NURS350 Exam 2

Maintaining an aseptic environment in the OR is essential to patient safety and infection control. When moving around surgical areas, what distance must the nurse maintain from the sterile field?

1 foot.

A patient has been admitted to the critical care unit with a diagnosis of toxic hepatitis. When planning the patients care, the nurse should be aware of what potential clinical course of this health problem? Place the following events in the correct sequence. 1. Fever rises. 2. Hematemesis. 3. Clotting abnormalities. 4. Vascular collapse. 5. Coma.

1, 2, 3, 4, 5.

After the initial postanesthesia care unit assessment, vital signs should be assessed every _____ minutes.

15

You are caring for a patient who was admitted to have a low-profile gastrostomy device (LPGD) placed. How soon after the original gastrostomy tube placement can an LPGD be placed?

2 to 3 months.

A nurse who provides care in a walk-in clinic assesses a wide range of individuals. The nurse should identify which of the following patients as having the highest risk for chronic pancreatitis?

A 39-year-old man with chronic alcoholism.

A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which patient most closely during the intraoperative period because of the increased risk for hypothermia?

A 74-year-old woman with a low body mass index.

A patient has come to the clinic complaining of pain just above her umbilicus. When assessing the patient, the nurse notes Sister Mary Josephs nodules. The nurse should refer the patient to the primary care provider to be assessed for what health problem?

A GI malignancy.

A surgical patient has just been admitted to the unit from PACU with patient-controlled analgesia (PCA). The nurse should know that the requirements for safe and effective use of PCA include what?

A clear understanding of the need to self-dose.

A nursing instructor is discussing hemorrhoids with the nursing class. Which patients would the nursing instructor identify as most likely to develop hemorrhoids?

A pregnant woman at 28 weeks gestation.

A patient has come to the clinic complaining of blood in his stool. A FOBT test is performed but is negative. Based on the patients history, the physician suggests a colonoscopy, but the patient refuses, citing a strong aversion to the invasive nature of the test. What other test might the physician order to check for blood in the stool?

A quantitative fecal immunochemical test.

A patient with a history of injection drug use has been diagnosed with hepatitis C. When collaborating with the care team to plan this patients treatment, the nurse should anticipate what intervention?

A regimen of antiviral medications.

A nurse is performing an admission assessment for an 81-year-old patient who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what finding?

A slightly decreased size of the liver

A patient has experienced symptoms of dumping syndrome following bariatric surgery. To what physiologic phenomenon does the nurse attribute this syndrome?

A sudden release of peptides.

A patient has been diagnosed with advanced stage breast cancer and will soon begin aggressive treatment. What assessment findings would most strongly suggest that the patient may have developed liver metastases?

Abdominal pain and hepatomegaly.

A female patient has presented to the emergency department with right upper quadrant pain; the physician has ordered abdominal ultrasound to rule out cholecystitis (gallbladder infection). The patient expresses concern to the nurse about the safety of this diagnostic procedure. How should the nurse best respond?

Abdominal ultrasound poses no known safety risks of any kind.

An intraoperative nurse is applying interventions that will address surgical patients risks for perioperative positioning injury. Which of the following factors contribute to this increased risk for injury in the intraoperative phase of the surgical experience? Select all that apply.

Absence of reflexes. Diminished ability to communicate. Loss of pain sensation.

A patients colorectal cancer has necessitated a hemicolectomy with the creation of a colostomy. In the 4 days since the surgery, the patient has been unwilling to look at the ostomy or participate in any aspects of ostomy care. What is the nurses most appropriate response to this observation?

Acknowledge the patients reluctance and initiate discussion of the factors underlying it.

The policies and procedures on a preoperative unit are being amended to bring them closer into alignment with the focus of the Surgical Care Improvement Project (SCIP). What intervention most directly addresses the priorities of the SCIP?

Actions aimed at preventing surgical site infections.

A nurse is caring for a patient who has been admitted to the hospital with diverticulitis. Which of the following would be appropriate nursing diagnoses for this patient? Select all that apply.

Acute Pain Related to Increased Peristalsis and GI Inflammation. Activity Intolerance Related to Generalized Weakness. Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea.

A nurse is caring for a patient admitted with symptoms of an anorectal infection; cultures indicate that the patient has a viral infection. The nurse should anticipate the administration of what drug?

Acyclovir (Zovirax).

The nurse is creating the plan of care for a patient who is status postsurgery for reduction of a femur fracture. What is the most important short-term goal for this patient?

Adequate respiratory function.

A patient comes to the bariatric clinic to obtain information about bariatric surgery. The nurse assesses the obese patient knowing that in addition to meeting the criterion of morbid obesity, a candidate for bariatric surgery must also demonstrate what?

Adequate understanding of required lifestyle changes.

A participant in a health fair has asked the nurse about the role of drugs in liver disease. What health promotion teaching has the most potential to prevent drug-induced hepatitis?

Adhere to dosing recommendations of OTC analgesics.

A nurse is caring for a patient who has an order to discontinue the administration of parenteral nutrition. What should the nurse do to prevent the occurrence of rebound hypoglycemia in the patient?

Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN.

A patient with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the patients fluid volume excess? Select all that apply.

Administering diuretics. Implementing fluid restrictions. Enhancing patient positioning.

The nurse is caring for a 78-year-old female patient who is scheduled for surgery to remove her brain tumor. The patient is very apprehensive and keeps asking when she will get her preoperative medicine. The medicine is ordered to be given on call to OR. When would be the best time to give this medication?

After being notified by the OR and before other preoperative preparations.

The recovery room nurse is admitting a patient from the OR following the patients successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted patient?

Airway patency.

The nurse is performing a preoperative assessment on a patient going to surgery. The patient informs the nurse that he drinks approximately two bottles of wine each day and has for the last several years. What postoperative difficulties can the nurse anticipate for this patient?

Alcohol withdrawal syndrome 2 to 4 days after his last alcoholic drink.

A patients health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohns disease, rather that ulcerative colitis, as the cause of the patients signs and symptoms?

An absence of blood in stool.

A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at this restaurant and have never received the hepatitis A vaccine?

An immune globulin injection.

A patient with dysphagia is scheduled for PEG tube insertion and asks the nurse how the tube will stay in place. What is the nurses best response?

An internal retention disc secures the tube against the stomach wall.

The OR will be caring for a patient who will receive a transsacral block. For what patient would the use of a transsacral block be appropriate for pain control?

An older adult man who will undergo an inguinal hernia repair.

The patients surgery is nearly finished and the surgeon has opted to use tissue adhesives to close the surgical wound. This requires the nurse to prioritize assessments related to what complication?

Anaphylaxis.

The OR nurse is providing care for a 25-year-old major trauma patient who has been involved in a motorcycle accident. The nurse should know that the patient is at increased risk for what complication of surgery?

Anesthesia awareness.

A patient has been diagnosed with peptic ulcer disease and the nurse is reviewing his prescribed medication regimen with him. What is currently the most commonly used drug regimen for peptic ulcers?

Antibiotics, proton pump inhibitors, and bismuth salts.

The nurse is providing care for a patient whose inflammatory bowel disease has necessitated hospital treatment. Which of the following would most likely be included in the patients medication regimen?

Anticholinergic medications 30 minutes before a meal.

A patient has had a laparoscopic cholecystectomy. The patient is now complaining of right shoulder pain. What should the nurse suggest to relieve the pain?

Application of heat 15 to 20 minutes each hour.

A patient has had an ileostomy created for the treatment of irritable bowel disease and the patient is now preparing for discharge. What should the patient be taught about changing this device in the home setting?

