostomy appliance daily and as needed B) I will use warm water and a soft wash cloth to clean around the stoma C) I should size the barrier appropriately to hug the stoma and not to expose the peristomal skin D) I will check the stoma regularly to make sure that it stays a deep red color E) I must avoid dairy products to reduce gas and ordor in the pouch

B) I will use warm water and a soft wash cloth to clean around the stoma C) I should size the barrier appropriately to hug the stoma and not to expose the peristomal skin

What does the nurse expect the nephrology healthcare provider to prescribe want to post kidney transplant client develops Algeria, elevated temperature of 100°F, increased blood pressure, insides of fluid retention nine days after surgery A) Immediate removal of the transplanted kidney B) Increased doses of immunosuppressant drugs C) Immediate return to either hemodialysis or peritoneal dialysis D) Antibiotic therapy until infection symptoms are resolved

B) Increased doses of immunosuppressant drugs

A nurse cares for a patient who has a pleural chest tube. What action would the nurse take to ensure safe use of this equipment? A) Secure tubing junctions with clamps to prevent accidental disconnections. B) Keep padded clamps at the bedside for use if the drainage system is interrupted. C) Connect the chest tube to wall suction at the level prescribed by the provider. D) Strip the tubing to minimize clot formation and ensure patency.

B) Keep padded clamps at the bedside for use if the drainage system is interrupted.

The nurse is caring for a client who is post- op craniotomy when writing the plan of care the nurse identify as a diagnosis of deficient fluid volume related to fluid restriction an osmotic diuretic use. What is the nurse is most appropriate intervention for this diagnosis A) Change the clients position as indicated B) Monitor serum electrolytes C) Maintain NPO status D) Winder arterial blood gas values

B) Monitor serum electrolytes

Which of the following patients undergoing surgery are considered to be high risk for VTE (SATA) A) Patient with humerus fracture B) Patient who underwent prolonged surgical procedure C) Patient with severe HF D) Wheelchair bound patient E) Morbidly obese patient

B) Patient who underwent prolonged surgical procedure C) Patient with severe HF D) Wheelchair bound patient E) Morbidly obese patient

A patient who underwent valve replacement is DC home. What health education should the nurse prioritize in anticipation of DC A) Heavy lifting for 3 to 6 weeks B) Provider of any bleeding or excessive bruising it, dyspnea, syncope, dizziness, edema and palpitations C) Using electric razor to avoid skin cuts D) Increasing foods containing high Vit. K E) The need for regular INR testing F) Importance of antibiotic prophylaxis prior to dental work

B) Provider of any bleeding or excessive bruising it, dyspnea, syncope, dizziness, edema and palpitations C) Using electric razor to avoid skin cuts E) The need for regular INR testing F) Importance of antibiotic prophylaxis prior to dental work

A client and a critical care unit postop day one following kidney transplant from a living donor has copious amounts of dilute urine. What is the nurse is most appropriate response A) Assess the client for further signs or symptoms of rejection B) Recognize this as an expected finding C) Inform the primary provider D) Administer exogenus antidiuretic hormone as prescribed

B) Recognize this as an expected finding

A nurse is caring for a client with a newly created ileostomy assesses the client know that the client has not had asked me out but for the past 12 hours. The client also reports worsening nausea. What is the nurses priority action A) Facilitate a referral to the wound ostomy continence nurse (WON) B) Report signs and symptoms of obstruction to the healthcare provider C) Encourage the client to mobilize in order to enhance motility D) Contact physician and obtain a swab of the stoma for culture

B) Report signs and symptoms of obstruction to the healthcare provider

A nurse caring for a post-op patient who was in the initial stage of shock. Assessment reveals that the patient has increased HR, RR, and narrow pulse pressure. Which of the following is a correct explanation of the cause of the narrowed pulse pressure A) Shock causes MAP to increase to 70-100 mmHg thus narrowing the pulse pressure B) The compensatory mechanisms cause the diastolic pressure to increase thus narrowing the pulse pressure C) The shock causes the diastolic pressure to drop thus narrowing the pulse pressure D) In shock the narrowed pulse pressure is caused by the activation of the parasympathetic nervous system

B) The compensatory mechanisms cause the diastolic pressure to increase thus narrowing the pulse pressure

A 91-year-old client is slated for orthopedic surgery and the nurse is integrated gerontologic considerations into the client's plan of care. What intervention is most justified in the care of this client? A) Administration of prophylactic antibiotics B) Use of a pressure-relieving mattress C) Use of a Foley catheter until discharge D) Total parenteral nutrition (TPN)

