NRS 212 Acute 1 Exam 1

The nurse is preparing discharge instructions to a client who has undergone minor same-day surgery. Which client statement indicates that teaching has been effective?

"I am not permitted to drive myself home after surgery."

A client asks the nurse about possible ill effects from general anesthesia. What is the best response by the nurse?

"Some possible negative effects include difficulty waking up and slow heart rate."

A client asks the nurse how an inhalant general anesthetic is expelled by the body. What is the best response by the nurse?

"The lungs primarily eliminate the anesthesia."

The nurse has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statement, made by the client, would indicate that further instruction is needed?

"The nurse will explain the details of the surgery before I sign a consent."

Which question is most important for the nurse to ask the client when obtaining the preoperative admission history?

"When is the last time you ate or drank?"

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."

The nurse assesses an older adult patient who complains of dimmed vision. What does this alert the nurse to plan for?

A safe environment

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes:

Ambulating the client as soon as possible

A client newly diagnosed with emphysema asks the nurse to explain all about the disease. The nurse would include the following response when defining emphysema:

An abnormal distention of the air spaces with destruction of the alveolar walls

In women, which of the following types of cancer exceeds colorectal cancer?

Breast

The nurse is evaluating the client's understanding of diet teaching aimed at promoting wound healing following surgery. The nurse would conclude teaching was ineffective if the client selects which of the following?

Cheeseburger, french fries, coleslaw, and ice cream

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

Diet modifications are part of nutritional therapy for the management of ARF. Select the high-potassium food that should be restricted.

Citrus fruits

A PACU nurse is caring for a postoperative client who received general anesthesia and has a hard, plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and 98% oxygen saturation. The client is minimally responsive to painful stimuli. What action by the nurse is most appropriate?

Continue with frequent client assessments.

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?

Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer

The client is experiencing painful oral lesions following radiation for oropharyngeal cancer. Which instruction should the nurse give this client?

Eat soft or liquid foods.

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?

Halothane

The nurse is assessing the skin graft site of a client who has undergone a radical neck dissection. The skin graft site is pink. The nurse documents which result?

Healthy graft

An anxious client being prepared for surgery is encouraged to concentrate on a pleasant experience or restful scene. What cognitive coping strategy would the nurse document as being used?

Imagery

Which of the following would the nurse expect to find when reviewing the laboratory test results of a client with renal failure?

Increased serum creatinine level

A nurse is planning a group teaching session on the topic of urinary tract infection (UTI) prevention. Which point should the nurse include?

Notify the physician if urinary urgency, burning, frequency, or difficulty occurs.

A 45-year-old obese man arrives in a clinic reporting daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of which health problem?

Obstructive sleep apnea

What is the priority action when the circulating nurse is completing a second verification of the surgical procedure and surgical site?

Obtain the attention of all members of the surgical team.

A postoperative client with an open abdominal wound is currently taking corticosteroids. The physician orders a culture of the abdominal wound even though no signs or symptoms of infection are seen. What action by the nurse is appropriate?

Obtain the wound culture specimen

An OR nurse needs to assist a patient to the Trendelenburg position. Which of the following is the correct position?

On his back, with his head lowered, so that the plane of his body meets the horizontal on an angle

The nurse has medicated a postoperative client who reported nausea. Which medication would the nurse document as having been given?

Ondansetron

A nurse is teaching a client with asthma about the proper use of the prescribed inhaled corticosteroid. Which adverse effect should the nurse be sure to address in client teaching?

Oral candidiasis

A client is in the hospital for the treatment of peptic ulcer disease. The client reports vomiting and a sudden severe pain in the abdomen. The nurse then assesses a board-like abdomen. What does the nurse suspect these symptoms indicate?

Perforation of the peptic ulcer

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue?

Pink to red and soft, noting that it bleeds easily

n COPD, the body attempts to improve oxygen-carrying capacity by increasing the amount of red blood cells. Which term refers to this process?

Polycythemia

A patient is to receive local anesthesia in combination with epinephrine. The nurse understands that epinephrine is used for which reason?

Prolongs the local action

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Reinforcing dressings or applying pressure if bleeding is frank

Which of the following techniques least exhibits surgical asepsis?

Suctioning the nasopharyngeal cavity of a client

A nurse is developing a teaching plan for a client with asthma. Which teaching point has the highest priority?

Take ordered medications as scheduled.

The nurse is caring for a client receiving hemodialysis three times weekly. The client has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this client?

Taking a BP reading on the affected arm can damage the fistula.

A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client?

The client can be discharged from the PACU.

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 client is brought to the operating room for an elective surgery. What is the priority action by the circulating nurse?

Verify consent.

Which nutrient plays an important role in normal blood clotting?

Vitamin K

The nurse is teaching a client with recurrent urinary tract infections (UTIs) ways to decrease risk for additional UTIs. The nurse includes which information?

Void immediately after sexual intercourse.

Which of the following is an inappropriate nursing action by the surgical nurse?