Apply a skin barrier to the peristomal skin prior to applying the pouch.

A nurse is caring for a patient with recurrent hematemesis who is scheduled for upper gastrointestinal fibroscopy (UGF). How should the nurse in the radiology department prepare this patient?

Apply local anesthetic to the back of the patients throat.

A community health nurse is caring for a patient whose multiple health problems include chronic pancreatitis. During the most recent visit, the nurse notes that the patient is experiencing severe abdominal pain and has vomited 3 times in the past several hours. What is the nurses most appropriate action?

Arrange for the patient to be transported to the hospital.

The nurse is planning patient teaching for a patient who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching?

As soon as possible before the surgical procedure.

An older adult who resides in an assisted living facility has sought care from the nurse because of recurrent episodes of constipation. Which of the following actions should the nurse first perform?

Assess the patients food and fluid intake.

The nurse is performing the shift assessment of a postsurgical patient. The nurse finds his mental status, level of consciousness, speech, and orientation are intact and at baseline, but the patient tells you he is very anxious. What should the nurse do next?

Assess the patients oxygen levels.

A patient with liver cancer is being discharged home with a biliary drainage system in place. The nurse should teach the patients family how to safely perform which of the following actions?

Assessing the patency of the drainage catheter.

A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this patients plan of care?

Assessment for variceal bleeding.

A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?

Asterixis.

The perioperative nurse is providing care for a patient who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The patient is reluctant to ambulate, citing the need to recover in bed. For what complication is the patient most at risk?

Atelectasis.

A nurse is providing care for a patient who is postoperative day 2 following gastric surgery. The nurses assessment should be planned in light of the possibility of what potential complications? Select all that apply.

Atelectasis. Pneumonia. Metabolic imbalances.

A patients NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next?

Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating.

A patient with a peptic ulcer disease has had metronidazole (Flagyl) added to his current medication regimen. What health education related to this medication should the nurse provide?

Avoid drinking alcohol while taking the drug.

A nurse is caring for a patient with constipation whose primary care provider has recommended senna (Senokot) for the management of this condition. The nurse should provide which of the following education points?

Avoid taking the drug on a long-term basis.

Probably the most widely used in-office or at-home occult blood test is the Hemoccult II. The patient has come to the clinic because he thinks there is blood in his stool. When you reviewed his medications, you noted he is on antihypertensive drugs and NSAIDs for early arthritic pain. You are sending the patient home with the supplies necessary to perform 2 hemoccult tests on his stool and mail the samples back to the clinic. What instruction would you give this patient?

Avoid vitamin C for 72 hours before you start the test.

A nurse is creating a care plan for a patient with acute pancreatitis. The care plan includes reduced activity. What rationale for this intervention should be cited in the care plan?

Bed rest lowers the metabolic rate and reduces enzyme production.

A nurse is caring for a patient with biliary colic and is aware that the patient may experience referred abdominal pain. Where would the nurse most likely expect this patient to experience referred pain?

Below the right nipple.

A patient returns to the floor after a laparoscopic cholecystectomy. The nurse should assess the patient for signs and symptoms of what serious potential complication of this surgery?

Bile duct injury.

The nurse is caring for a patient who has just returned from the ERCP removal of gallstones. The nurse should monitor the patient for signs of what complications?

Bleeding and perforation.

A student nurse is caring for a patient who has a diagnosis of acute pancreatitis and who is receiving parenteral nutrition. The student should prioritize which of the following assessments?

Blood glucose levels.

A patient is scheduled for surgery the next day and the different phases of the patients surgical experience will require input from members of numerous health disciplines. How should the patients care best be coordinated?

By implementing an interdisciplinary approach to care.

As an intraoperative nurse, you are the advocate for each of the patients who receives care in the surgical setting. How can you best exemplify the principles of patient advocacy?

By maintaining each of your patients privacy.

A patient with cirrhosis has experienced a progressive decline in his health; and liver transplantation is being considered by the interdisciplinary team. How will the patients prioritization for receiving a donor liver be determined?

By objectively determining the patients medical need.

The nurse is preparing a patient for surgery. The patient states that she is very nervous and really does not understand what the surgical procedure is for or how it will be performed. What is the most appropriate nursing action for the nurse to take?

Call the physician to review the procedure with the patient.

Which disorder results in malabsorption which is caused by an autoimmune response to the consumption of products containing gluten?

Celiac disease

A nurse is teaching a group of adults about screening and prevention of colorectal cancer. The nurse should describe which of the following as the most common sign of possible colon cancer?

Change in bowel habits.

A nurse is aware of the high incidence of catheter-related bloodstream infections in patients receiving parenteral nutrition. What nursing action has the greatest potential to reduce catheter-related bloodstream infections?

Change the dressing no more than weekly.

A patient has been discharged home on parenteral nutrition (PN). Much of the nurses discharge education focused on coping. What must a patient on PN likely learn to cope with? Select all that apply.

Changes in lifestyle. Loss of eating as a social behavior. Sleep disturbances related to frequent urination during nighttime infusions.

The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurses assessments most directly addresses a major complication of TPN?

Checking the patients capillary blood glucose levels regularly.

A patients health decline necessitates the use of total parenteral nutrition. The patient has questioned the need for insertion of a central venous catheter, expressing a preference for a normal IV. The nurse should know that peripheral administration of high-concentration PN formulas is contraindicated because of the risk for what complication?

Chemical phlebitis.

A patient has just been diagnosed with chronic pancreatitis. The patient is underweight and in severe pain and diagnostic testing indicates that over 80% of the patients pancreas has been destroyed. The patient asks the nurse why the diagnosis was not made earlier in the disease process. What would be the nurses best response?

Chronic pancreatitis often goes undetected until a large majority of pancreatic function is lost.

A 68-year-old patient is scheduled for a bilateral mastectomy. The OR nurse has come out to the holding area to meet the patient and quickly realizes that the patient is profoundly anxious. What is the most appropriate intervention for the nurse to apply?

Clearly explain any information that the patient seeks.

The nurse just received a postoperative patient from the PACU to the medicalsurgical unit. The patient is an 84-year-old woman who had surgery for a left hip replacement. Which of the following concerns should the nurse prioritize for this patient in the first few hours on the unit?

Close monitoring of neurologic status.

A nurse is creating a care plan for a patient who is receiving parenteral nutrition. The patients care plan should include nursing actions relevant to what potential complications? Select all that apply.

Clotted or displaced catheter. Pneumothorax. Hyperglycemia. Line sepsis.

A ______________ is a procedure in which direct visual inspection of the large intestine is performed.

Colonoscopy

A patient has come to the outpatient radiology department for diagnostic testing. Which of the following diagnostic procedures will allow the care team to evaluate and remove polyps?

Colonoscopy.

A patients new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patients care plan accordingly. What intervention should the nurse include in the patients plan of care?

Confirm placement of the tube prior to each medication administration.

The surgical nurse is preparing to send a patient from the presurgical area to the OR and is reviewing the patients informed consent form. What are the criteria for legally valid informed consent? Select all that apply.

Consent must be freely given. Consent must be obtained by a physician. Signature must be witnessed by a professional staff member.

Patients who receive gastric or enteric tube feedings can experience which two elimination patterns?

Constipation and diarrhea

A nurse is working with a patient who has chronic constipation. What should be included in patient teaching to promote normal bowel function?

Consume high-residue, high-fiber foods.

A nurse is preparing to administer a patients scheduled parenteral nutrition (PN). Upon inspecting the bag, the nurse notices that the presence of small amounts of white precipitate are present in the bag. What is the nurses best action?