B) Use of a pressure-relieving mattress

A nurse cares for a patient who has a chest tube. When would this patient be at highest risk for developing a pneumothorax? A) A nurse cares for a patient who has a chest tube. When would this patient be at highest risk for developing a pneumothorax? B) When the tube becomes disconnected from the drainage system C) When the patient experiences pain at the insertion site D) When the tube drainage decreases and becomes sanguineous

B) When the tube becomes disconnected from the drainage system

The nurse is caring for a 66-year-old client with end-stage kidney disease. The client was informed by a physician that it is time to consider hemodialysis until a transplant can be found. The client tells the nurse she is not sure she wants to undergo a kidney transplant. What would be an appropriate response for the nurse to make? A) The decision is certainly yours to make, but be sure not to make a mistake." B) "I understand your hesitancy to commit to a transplant surgery. Success is comparatively rare." C) "Kidney transplants in clients your age are as successful as they are in younger clients." D) "Have you talked this over with your family?"

C) "Kidney transplants in clients your age are as successful as they are in younger clients."

A nurse is monitoring urinary output for adult a client who had a colon resection. Which of the following 24 hour output totals indicates oliguria A) 720 mL B) 550 mL C) 380 mL D) 600 mL

C) 380 mL (anything less than 400/24hr or 30mL/hr)

Nurse notices a patient's RR has increased from 13-18 and HR increased from 85 to 97 since 4hrs ago. Which of the following is the best nurse action A) Increase the rate of patient's IV infusion B) Document findings in patient's chart C) Assess the patient's tissue perfusion further D) Ask if the patient needs pain meds

C) Assess the patient's tissue perfusion further

A nurse is caring for a client who was one day post up following a transsphenodial hypophysectomy. Assessing a client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurses initial action A) Document the amount of drainage B) Obtain a culture of the drainage C) Check the drainage for glucose D) Notify the clients provider

C) Check the drainage for glucose

Pre-op assessment revealed that the patient has brittle nails and hair, dry skin turgid, and muscle wasting. What is the nurse's best action A) Refers patient to Meals on Wheels B) Document findings thoroughly in patient's chart C) Consult the surgeon about postoperative dietitian referral D) Encourage the patient to eat more after recovery

C) Consult the surgeon about postoperative dietitian referral

A client who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurse's most appropriate action? A) Document the client's low urine output and monitor closely for the next several hours. B) Contact the dietitian and suggest the need for increased oral fluid intake. C) Contact the client's health care provider and suggest assessment of fluid balance and renal function. D) Increase the infusion rate of the client's IV fluid to prompt an increase in renal function

C) Contact the client's health care provider and suggest assessment of fluid balance and renal function.

A client is receiving education about his upcoming Billroth I procedure (gastroduodenostomy). This client should be informed that he may experience which of the following adverse effects associated with this procedure? A) Constipation or bowel incontinence B) Gastric reflux and belching C) Diarrhea and feelings of fullness D) Persistent feelings of hunger and thirst

C) Diarrhea and feelings of fullness

A nurse is assessing a client stoma and postoperative day three. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse respond to this assessment. A) Irrigate the ostomy to clear a possible obstruction B) Contact the primary provider to report this finding C) Document that the stoma appears healthy and well perfused D) Document a nursing diagnosis of impaired skin integrity

C) Document that the stoma appears healthy and well perfused

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take A) Teach controlled coughing and deep breathing B) Provide a brightly lit environment C) Elevate the head of bed 20° D) Encourage a minimum intake of 2000mL of clear fluids per day

C) Elevate the head of bed 20°

A client is scheduled for the creation of a continent ileostomy. What dietary guidelines should the nurse encouraged during the weeks following surgery A) Minimum of 30g of solvable fiber daily B) Increased intake of free water and clear juices C) High intake of strained fruits and vegetables D) High calorie, high residue diet

C) High intake of strained fruits and vegetables

A client is scheduled for the creation of ileostomy. What dietary guidelines and the nurse encouraged during the weeks following surgery A) A minimum of 30 g of soluble fiber daily B) Increased and take a free water and clear juices C) High intake of strained fruits and vegetables D) High calorie, high residual diet

C) High intake of strained fruits and vegetables

A client has experienced symptoms of dumping syndrome following gastric surgery. To what physiologic phenomenon does the nurse attribute this syndrome? A) Reflux of bile into the distal esophagus B) Irritation of the phrenic nerve due to diaphragmatic pressure C) Influx of extracellular fluid into the small intestine D) Chronic malabsorption of iron and vitamins A and C

