Midterm 1 quiz med surg

Which action is the priority when the preoperative nurse learns that a client is taking several herbal suplements?

Ask the client which herbs have been taken

Utilizing the SBAR process to improve communication among members of the health care team, which term would the nurse associate with the A in SBAR

Assessment

A patient with emphysema is in acute respiratory distress and is becoming more confused. Respirations remain rapid but are shallower. The most recent blood gas results are pH 7.29, PaO2 62 mm Hg, PaCO2 56 mm hG, and bicarbonate HCO3 25 mEq/L. Which intervention would the nurse take?

Call RRT

When performing preoperative teaching for a patient who smokes a pack of cigarettes a day, which instruction is a priority?

Teach the patient how to use the incentive spirometer

Which acid-base imbalance would be expected in a patient who has been having acute diarrhea for more than 24 hrs?

Metabolic acidosis

When caring for a patient who is receiving morphine, the nurse prioritizes assessing for which medication side effect?

Respiratory depression

Which topic is included in preoperative patient teaching? Select all that apply incisional care pain management incentive spirometry lower extremity exercises splinting

1,3,4,5

Which mechanism in the body compensates for a low pH?

Increases respiratory rate

The nurse is assessing a patients peripheral IV site. Which assessment data indicates the need for nursing intervention?

The vein feels hard and cordlike above the insertion site

To prevent adverse outcome while providing care for a client experiencing diarrhea, which client data would the nurse closely monitor?

fluid and electrolyte balance

Which finding would the nurse expect when assessing a client hospitalized for dehydration? Select all postural hypotension skin on forehead remains tented after being pinched Client reports eating an average of 2 meals a day weight loss of 4 oz over 4 days protruding eyeballs

1, 2

Which information does the nurse educator include when giving a classroom presentation neuropathic pain? Select all that apply neuropathic pain involves the abnormal processing of stimuli subcategories of neuropathic pain include somatic and visceral pain examples of neuropathic pain include pain associated trauma and surgery neuropathic pain arises from the skin and musculoskeletal structures neuropathic pain may occur in the absence of tissue damage or inflammation

1, 5

Which potassium level would indicate that therapy for hyperkalemia was effective?

4.6

Which of the following preoperative patients has the greatest risk of bleeding as a result of his or her medication?

A male patient who takes warfarin for a history of stroke

The nurse is caring for a client after abdominal surgery and encourages the client to engage in deep breathing exercises and turn from side to side. Which complication in the nurse trying to prevent?

Respiratory acidosis

As a patient advocate, which action is the primary role of the nurse in pain management?

Accepting the patients report of pain

When caring for a patient receiving an opioid analgesic medication via patient-controlled analgesia, which action will the nurse implement immediately when whitnessing the patients spouse activate the PCA button?

Advise the patient and the spouse that only the patient may activate the PCA

Which substance causes the collecting tubules in the kidneys to reabsorb sodium as part of a blood pressure BP control system?

Aldosterone

Which task would the medical surgical nurse appropriately delegate to assistive personnel?

Ambulate a patient with a walker in the hall

Which acid base imbalance would the nurse anticipate that a patient with morbid obesity may develop?

Respiratory acidosis

Which food does the nurse recommend to a patient when the assessment findings include an ST depression on the ECG strip and a potassium level of 3.1 mEq/L?

Bananas and avocados

when making decisions about patient care, which term would the nurse associate with the act of integrating current research and statistical information?

Evidence based practice

When a post operative patients oxygen saturation rate drops from 97% to 90%, the medical surgical nurse elevated the patients head of bed to a 45 degree angle and encouraged the patient to deep breathe and cough. Which part of the nursing process was a result of the nurses clinical judgement?

Implementation

Which finding would the nurse expect when assessing a client with compensated metabolic acidosis?

Deep and rapid respirations

A patient has dry skin, a heart rate of 115 beats/min, a respiratory rate of 28 breaths/min, and weight loss of 1 lb in 1 day. Which condition would the nurse suspect?

Dehydration

Which clinical indicators would the nurse expect when an IV line has infiltrated? Select all edema heat decreased flow rate pallor increased BP

Edema, decreased flow rate, pallor

Which nursing action reflects correct use of the Wong-Baker FACES Pain Rating Scale?