Contact the pharmacy to obtain a new bag of PN.

A patient admitted with acute diverticulitis has experienced a sudden increase in temperature and complains of a sudden onset of exquisite abdominal tenderness. The nurses rapid assessment reveals that the patients abdomen is uncharacteristically rigid on palpation. What is the nurses best response?

Contact the primary care provider promptly and report these signs of perforation.

A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem?

Daily weights and abdominal girth measurement.

The home health nurse is caring for a postoperative patient who was discharged home on day 2 after surgery. The nurse is performing the initial visit on the patients postoperatative day 2. During the visit, the nurse will assess for wound infection. For most patients, what is the earliest postoperative day that a wound infection becomes evident?

Day 5.

A patient with a diagnosis of cirrhosis has developed variceal bleeding and will imminently undergo variceal banding. What psychosocial nursing diagnosis should the nurse most likely prioritize during this phase of the patients treatment?

Death Anxiety.

A patient has been experiencing significant psychosocial stress in recent weeks. The nurse is aware of the hormonal effects of stress, including norepinephrine release. Release of this substance would have what effect on the patients gastrointestinal function?

Decreased motility.

A nurse is performing an abdominal assessment of an older adult patient. When collecting and analyzing data, the nurse should be cognizant of what age-related change in gastrointestinal structure and function?

Decreased mucus secretion.

A patient who is obese is exploring bariatric surgery options and presented to a bariatric clinic for preliminary investigation. The nurse interviews the patient, analyzing and documenting the data. Which of the following nursing diagnoses may be a contraindication for bariatric surgery?

Deficient Knowledge Related to Risks and Expectations of Surgery.

The nursing instructor is talking with a group of medicalsurgical students about deep vein thrombosis (DVT). A student asks what factors contribute to the formation of a DVT. What would be the instructors best response?

Dehydration is a contributory factor to the formation of deep vein thrombi.

Prior to a patients scheduled jejunostomy, the nurse is performing the preoperative assessment. What goal should the nurse prioritize during the preoperative assessment?

Determining the patients ability to understand and cooperate with the procedure.

A patient is receiving education about his upcoming Billroth I procedure (gastroduodenostomy). This patient should be informed that he may experience which of the following adverse effects associated with this procedure?

Diarrhea and feelings of fullness.

A patient with cystic fibrosis takes pancreatic enzyme replacements on a regular basis. The patients intake of trypsin facilitates what aspect of GI function?

Digestion of proteins.

A patient receiving tube feedings is experiencing diarrhea. The nurse and the physician suspect that the patient is experiencing dumping syndrome. What intervention is most appropriate?

Dilute the concentration of the feeding solution.

The nurse is packing a patients abdominal wound with sterile, half-inch Iodoform gauze. During the procedure, the nurse drops some of the gauze onto the patients abdomen 2 inches (5 cm) away from the wound. What should the nurse do?

Discard the gauze packing and repack the wound with new Iodoform gauze.

While the surgical patient is anesthetized, the scrub nurse hears a member of the surgical team make an inappropriate remark about the patients weight. How should the nurse best respond?

Discourage the colleague from making such comments.

A group of nurses have attended an inservice on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurses risk of acquiring hepatitis C in the workplace?

Disposing of sharps appropriately and not recapping needles.

When creating plans of nursing care for patients who are undergoing surgery using general anesthetic, what nursing diagnoses should the nurse identify? Select all that apply.

Disturbed sensory perception related to anesthetic. Risk of latex allergy response related to surgical exposure. Anxiety related to surgical concerns.

A nurse is assessing a patients stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding?

Document that the stoma appears healthy and well perfused.

A nurse is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system. The nurses most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurses best response to this assessment finding?

Document the presence of normal bile output.

A patient with gastritis required hospital treatment for an exacerbation of symptoms and receives a subsequent diagnosis of pernicious anemia due to malabsorption. When planning the patients continuing care in the home setting, what assessment question is most relevant?

Does anyone in your family have experience at giving injections?

A patient comes to the clinic complaining of pain in the epigastric region. What assessment question during the health interview would most help the nurse determine if the patient has a peptic ulcer?

Does your pain resolve when you have something to eat?

The nurse is preparing to change a patients abdominal dressing. The nurse recognizes the first step is to provide the patient with information regarding the procedure. Which of the following explanations should the nurse provide to the patient?

During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to.

A nurse caring for a patient who has had bariatric surgery is developing a teaching plan in anticipation of the patients discharge. Which of the following is essential to include?

Eat several small meals daily spaced at equal intervals.

A patient has received a diagnosis of gastric cancer and is awaiting a surgical date. During the preoperative period, the patient should adopt what dietary guidelines?

Eat small, frequent meals with high calorie and vitamin content.

A patient is one month postoperative following restrictive bariatric surgery. The patient tells the clinic nurse that he has been having trouble swallowing for the past few days. What recommendation should the nurse make?

Eating more slowly and chewing food more thoroughly

A patient has been admitted to the hospital for the treatment of chronic pancreatitis. The patient has been stabilized and the nurse is now planning health promotion and educational interventions. Which of the following should the nurse prioritize?

Educating the patient about post-discharge lifestyle modifications.

The nurse is doing a preoperative assessment of an 87-year-old man who is slated to have a right lung lobe resection to treat lung cancer. What underlying principle should guide the nurses preoperative assessment of an elderly patient?

Elderly patients have less physiologic reserve than younger patients.

The surgeons preoperative assessment of a patient has identified that the patient is at a high risk for venous thromboembolism. Once the patient is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the patients risk of developing this complication?

Encourage early ambulation.

A patient has been treated in the hospital for an episode of acute pancreatitis. The patient has acknowledged the role that his alcohol use played in the development of his health problem, but has not expressed specific plans for lifestyle changes after discharge. What is the nurses most appropriate response?

Encourage the patient to connect with a community-based support group.

The nurse is admitting a patient to the medicalsurgical unit from the PACU. What should the nurse do to help the patient clear secretions and help prevent pneumonia?

Encourage the patient to use the incentive spirometer every 2 hours.

A nurse is providing care for a patient whose recent colostomy has contributed to a nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention best addresses this diagnosis?

Engage the patient in the care of the ostomy to the extent that the patient is willing.

The OR nurse is participating in the appendectomy of a 20 year-old female patient who has a dangerously low body mass index. The nurse recognizes the patients consequent risk for hypothermia. What action should the nurse implement to prevent the development of hypothermia?

Ensure that IV fluids are warmed to the patients body temperature.

A patient will be undergoing a total hip arthroplasty later in the day and it is anticipated that the patient may require blood transfusion during surgery. How can the nurse best ensure the patients safety if a blood transfusion is required?

Ensure that the patient has had a current cross-match.

A patients enteral feedings have been determined to be too concentrated based on the patients development of dumping syndrome. What physiologic phenomenon caused this patients complication of enteral feeding?

Entry of large amounts of water into the small intestine because of osmotic pressure.

A nurse is caring for a patient who just has been diagnosed with a peptic ulcer. When teaching the patient about his new diagnosis, how should the nurse best describe a peptic ulcer?

Erosion of the lining of the stomach or intestine.

A patient was treated in the emergency department and critical care unit after ingesting bleach. What possible complication of the resulting gastritis should the nurse recognize?

Esophageal or pyloric obstruction related to scarring.

A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this patient? Select all that apply.

Establishing an IV line. Verifying the surgical site with the patient. Taking measure to ensure the patients comfort.