C) Influx of extracellular fluid into the small intestine

A client who underwent a gastric resection three weeks ago is having her diet progressed on a daily basis. Following her latest meal, the client reports dizziness and palpitations. Inspection revealed that the client is diaphoretic. What is the nurses best action A) Insert an NG tube probably B) Re-position the client supine C) Monitor the client closely for further signs of dumping syndrome D) Says the client for signs and symptoms of aspiration

C) Monitor the client closely for further signs of dumping syndrome

A nurse is assessing a client who is 3 days post up following abdominal surgery. Notes absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect A) UC B) Cholecystitis C) Paralytic Ileus D) Wound dehiscence

C) Paralytic Ileus

The nurse is caring for a client in the ICU who has a brain stem herniation and he was exhibiting an altered level of consciousness. Monitoring reveals that the clients mean arterial pressure is 60 mmHg within intercranial pressure reading of 20 mmHg what is the nurse is most appropriate action A) Position the client in the high-Fowler's position as tolerated B) Administer osmotic diuretics as prescribed C) Participate in interventions to increase cerebral perfusion pressure D) Prepare the client for craniotomy

C) Participate in interventions to increase cerebral perfusion pressure (should be 70-100)

The nurse is caring for a client who is postoperative day 1 following intracranial surgery. Assessment reveals that the client's LOC is slightly decreased compared with the day of surgery. What is the nurse's best action in response to this finding? A) Recognize the need to refer the client to the palliative care team B) Alert the surgeon to the possibility of an intracranial hemorrhage C) Recognize that this may represent the peak of postsurgical cerebral edema D) Understand that the surgery may have been unsuccessful

C) Recognize that this may represent the peak of postsurgical cerebral edema

A nurse is teaching a client who's post-op following colectomy. The client asked the nurse why he needs a large-bore NG tube. Which of the following statements should the nurse make A) The tube is the routine standard following this type of surgery B) The tube will allow us to provide you with nutrition C) The tube will remove gas and fluid from your stomach D) This can be explained to you once you are stable after surgery

C) The tube will remove gas and fluid from your stomach

What is the nurses best interpretation want to post intercranial surgery client developed severe hypertension with widened pulse pressure and bradycardia A) The client needs an emergency craniotomy B) Intravenous antihypertensive drugs will be administered C) This is a late sign of increased ICP and that is imminent D) A cardiac monitor should be placed followed by IV atropine

C) This is a late sign of increased ICP and that is imminent

A post-op patient is not comfortable with anti-embolic stockings and asks the nurse to remove them. What response by the nurse is the best A) No, you have to use those for 24hrs after surgery B) Let me call the surgeon to see if you really need them C) To prevent blood clots, you need them a few more hrs D) OK we can remove them since you are stable now

C) To prevent blood clots, you need them a few more hrs

A nurse is assessing a client who is 48 hours post op following abdominal surgery. Which of the following findings should the nurse report to the provider A) Blood pressure of 102/66 mmHg B) Straw colored urine from an indwelling urinary catheter C) Yellow-green drainage on the surgical incision D) Respiratory rate of 18

C) Yellow-green drainage on the surgical incision

A nurse is providing teaching to a client with a colostomy about appropriate food choices. Which of the following foods to the nurse include in the teaching A) eggs B) dried peas C) pasta D) dried fruits

C) pasta

The OR nurse is explaining to a client that cardiac surgery requires the absence of blood from the surgical field. At the same time, it is imperative to maintain perfusion of body organs and tissues. What technique for achieving these simultaneous goals should the nurse describe? A) Coronary artery bypass graft (CABG) B) Percutaneous transluminal coronary angioplasty (PTCA) C) Atherectomy D) Cardiopulmonary bypass

D) Cardiopulmonary bypass

A nurse is caring for an older adult client who is preparing for discharge following recovery from a total hip replacement. What outcome must be met prior to discharge? A) Client is able to demonstrate full ROM of the affected hip. B) Client is able to perform ADLs independently. C) Client is able to weight-bear equally on both legs. D) Client is able to perform transfers safely.

D) Client is able to perform transfers safely.

While assessing a patient who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action by the nurse is best? A) Assess for drainage from the site. B) Reinsert the tube using sterile technique. C) Contact the provider and obtain a suture kit D) Cover the insertion site with sterile gauze.

D) Cover the insertion site with sterile gauze.