Wearing sterile gloves over artificial nails

Which of the following is the most accurate indicator of fluid loss or gain?

Weight

At what point does the preoperative period end?

When the client is transferred onto the operating table

A client is admitted to the emergency department with reports right lower quadrant pain. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the health care provider immediately?

White blood cell (WBC) count 22.8/mm3

A longitudinal tear or ulceration in the lining of the anal canal is termed a(n):

anal fissure.

An example of a curative surgical procedure is

tumor excision.

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

80 to 110 mg/dL

The nurse recognizes that which of the following clients is at the lowest risk for perioperative complications?

A client who has a history of arthritis

Which of the following is accurate regarding status asthmaticus?

A severe asthma episode that is refractory to initial therapy

Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency?

Adrenal

A client has a decreased secretion of erythropoietin from the kidneys due to end-stage kidney disease. The nurse explains that the decrease in erythropoietin will have what effect?

Anemia from the decrease in maturation of red blood cells

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

When should the nurse encourage the postoperative patient to get out of bed?

As soon as it is indicated

A nurse is assessing a client who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?

Assess for a patent airway.

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects the client's stools to have which description?

Black and tarry

A perioperative nurse is conducting an in-service education program about maintaining surgical asepsis during the intraoperative period. Which of the following would the nurse emphasize?

The edges of a sterile package, once opened, are considered unsterile.

What is the priority action by the scrub nurse when the surgeon begins to close the surgical wound?

Count the sponges.

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?

Dehiscence

A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client?

Developing a list of people with whom the client has had contact

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as

Emergency

A fractured skull would be classified under which category of surgery based on urgency?

Emergent

The nurse is caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery?

Encourage the client to move legs frequently and do leg exercises.

A nurse identifies a nursing diagnosis of risk for ineffective breathing pattern related to incisional pain and restricted positioning for a client who has had a nephrectomy. Which of the following would be most appropriate for the nurse to include in the client's plan of care?

Encourage use of incentive spirometer every 2 hours.

The nurse assesses a client who is bleeding profusely from the nose. The nurse documents this finding as which condition?

Epistaxis

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding?

Evisceration

The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis?

Incentive spirometry

A client who is recovering from anesthesia following oral surgery for lip cancer is experiencing difficulty breathing deeply and coughing up secretions. Which measure will help ease the client's discomfort?

Keeping the head of the bed elevated

The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?

Localized calf tenderness

A client is being treated for renal calculi and suspected hydronephrosis. Which measure should the nurse take to help maintain a record of the kidneys' function?

Monitor the client's intake and output.

Which is a true statement regarding gastric cancer?

Most clients are asymptomatic during the early stage of the disease.

A female client is undergoing a bladder training program as treatment for urinary incontinence. Which technique would be the most appropriate for the nurse to suggest?

Performing Kegel exercises

Post appendectomy, a nurse should assess the patient for abdominal rigidity and tenderness, fever, loss of bowel sounds, and tachycardia, all clinical signs of:

Peritonitis

Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections?

Receiving vaccinations

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?

Request that the surgeon come and answer the questions.

The client is undergoing a surgical procedure that is expected to last several hours. Which nursing diagnosis is most related to the duration of the procedure?

Risk for perioperative positioning injury related to positioning in the OR

A client receiving moderate sedation for a minor surgical procedure begins to vomit. What should the nurse do first?

Roll the client onto his or her side.

A client who has an altered level of consciousness is receiving a tube feeding. Clients receiving tube feeding should be placed in which position?

Semi-Fowler's or higher

A client is scheduled for surgery that will require bed rest and arrives for preoperative teaching. Which exercise will the nurse instruct the client to perform to decrease likelihood of venous thrombosis?

Side-lying bicycle riding

A client is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications?

Splint the incision site using a pillow during deep breathing and coughing exercises.

A client is admitted with a gastrointestinal bleed. What client symptom may indicate a peptic ulcer perforation to the nurse?

Sudden, severe upper abdominal pain

A nurse is working as a registered nurse first assistant as defined by the state's nurse practice act. This nurse practices under the direct supervision of which surgical team member?

Surgeon

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

Tachycardia (heart rate >150 beats per minute)

The nurse is caring for the client in the preoperative period and documenting rationale for a palliative surgical procedure. Which rationale is appropriate?

The client and physician are focusing on symptom relief not a cure.

A client realizes that regular use of laxatives has greatly improved bowel patterns. However, the nurse cautions this client against the prolonged use of laxatives for which reason?

The client's natural bowel function may become sluggish.

The nurse is working on the renal transplant unit. To reduce the risk of infection in a client with a transplanted kidney, it is imperative for the nurse to take what action?

Wash hands carefully and frequently.

The nurse is caring for a client during the immediate postoperative period and is assessing for signs of shock. What signs and symptoms indicate that the client may be in shock?

Weak and rapid pulse rate

The primary objective in the immediate postoperative period is

maintaining pulmonary ventilation.

A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client's risk of:

water and sodium retention secondary to a severe decrease in the glomerular filtration rate.