Prior to a patients scheduled surgery, the nurse has described the way that members of diverse health disciplines will collaborate in the patients care. What is the main rationale for organizing perioperative care in this collaborative manner?

Evidence-based practice.

A nurse is performing the admission assessment of a patient whose high body mass index (BMI) corresponds to class III obesity. In order to ensure empathic and patient-centered care, the nurse should do which of the following?

Examine ones own attitudes towards obesity in general and the patient in particular.

The nurse is caring for a patient who is admitted to the ER with the diagnosis of acute appendicitis. The nurse notes during the assessment that the patients ribs and xiphoid process are prominent. The patient states she exercises two to three times daily and her mother indicates that she is being treated for anorexia nervosa. How should the nurse best follow up these assessment data?

Facilitate a detailed analysis of the patients electrolyte levels.

A nurse is providing anticipator guidance to a patient who is preparing for bariatric surgery. The nurse learns that the patient is anxious about numerous aspects of the surgery. What intervention is most appropriate to alleviate the patients anxiety?

Facilitate the patients contact with a support group.

In order to prevent wrong site surgery the surgical site should be marked by the patient and the nurse prior to surgery. True or False?

False.

A patient is receiving care in the intensive care unit for acute pancreatitis. The nurse is aware that pancreatic necrosis is a major cause of morbidity and mortality in patients with acute pancreatitis. Consequently, the nurse should assess for what signs or symptoms of this complication?

Fever, increased heart rate and decreased blood pressure.

The nurses aide notifies the nurse that a patient has decreased oxygen saturation levels. The nurse assesses the patient and finds that he is tachypnic, has crackles on auscultation, and his sputum is frothy and pink. The nurse should suspect what complication?

Flash pulmonary edema.

A patient has been prescribed orlistat (Xenical) for the treatment of obesity. When providing relevant health education for this patient, the nurse should ensure the patient is aware of what potential adverse effect of treatment?

Flatus with oily discharge.

An adult patient is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the patient has completed the test?

Fluids must be increased to facilitate the evacuation of the stool.

The nurse is caring for a patient who is undergoing diagnostic testing for suspected malabsorption. When taking this patients health history and performing the physical assessment, the nurse should recognize what finding as most consistent with this diagnosis?

Foul-smelling diarrhea that contains fat.

A nurse in the postanesthesia care unit admits a patient following resection of a gastric tumor. Following immediate recovery, the patient should be placed in which position to facilitate patient comfort and gastric emptying?

Fowlers.

A patient with a diagnosis of colon cancer is 2 days postoperative following bowel resection and anastomosis. The nurse has planned the patients care in the knowledge of potential complications. What assessment should the nurse prioritize?

Frequent abdominal auscultation.

A nurse is providing care for a patient with a diagnosis of late-stage Alzheimers disease. The patient has just returned to the medical unit to begin supplemental feedings through an NG tube. Which of the nurses assessments addresses this patients most significant potential complication of feeding?

Frequent lung auscultation.

A patient has been experiencing disconcerting GI symptoms that have been worsening in severity. Following medical assessment, the patient has been diagnosed with lactose intolerance. The nurse should recognize an increased need for what form of health promotion?

Frequent screening for osteoporosis.

A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a patient admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?

Fried chicken.

A nurse is assessing the abdomen of a patient just admitted to the unit with a suspected GI disease. Inspection reveals several diverse lesions on the patients abdomen. How should the nurse best interpret this assessment finding?

GI diseases often produce skin changes.

A patient presents to the emergency department (ED) complaining of severe right upper quadrant pain. The patient states that his family doctor told him he had gallstones. The ED nurse should recognize what possible complication of gallstones?

Gangrene of the gallbladder.

The nurse is caring for a patient who is postoperative from having a gastrostomy tube placed. What should the nurse do on a daily basis to prevent skin breakdown?

Gently rotate the tube.

A patient has a recent diagnosis of chronic pancreatitis and is undergoing diagnostic testing to determine pancreatic islet cell function. The nurse should anticipate what diagnostic test?

Glucose tolerance test.

A nurse has entered the room of a patient with cirrhosis and found the patient on the floor. The patient states that she fell when transferring to the commode. The patients vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurses most appropriate action?

Have the patient assessed by the physician due to the risk of internal bleeding.

A patient has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study?

Have the patient refrain from food and fluids after midnight.

An adult patient has just been admitted to the PACU following abdominal surgery. As the patient begins to awaken, he is uncharacteristically restless. The nurse checks his skin and it is cold, moist, and pale. The nurse concerned the patient may be at risk for what?

Hemorrhage and shock.

A clinic patient has described recent dark-colored stools;the nurse recognizes the need for fecal occult blood testing (FOBT). What aspect of the patients current health status would contraindicate FOBT?

Hemorrhoids.

A patient asks the nursing assistant for a bedpan. When the patient is finished, the nursing assistant notifies the nurse that the patient has bright red streaking of blood in the stool. What is this most likely a result of?

Hemorrhoids.

Which type of Hepatitis requires proper hand hygiene and proper food handling?

Hepatitis A

A nurse is presenting an educational event to a local community group. When speaking about colorectal cancer, what risk factor should the nurse cite?

High levels of alcohol consumption.

A patient has been diagnosed with pancreatic cancer and has been admitted for care. Following initial treatment, the nurse should be aware that the patient is most likely to require which of the following?

Hospice care.

A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this patients presentation?

How many alcoholic drinks do you typically consume in a week?

A patients assessment and diagnostic testing are suggestive of acute pancreatitis. When the nurse is performing the health interview, what assessment questions address likely etiologic factors? Select all that apply.

How many alcoholic drinks do you typically consume in a week? Have you ever been diagnosed with gallstones?

A patient presents at the walk-in clinic complaining of recurrent sharp stomach pain that is relieved by eating. The nurse suspects that the patient may have an ulcer. How would the nurse explain the formation and role of acid in the stomach to the patient?

Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food.

The perioperative nurse has completed the presurgical assessment of an 82-year-old female patient who is scheduled for a left total knee replacement. When planning this patients care, the nurse should address the consequences of the patients aging cardiovascular system. These include an increased risk of which of the following?

Hypervolemia.

A nursing student has auscultated a patients abdomen and noted one or two bowel sounds in a 2-minute period of time. How would you tell the student to document the patients bowel sounds?

Hypoactive.

The nurse is planning the care of a patient who has type 1 diabetes and who will be undergoing knee replacement surgery. This patients care plan should reflect an increased risk of what postsurgical complications? Select all that apply.

Hypoglycemia. Acidosis. Glucosuria.

You are caring for a 71-year-old patient who is 4 days postoperative for bilateral inguinal hernias. The patient has a history of congestive heart failure and peptic ulcer disease. The patient is highly reluctant to ambulate and will not drink fluids except for hot tea with her meals. The nurses aide reports to you that this patients vital signs are slightly elevated and that she has a nonproductive cough. When you assess the patient, you auscultate crackles at the base of the lungs. What would you suspect is wrong with your patient?

Hypostatic pulmonary congestion.

The PACU nurse is caring for a 45-year-old male patient who had a left lobectomy. The nurse is assessing the patient frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU include what? Select all that apply.

Hypotension. Dysrhythmias. Hypertension.

The nurse is preparing an elderly patient for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the patient?

Hypothermia.

The nurse admits a patient to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the patients blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the patients skin is cold, moist, and pale. Of what is the patient showing signs?

Hypovolemic shock.

The intraoperative nurse is implementing a care plan that addresses the surgical patients risk for vomiting. Interventions that address the potential for vomiting reduce the risk of what subsequent surgical complication?