The nurse is caring for a post intercranial surgery client with hemorrhaging stroke. Which assessment finding is the earliest sign of increasing intercranial pressure for the client A) Projectile vomiting B) Dilated and non-reactive pupils C) Severe hypertension D) Decreased level of consciousness

D) Decreased level of consciousness

The nurse is caring for a post craniotomy patient. The assessment revealed that the patient hourly urine output from a catheter is1500 mL for two consecutive hours. This assessment finding should alert the nurse to which of the following condirions? A) Cushing syndrome B) Syndrome of inappropriate antidiuretic hormone (SIADH) C) Adrenal crisis D) Diabetes insipidus

D) Diabetes insipidus

What should the nurse expect when hourly assessment of your an output on a client post craniotomy exhibit a urine output from a catheter of 1500 mL for two consecutive hours A) Cushing syndrome B) Syndrome of inappropriate antidiuretic hormone (SIADH) C) Adrenal crisis D) Diabetes insipidus

D) Diabetes insipidus

Patient in shock has BGL of 209. Nurse is administering insulin and wife asks "my husband is not diabetic, why is he getting insulin" Which of the responses is best A) Stress of illness made your spouse a diabetic B) Some of the meds we are giving are to raise sugar C) IV solution has lots of glucose D) High glucose is common in shock and needs to be treated

D) High glucose is common in shock and needs to be treated

The nurse is caring for a client who will have coronary artery revascularization. When explaining the pre- and postoperative regimens, the nurse should address which subject? A) Symptoms of hypovolemia B) Symptoms of low blood pressure C) Complications requiring graft removal D) Intubation and mechanical ventilation

D) Intubation and mechanical ventilation

A nurse is caring for a client who is postoperative day 1 right hip replacement. How should the nurse position the client? A) Keep hips flexed at no less than 90 degrees B) Elevate the head of the bed to high Fowler's C) Seat the client in a low chair as soon as possible D) Keep the client's hips in abduction at all times

D) Keep the client's hips in abduction at all times

A PACU nurse is caring for multiple post-op patients who are at risk for shock. Which of the following lab levels necessitate that the nurse contact the PCP A) Creatinine: 0.9 B) Sodium: 150 C) WBC: 11,000 D) Lactate: 54

D) Lactate: 54

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate A) Restrain the client to prevent injury B) Open the clients jaw to insert an oral airway C) Place the client in high Fowlers position D) Loose in the clients restrictive clothing

D) Loose in the clients restrictive clothing

The nurse is caring for a client with increased ICP. The client has a Nursing Diagnosis of ineffective cerebral tissue perfusion. What would be an expected outcome that the nurse would document after providing interventions for this diagnosis A) Copes with sensory deprivation B) Registers is normal body temperature C) Pays attention to grooming and appearance D) Obey his commands with appropriate motor responses

D) Obey his commands with appropriate motor responses

The nurse is caring for a patient in septic shock. Which specific client symptom indicates to the nurse that DIC may be present A) Hypotention B) Pale, clammy skin C)Anxiety and confusion D) Oozing of blood at the IV site

D) Oozing of blood at the IV site

The ICU nurse is caring for a client who is postoperative day 1 following kidney transplantation from a living donor. The assessment revealed that the client is producing copious quantities of dilute urine. What is the nurse's most appropriate response? A) Administer exogenous antidiuretic hormone as prescribed. B) Assess the client for further signs or symptoms of rejection. C) Inform the primary provider of this finding. D) Recognize this as an expected finding.

D) Recognize this as an expected finding.

A nurse is providing teaching to a client who has a new colostomy. Which of the following information should the nurse include in the teaching A) You can expect fecal output within 24 hours B) You will need to increase your dietary intake of raw vegetables C) You can expect the stoma to be purpleish color for the first week D) You may experience a small amount of bleeding around the stoma

D) You may experience a small amount of bleeding around the stoma

A nurse is providing teaching to a client who has a new colostomy. Which of the following information should the nurse include in the teaching A) You can expect vehicle I'll put within 24 hours B) You will need to increase your dietary intake a raw vegetables C) You can expect the stoma to be purple skin color for the first week D) You may experience a small amount of bleeding around the stoma

D) You may experience a small amount of bleeding around the stoma

The PACU nurse is assessing a post surgical patient. The patient had abdominal surgery the previous day and has a NG tube. Put in order the correct sequence for performing an accurate assessment of abdomen A) Gently palpate abdomen B) Ask patient whether they have passed flatus C) Observe for abdominal distention D) Turn off suction to the NG tube E) Auscultate for bowel sounds in all 4 quads

D, C, E, A, B

Patient is scheduled for a total gastrectomy for gastric cancer. What pre-operative laboratory results with the nurse report to the surgeon immediately A) Albumin 2.1 B) Hematocrit 28% C) HBG 8.1 D INR 4.2

INR 4.2 (patient at risk for bleeding) - normal INR is 1