Encouraging the patient to choose a cartoon face that best represents the pain

A patient who was involved in a motor vehicle accident arrives at the emergency department and requires immediate surgery to stop massive internal hemorrhaging. The patient is unconscious and no family or spouse is present. Which action would the nurse anticipate?

Getting written consultation from two other health care providers before surgery

A diabetic patient, well controlled with insulin injections, is scheduled for a mastectomy today. The patient has been NPO since midnight and the nurse notes that there are no preoperative orders regarding the daily insulin dose. The most appropriate action for the nurse to take is?

Give the patient the usual daily dosage since the stress of surgery will increase the blood glucose

A patient admitted with diabetic ketoacidosis was treated for metabolic acidosis with IV fluids and insulin. Which electrolyte imbalance would the nurse monitor for as the acid-base imbalance resolves?

Hypokalemia

Which statement describes a function of the circulating nurse?

Identifies and assesses the patient

The nurse is reviewing laboratory values for a patient recently admitted to the med-surg unit. Which laboratory result is of concern

Magnesium 6.2 mEq/L

A laboratory report for a patient shows the following results: pH 7.32; bicarbonate 24 mEq/L; partial pressure of arterial oxygen (PaO2) 77 mm Hgl and partial pressure of arterial CO2 (PaCO2) 48 mm hG. These findings are consistent with which acid base imbalance?

Respiratory acidosis

For a patient with an acid base imbalance, which method would the nurse use to determine the type of acid base imbalance the patient is experiencing?

Monitor arterial blood gases

A patient who has received a sedative preoperative lay is ready for surgery when the nurse realizes that the informed consent form has not been signed. The surgeon explained the procedure earlier and the patient reported no further questions. There is no family or next of kin present. Which action would the nurse take?

Notify the surgeon and anticipate surgery cancellation

Ten minutes after receiving scheduled preoperative sedative medications by IM injection, a patient asks to get up and use the bathroom. Which action by the nurse is MOST appropriate?

Offer the patient a bedpan/urinal and position in bed to promote voiding

Which assessment data provide the nurse with the best indicator of pain the patient is experiencing?

Pain rating of 6 on a scale of 0 to 10

Which statement by the nurse would be most useful in differentiating between nociceptive and neuropathic pain?

Please describe what your pain feels like

Which adverse effect of morphine indicates the need for naloxone administration?

Respiratory depression

Which laboratory result may indicate the need for a change in a furosemide prescription in a patient with heart failure

Serum potassium level of 2.8 mEq/L

Which intervention would the nurse expect to be prescribed for a patient with hyponatremia?

Small volume IV infusions of 3% NS

The nurse conducts preoperative teaching for a patient who is scheduled for abdominal surgery. The patient asks why he should splint the incisional area during coughing and deep breathing. The best response by the nurse is:

Splinting helps to support the area and keep pain at a minimum

When assigning a task to assistive personnel, which process will the nurse implement to ensure appropriate performance of the task?

Supervision

Which explanation is the rationale for performing sponge, needle, and instrument counts in the operating room?

The nurse is responsible for performing sponge counts as part of routine surgical standards

A patient rates pain at a 2 or 3 on a pain rating scale of 0 to 10. Which statement describes the correct interpretation of this finding?

The patient has mild pain

A patient on IV therapy reports shortness of breath. The nurse finds that the patient has elevated blood pressure, puffiness around the eyes, and distended neck veins. Which situation would the nurse suspect?

The patient is showing signs of circulatory overload

A patient is schedules for a hernia repair under general anesthesia. Which information obtained by the nurse is MOST important to communicate to the surgeon and anesthesia care provider prior to surgery?

The patients mother died after receiving general anesthesia for abdominal surgery

A patient diagnosed with myocardial infarction has the following laboratory values: potassium 2.9 mEq/L, calcium 8.5 mg/L, magnesium 1.8 mEq/L, and pH 7.39. What value should be reported to the health care provider first?

potassium 2.9 mEq/L

Which enzyme acts on angiotensinorgen to split off angiotensin 1 as part of a blood pressure control system?

renin

A patient with a history of hypertension asks the nurse what dietary changes are needed to control the blood pressure. Which item in the diet would the nurse recommend reducing?

sodium