Hypoxia.

The management of the patients gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the patient is managing the tube correctly?

I flush my tube with water before and after each of my medications.

A patient with gallstones has been prescribed ursodeoxycholic acid (UDCA). The nurse understands that additional teaching is needed regarding this medication when the patient states:

I will take this medication for 2 weeks and then gradually stop taking it.

A nurse is participating in the emergency care of a patient who has just developed variceal bleeding. What intervention should the nurse anticipate?

IV administration of octreotide (Sandostatin).

A patient has been diagnosed with acute pancreatitis. The nurse is addressing the diagnosis of Acute Pain Related to Pancreatitis. What pharmacologic intervention is most likely to be ordered for this patient?

IV hydromorphone (Dilaudid).

The nurse is providing teaching about tissue repair and wound healing to a patient who has a leg ulcer. Which of the following statements by the patient indicates that teaching has been effective?

Ill eat plenty of fruits and vegetables.

A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply.

Immunization. Use of standard precautions.

A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patients increased risk of bleeding. The nurse recognizes that this risk is related to the patients inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function?

Inability of the liver to use vitamin K.

A critical care nurse is caring for a patient diagnosed with acute pancreatitis. The nurse knows that the indications for starting parenteral nutrition (PN) for this patient are what?

Inability to take in adequate oral food or fluids within 7 days.

As an intraoperative nurse, you know that the patients emotional state can influence the outcome of his or her surgical procedure. How would you best reinforce the patients ability to influence outcome?

Incorporate cultural and religious considerations, as appropriate.

A patient who has been experiencing changes in his bowel function is scheduled for a barium enema. What instruction should the nurse provide for postprocedure recovery?

Increase fluid intake to evacuate the barium.

A patients abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the patients laboratory studies, what finding is most closely associated with this diagnosis?

Increased bilirubin.

An adult patient has been diagnosed with diverticular disease after ongoing challenges with constipation. The patient will be treated on an outpatient basis. What components of treatment should the nurse anticipate? Select all that apply.

Increased fiber intake. Reduced fat intake.

During a patients scheduled home visit, an older adult patient has stated to the community health nurse that she has been experiencing hemorrhoids of increasing severity in recent months. The nurse should recommend which of the following?

Increased fluid and fiber intake.

A nurse is caring for a patient who is receiving parenteral nutrition. When writing this patients plan of care, which of the following nursing diagnoses should be included?

Ineffective Role Performance Related to Parenteral Nutrition.

Which of the following is the most plausible nursing diagnosis for a patient whose treatment for colon cancer has necessitated a colonostomy?

Ineffective Sexuality Patterns Related to Changes in Self-Concept.

A patient is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this patients care, which of the following nursing diagnoses should the nurse prioritize?

Ineffective Tissue Perfusion Related to Bowel Ischemia.

A nurse is assessing a patient who has peptic ulcer disease. The patient requests more information about the typical causes of Helicobacter pylori infection. What would it be appropriate for the nurse to instruct the patient?

Infection typically occurs due to ingestion of contaminated food and water.

A patient presents to the walk-in clinic complaining of vomiting and burning in her mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the physician is likely to order a diagnostic test to detect the presence of what?

Infection with Helicobacter pylori.

The clinic nurse is doing a preoperative assessment of a patient who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the patients medical history, the nurse notes that this patient had a kidney transplant 8 years ago and that the patient is taking immunosuppressive drugs. For what is this patient at increased risk when having surgery?

Infection.

The nurse is creating the care plan for a 70-year-old obese patient who has been admitted to the postsurgical unit following a colon resection. This patients age and increased body mass index mean that she is at increased risk for what complication in the postoperative period?

Infection.

A nurse is caring for a patient who is scheduled for a colonoscopy and whose bowel preparation will include polyethylene glycol electrolyte lavage prior to the procedure. The presence of what health problem would contraindicate the use of this form of bowel preparation?

Inflammatory bowel disease.

The nurse is caring for a patient who has a diagnosis of AIDS. Inspection of the patients mouth reveals the new presence of white lesions on the patients oral mucosa. What is the nurses most appropriate response?

Inform the primary care provider of this finding.

Verification that all required documentation is completed is an important function of the intraoperative nurse. The intraoperative nurse should confirm that the patients accompanying documentation includes which of the following?

Informed consent.

A nurse is initiating parenteral nutrition (PN) to a postoperative patient who has developed complications. The nurse should initiate therapy by performing which of the following actions?

Initiating the infusion slowly and monitoring the patients fluid and glucose tolerance.

A nurse is working with a patient who is learning to care for a continent ileostomy (Kock pouch). Following the initial period of healing, the nurse is teaching the patient how to independently empty the ileostomy. The nurse should teach the patient to do which of the following actions?

Insert the catheter approximately 5 cm into the pouch.

A 35-year-old male patient presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize?

Insertion of a nasogastric tube.

A patient has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurses priority intervention?

Insertion of an NG tube for decompression.

The nurse is preparing to perform a patients abdominal assessment. What examination sequence should the nurse follow?

Inspection, auscultation, percussion, and palpation.

You are providing preoperative teaching to a patient scheduled for hip replacement surgery in 1 month. During the preoperative teaching, the patient gives you a list of medications she takes, the dosage, and frequency. Which of the following interventions provides the patient with the most accurate information?

Instruct the patient to stop taking St. Johns wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents.

A patient is undergoing diagnostic testing for a tumor of the small intestine. What are the most likely symptoms that prompted the patient to first seek care?

Intermittent pain and bloody stool.

A nurse is preparing to administer a patients intravenous fat emulsion simultaneously with parenteral nutrition (PN). Which of the following principles should guide the nurses action?

Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered.

A 21-year-old patient is positioned on the OR bed prior to knee surgery to correct a sports-related injury. The anesthesiologist administers the appropriate anesthetic. The OR nurse should anticipate which of the following events as the teams next step in the care of this patient?

Intubating.

A nurse is caring for a patient with gallstones who has been prescribed ursodeoxycholic acid (UDCA). The patient askshow this medicine is going to help his symptoms. The nurse should be aware of what aspect of this drugs pharmacodynamics?

It inhibits the synthesis and secretion of cholesterol.

A nurse is providing patient education for a patient with peptic ulcer disease secondary to chronic nonsteroidal anti-inflammatory drug (NSAID) use. The patient has recently been prescribed misoprostol (Cytotec). What would the nurse be most accurate in informing the patient about the drug?

It protects the stomachs lining.

A nurse is caring for a patient following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache?

Keep the patient positioned supine.

A patient is concerned about leakage of gastric contents out of the gastric sump tube the nurse has just inserted. What would the nurse do to prevent reflux gastric contents from coming through the blue vent of a gastric sump tube?

Keep the vent lumen above the patients waist.

The intraoperative nurse is transferring a patient from the OR to the PACU after replacement of the right knee. The patient is a 73-year-old woman. The nurse should prioritize which of the following actions?

Keeping the patient warm.

The nurse is preparing to send a patient to the OR for a scheduled surgery. What should the nurse ensure is on the chart when it accompanies the patient to surgery? Select all that apply.

Laboratory reports. Nurses notes. Verification form.

A patient with ongoing back pain, nausea, and abdominal bloating has been diagnosed with cholecystitis secondary to gallstones. The nurse should anticipate that the patient will undergo what intervention?

Laparoscopic cholecystectomy

A patient with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure?

Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure.

The anesthetist is coming to the surgical admissions unit to see a patient prior to surgery scheduled for tomorrow morning. Which of the following is the priority information that the nurse should provide to the anesthetist during the visit?

Latex allergy.

The nurse is assessing placement of a nasogastric tube that the patient has had in place for 2 days. The tube is draining green aspirate. What is the nurses most appropriate action?

Leave the tube in its present position.

A nurse is providing preoperative teaching to a patient who will soon undergo a cardiac bypass. The nurses teaching plan includes exercises of the extremities. What is the purpose of teaching a patient leg exercises prior to surgery?

Leg exercises improve circulation and prevent venous thrombosis.

A nurse is caring for a patient admitted with a suspected malabsorption disorder. The nurse knows that one of the accessory organs of the digestive system is the pancreas. What digestive enzymes does the pancreas secrete? Select all that apply.

Lipase. Amylase. Trypsin.

A 59-year-old male patient is scheduled for a hemorrhoidectomy. The OR nurse should anticipate assisting the other team members with positioning the patient in what manner?

Lithotomy position.

A previously healthy adults sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the patient has been admitted to the intensive care unit. The nurse should be aware that the treatment of choice for this patient is what?

Liver transplantation.

Diagnostic testing has revealed that a patients hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this patients plan of care will focus on what intervention?

Lobectomy.

A nurse is providing discharge education to a patient who has undergone a laparoscopic cholecystectomy. During the immediate recovery period, the nurse should recommend what foods?

Low-fat foods high in proteins and carbohydrates.

The nurse is providing health education to a patient scheduled for a colonoscopy. The nurse should explain that she will be placed in what position during this diagnostic test?

Lying on the left side with legs drawn toward the chest.

A nurse is talking with a patient who is scheduled to have a hemicolectomy with the creation of a colostomy. The patient admits to being anxious, and has many questions concerning the surgery, the care of a stoma, and necessary lifestyle changes. Which of the following nursing actions is most appropriate?

Maintain an open dialogue with the patient and facilitate a referral to the wound-ostomy- continence (WOC) nurse.

A patient is being treated on the acute medical unit for acute pancreatitis. The nurse has identified a diagnosis of Ineffective Breathing Pattern Related to Pain. What intervention should the nurse perform in order to best address this diagnosis?

Maintain the patient in a semi-Fowlers position whenever possible.

The nurse is caring for a patient who has just been transferred to the PACU from the OR. What is the highest nursing priority?

Maintaining a patent airway.

A patient has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurses care should prioritize which of the following outcomes?

Maintaining fluid and electrolyte balance.

A patient is recovering in the hospital following gastrectomy. The nurse notes that the patient has become increasingly difficult to engage and has had several angry outbursts at various staff members in recent days. The nurses attempts at therapeutic dialogue have been rebuffed. What is the nurses most appropriate action?

Make appropriate referrals to services that provide psychosocial support.

A home health nurse is caring for a patient discharged home after pancreatic surgery. The nurse documents the nursing diagnosis Risk for Imbalanced Nutrition: Less than Body Requirements on the care plan based on the potential complications that may occur after surgery. What are the most likely complications for the patient who has had pancreatic surgery?

Malabsorption and hyperglycemia.

Patients receiving inhaled anesthetics should be monitored for which rare severe complication?

Malignant hyperthermia

An OR nurse is teaching a nursing student about the principles of surgical asepsis as a requirement in the restricted zone of the operating suite. What personal protective equipment should the nurse wear at all times in the restricted zone of the OR?

Mask covering the nose and mouth.

A patient has a gastrostomy tube that has been placed to drain stomach contents by low intermittent suction. What is the nurses priority during this aspect of the patients care?

Measure and record drainage.

An adult patient has been admitted to the medical unit for the treatment of acute pancreatitis. What nursing action should be included in this patients plan of care?

Measure the patients abdominal girth daily.

A patient who is obese has been unable to lose weight successfully using lifestyle modifications and has mentioned the possibility of using weight-loss medications. What should the nurse teach the patient about pharmacologic interventions for the treatment of obesity?

Medications can be helpful, but few people achieve and maintain their desired weight loss with medications alone.

A nurse in a stroke rehabilitation facility recognizes that the brain regulates swallowing. Damage to what area of the brain will most affect the patients ability to swallow?

Medulla oblongata.

A patient who underwent gastric banding 3 days ago is having her diet progressed on a daily basis. Following her latest meal, the patient complains of dizziness and palpitations. Inspection reveals that the patient is diaphoretic. What is the nurses best action?

Monitor the patient closely for further signs of dumping syndrome.

An OR nurse will be participating in the intraoperative phase of a patients kidney transplant. What action will the nurse prioritize in this aspect of nursing care?

Monitoring the patients physiologic status.

A community health nurse is preparing for an initial home visit to a patient discharged following a total gastrectomy for treatment of gastric cancer. What would the nurse anticipate that the plan of care is most likely to include?

Monthly administration of injections of vitamin B12.

A patient has sought care because of recent dark-colored stools. As a result, a fecal occult blood test has been ordered. The nurse should instruct the patient to avoid which of the following prior to collecting a stool sample?

NSAIDs.

A patients physician has determined that for the next 3 to 4 weeks the patient will require parenteral nutrition (PN). The nurse should anticipate the placement of what type of venous access device?

Nontunneled central catheter.

A patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output recorded for this patient was 10 mL. The tubing of the Foley is patent. What should the nurse do?

Notify the physician and continue to monitor the hourly urine output closely.

A nurse is caring for a patient who has a diagnosis of GI bleed. During shift assessment, the nurse finds the patient to betachycardic and hypotensive, and the patient has an episode of hematemesis while the nurse is in the room. In addition to monitoring the patients vital signs and level of conscious, what would be a priority nursing action for this patient?

Notify the physician.

During the care of a preoperative patient, the nurse has given the patient a preoperative benzodiazepine. The patient is now requesting to void. What action should the nurse take?

Offer the patient a bedpan or urinal.

A patient has been brought to the emergency department by EMS after telling a family member that he deliberately took an overdose of NSAIDs a few minutes earlier. If lavage is ordered, the nurse should prepare to assist with the insertion of what type of tube?

Orogastric tube.

A patient with chronic pancreatitis had a pancreaticojejunostomy created 3 months ago for relief of pain and to restore drainage of pancreatic secretions. The patient has come to the office for a routine postsurgical appointment. The patient is frustrated that the pain has not decreased. What is the most appropriate initial response by the nurse?

Pain relief occurs by 6 months in most patients who undergo this procedure, but some people experience a recurrence of their pain.

The PACU nurse is caring for a male patient who had a hernia repair. The patients blood pressure is now 164/92 mm Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following surgery?

Pain, hypoxia, or bladder distention.

The nurse is caring for a hospice patient who is scheduled for a surgical procedure to reduce the size of his spinal tumor in an effort to relieve his pain. The nurse should plan this patient care with the knowledge that his surgical procedure is classified as which of the following?

Palliative.

The nurse is caring for a patient who is scheduled to have a needle biopsy of the pleura. The patient has had a consultation with the anesthesiologist and a conduction block will be used. Which local conduction block can be used to block the nerves leading to the chest?

Paravertebral block.

A nurse is providing care for a patient who has a diagnosis of irritable bowel syndrome (IBS). When planning this patients care, the nurse should collaborate with the patient and prioritize what goal?

Patient will accurately identify foods that trigger symptoms.

The nursing instructor is discussing the difference between ambulatory surgical centers and hospital- based surgical units. A student asks why some patients have surgery in the hospital and others are sent to ambulatory surgery centers. What is the instructors best response?

Patients admitted to the hospital for surgery usually have multiple health needs.

A nurse is promoting increased protein intake to enhance a patients wound healing. The nurse knows that enzymes are essential in the digestion of nutrients such as protein. What is the enzyme that initiates the digestion of protein?

Pepsin.

An advanced practice nurse is assessing the size and density of a patients abdominal organs. If the results of palpation are unclear to the nurse, what assessment technique should be implemented?

Percussion.

The OR nurse acts in the circulating role during a patients scheduled cesarean section. For what task is this nurse solely responsible?

Performing documentation.

Diagnostic imaging and physical assessment have revealed that a patient with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication?

Peritonitis.

A patient is being assessed for a suspected deficit in intrinsic factor synthesis. What diagnostic or assessment finding is the most likely rationale for this examination of intrinsic factor production?

Persistently low hemoglobin and hematocrit.

A nurse is preparing to place a patients ordered nasogastric tube. How should the nurse best determine the correct length of the nasogastric tube?

Place distal tip to nose, then ear tip and end of xiphoid process.

A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patients liver?

Place hand under right lower rib cage and press down lightly with the other hand.

The nurse is caring for a patient who is postoperative day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurses first response?

Place saline-soaked sterile dressings on the wound.

A patient is on call to the OR for an aortobifemoral bypass and the nurse administers the ordered preoperative medication. After administering a preoperative medication to the patient, what should the nurse do?

Place the bed in a low position with the side rails up.

A patient with a liver mass is undergoing a percutaneous liver biopsy. What action should the nurse perform when assisting with this procedure?

Position the patient on the right side with a pillow under the costal margin after the procedure.

The nurse is caring for an 82-year-old female patient in the PACU. The woman begins to awaken and responds to her name, but is confused, restless, and agitated. What principle should guide the nurses subsequent assessment?

Postoperative confusion is common in the older adult patent, but it could also indicate a significant blood loss.

The nurse is caring for an 88-year-old patient who is recovering from an ileac-femoral bypass graft. The patient is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the patient, it is clear that he is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. What should the nurse suspect is the problem with the patient?

Postoperative delirium.

A nurse is caring for an older adult who has been experiencing severeClostridium difficile-related diarrhea. When reviewing the patients most recent laboratory tests, the nurse should prioritize which of the following?

Potassium level.

The nurse is performing wound care on a 68-year-old postsurgical patient. Which of the following practices violates the principles of surgical asepsis?

Pouring solution onto a sterile field cloth.

A nurse is admitting a patient to the postsurgical unit following a gastrostomy. When planning assessments, the nurse should be aware of what potential postoperative complication of a gastrostomy?

Premature removal of the G tube

Results of a patients preliminary assessment prompted an examination of the patients carcinoembryonic antigen (CEA) levels, which have come back positive. What is the nurses most appropriate response to this finding?

Prepare to meet the patients psychosocial needs.

A patients large bowel obstruction has failed to resolve spontaneously and the patients worsening condition has warranted admission to the medical unit. Which of the following aspects of nursing care is most appropriate for this patient?

Preparing the patient for surgical bowel resection.

A nurse is preparing to discharge a patient home on parenteral nutrition. What should an effective home care teaching program address? Select all that apply.

Preparing the patient to troubleshoot for problems. Teaching the patient and family strict aseptic technique. Teaching the patient and family how to set up the infusion

The circulating nurse will be participating in a 78-year-old patients total hip replacement. Which of the following considerations should the nurse prioritize during the preparation of the patient in the OR?

Pressure points should be assessed and well padded.

A nursing educator is reviewing the care of patients with feeding tubes and endotracheal tubes (ET). The educator has emphasized the need to check for tube placement in the stomach as well as residual volume. What is the main purpose of this nursing action?

Prevent aspiration.

A patient is scheduled for a bowel resection in the morning and the patients orders include a cleansing enema tonight. The patient wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect?

Preventing potential contamination of the peritoneum.

You are caring for a male patient who has had spinal anesthesia. The patient is under a physicians order to lie flat postoperatively. When the patient asks to go to the bathroom, you encourage him to adhere to the physicians order. What rationale for complying with this order should the nurse explain to the patient?

Preventing the onset of a headache.

The nurse is discharging a patient home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the patient and her caregiver. What else should the nurse do before discharging the patient from the facility? Select all that apply.

Provide all discharge instructions in writing. Provide the nurses or surgeons contact information. Give prescriptions to the patient.

A patient has just been diagnosed with acute gastritis after presenting in distress to the emergency department with abdominal symptoms. What would be the nursing care most needed by the patient at this time?

Providing the patient with physical and emotional support.

A patient has been experiencing occasional episodes of constipation and has been unable to achieve consistent relief by increasing physical activity and improving his diet. What pharmacologic intervention should the nurse recommend to the patient for ongoing use?

Psyllium hydrophilic mucilloid (Metamucil).

The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following abdominal surgery. The patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication?

Pulmonary embolism.

A postoperative patient rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the patient is experiencing a hemorrhage. What should be the nurses first action?

Quickly attempt to determine the cause of hemorrhage.

The nurse is caring for a patient on the medicalsurgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection?

Red, warm, tender incision.

As a perioperative nurse, you know that the National Patient Safety Goals have the potential to improve patient outcomes in a wide variety of health care settings. Which of these Goals has the most direct relevance to the OR?

Reduce the risk of fires.

A patient who suffered a stroke had an NG tube inserted to facilitate feeding shortly after admission. The patient has since become comatose and the patients family asks the nurse why the physician is recommending the removal of the patients NG tube and the insertion of a gastrostomy tube. What is the nurses best response?

Regurgitation and aspiration are less likely.

A nurse is caring for a patient with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute. The patients oxygen saturation is 89% by pulse oximetry. After ensuring the patients immediate safety, what is the nurses most appropriate action?

Report possible signs of aspiration pneumonia to the primary care provider.

A nurse caring for a patient with a newly created ileostomy assesses the patient and notes that the patient has had not ostomy output for the past 12 hours. The patient also complains of worsening nausea. What is the nurses priority action?

Report signs and symptoms of obstruction to the physician.

A nurse has obtained an order to remove a patients NG tube and has prepared the patient accordingly. After flushing the tube and removing the nasal tape, the nurse attempts removal but is met with resistance. Because the nurse is unable to overcome this resistance, what is the most appropriate action?

Report this finding to the patients primary care provider.

A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurses most recent assessment reveals subtle changes in the patients cognition and behavior. What is the nurses most appropriate response?

Report this finding to the primary care provider due to the possibility of hepatic encephalopathy.

The surgical patient is a 35-year-old woman who has been administered general anesthesia. The nurse recognizes that the patient is in stage II (the excitement stage) of anesthesia. Which intervention would be most appropriate for the nurse to implement during this stage?

Restrain the patient.

A nurse is assessing a patient who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the patients pain, the nurse should anticipate that it may radiate to what region?

Right shoulder.

A patient who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this patient knows to immediately report what assessment finding to the physician?

Rigidity of the abdomen.

A patient has been scheduled for a urea breath test in one months time. What nursing diagnosis most likely prompted this diagnostic test?

Risk For Impaired Skin Integrity Related to Peptic Ulcers

A nurse is writing a care plan for a patient with a nasogastric tube in place for gastric decompression. What risk nursing diagnosis is the most appropriate component of the care plan?

Risk for Impaired Skin Integrity Related to the Presence of NG Tube.

A patient is being discharged after a liver transplant and the nurse is performing discharge education. When planning this patients continuing care, the nurse should prioritize which of the following risk diagnoses?

Risk for Infection Related to Immunosuppressant Use.

A 16-year-old presents at the emergency department complaining of right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this patients nursing care, the nurse should prioritize what nursing diagnosis?

Risk for Infection Related to Possible Rupture of Appendix.

A nurse is caring for a patient with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this patient, what nursing diagnosis should the nurse prioritize?

Risk for Infection Related to the Presence of a Subclavian Catheter.

A 90-year-old female patient is scheduled to undergo a partial mastectomy for the treatment of breast cancer. What nursing diagnosis should the nurse prioritize when planning this patients postoperative care?

Risk for Infection related to reduced immune function.

A teenage patient with a pilonidal cyst has been brought for care by her mother. The nurse who is contributing to the patients care knows that treatment will be chosen based on what risk?

Risk for infection.

The nurse is caring for a patient with a duodenal ulcer and is relating the patients symptoms to the physiologic functions of the small intestine. What do these functions include? Select all that apply.

Secretion of mucus. Absorption of nutrients. Movement of nutrients into the bloodstream.

A 37-year-old male patient presents at the emergency department (ED) complaining of nausea and vomiting and severe abdominal pain. The patients abdomen is rigid, and there is bruising to the patients flank. The patients wife states that he was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the patient for what health problem?

Severe pancreatitis with possible peritonitis.

A patient has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize which of the following topics?

Signs and symptoms of intra-abdominal complications.

A nurse is assessing an elderly patient with gallstones. The nurse is aware that the patient may not exhibit typical symptoms, and that particular symptoms that may be exhibited in the elderly patient may include what?

Signs and symptoms of septic shock.

A nurse is completing a health history on a patient whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the patients health problem?

Smokes one pack of cigarettes daily.

A nurse is presenting a class at a bariatric clinic about the different types of surgical procedures offered by the clinic. When describing the implications of different types of surgeries, the nurse should address which of the following topics? Select all that apply.

Specific lifestyle changes associated with each procedure. Implications of each procedure for eating habits. Effects of different surgeries on bowel function.

The nurse educator is reviewing the blood supply of the GI tract with a group of medical nurses. The nurse is explaining the fact that the veins that return blood from the digestive organs and the spleen form the portal venous system. What large veins will the nurse list when describing this system? Select all that apply.

Splenic vein. Inferior mesenteric vein. Gastric vein.

A surgical patient has been in the PACU for the past 3 hours. What are the determining factors for the patient to be discharged from the PACU? Select all that apply.

Stable blood pressure. Sufficient oxygen saturation. Adequate respiratory function.

A nurse is caring for a patient with hepatic encephalopathy. The nurses assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy?

Stage 3.

The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the patient do?

Stand upright for 2 to 3 minutes prior to ambulating.

An OR nurse is participating in an interdisciplinary audit of infection control practices in the surgical department. The nurse should know that a basic guideline for maintaining surgical asepsis is what?

Sterile surfaces or articles may touch other sterile surfaces.

A nurse is caring for an 83-year-old patient who is being assessed for recurrent and intractable nausea. What age-related change to the GI system may be a contributor to the patients health complaint?

Stomach emptying takes place more slowly.

The nurse is doing preoperative patient education with a 61-year-old male patient who has a 40-pack per year history of cigarette smoking. The patient will undergo an elective bunionectomy at a time that fits his work schedule in a few months. What would be the best instruction to give to this patient?

Stop smoking 4 to 8 weeks before the scheduled surgery to enhance pulmonary function and decrease infection.

A nurse is caring for a patient hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize?

Strategies for avoiding irritating foods and beverages.

An inpatient has returned to the medical unit after a barium enema. When assessing the patients subsequent bowel patterns and stools, what finding should the nurse report to the physician?

Streaks of blood present in the stool.

A patient is admitted to the unit with acute cholecystitis. The physician has noted that surgery will be scheduled in 4 days. The patient asks why the surgery is being put off for a week when he has a sick gallbladder. What rationale would underlie the nurses response?

Surgery is delayed until the acute symptoms subside.

The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The childs parents are thought to be en route to the hospital but have not yet arrived. No other family members are present and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to save her life. How should the need for informed consent be addressed?

Surgery should be done without informed consent.

A nurse is participating in a patients care conference and the team is deciding between parenteral nutrition (PN) and a total nutritional admixture (TNA). What advantages are associated with providing TNA rather than PN?

TNA is less costly than PN.

A patient who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the patients condition is now stable. For the next several hours, the nurse caring for this patient should assess for what signs and symptoms of recurrence?

Tachycardia, hypotension, and tachypnea.

The perioperative nurse is constantly assessing the surgical patient for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the patient is developing malignant hyperthermia?

Tachycardia.

The admitting nurse in a short-stay surgical unit is responsible for numerous aspects of care. What must the nurse verify before the patient is taken to the preoperative holding area?

That preoperative teaching was performed.

The nursing instructor is discussing postoperative care with a group of nursing students. A student nurse asks, Why does the patient go to the PACU instead of just going straight up to the postsurgical unit? What is the nursing instructors best response?

The PACU allows the patient to recover from the effects of anesthesia, and the patient stays in the PACU until he or she is oriented, has stable vital signs, and is without complications.

The physiology instructor is discussing the GI system with the pre-nursing class. What should the instructor describe as a major function of the GI tract?

The absorption into the bloodstream of nutrient molecules produced by digestion.

The family of a patient in the ICU diagnosed with acute pancreatitis asks the nurse why the patient has been moved to an air bed. What would be the nurses best response?

The bed automatically moves, so shes less likely to develop pressure sores while shes in bed.

A nurse at an outpatient surgery center is caring for a patient who had a hemorrhoidectomy. What discharge education topics should the nurse address with this patient?

The correct procedure for taking a sitz bath.

A nurse is admitting a patient diagnosed with late-stage gastric cancer. The patients family is distraught and angry that she was not diagnosed earlier in the course of her disease. What factor contributes to the fact that gastric cancer is often detected at a later stage?

The early symptoms of gastric cancer are usually not alarming or highly unusual.

The nurse knows that elderly patients are at higher risk for complications and adverse outcomes during the intraoperative period. What is the best rationale for this phenomenon?

The elderly patient has reduced ability to adjust rapidly to emotional and physical stress.

A 55-year-old man has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse most likely explain the pathophysiology of this patients health problem?

The enzymes that your pancreas produces have damaged the pancreas itself.

A nurse is planning discharge teaching for a 21-year-old patient with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the patients coping after discharge?

The family's ability to provide emotional support.

The nurse admitting a patient who is insulin dependent to the same-day surgical suite for carpal tunnel surgery. How should this patients diagnosis of type 1 diabetes affect the care that the nurse plans?

The nurse should assess the patients blood glucose levels vigilantly.

The nurse is checking the informed consent for a 17-year-old who has just been married and expecting her first child. She is scheduled for a cesarean section. She is still living with her parents and is on her parents health insurance. When obtaining informed consent for the cesarean section, who is legally responsible for signing?

The patient

A patients sigmoidoscopy has been successfully completed and the patient is preparing to return home. Which of the following teaching points should the nurse include in the patients discharge education?

The patient can resume a normal routine immediately.

The nurse is caring for a postoperative patient who needs daily dressing changes. The patient is 3 days postoperative and is scheduled for discharge the next day. Until now, the patient has refused to learn how to change her dressing. What would indicate to the nurse the patients possible readiness to learn how to change her dressing? Select all that apply.

The patient expresses interest in the dressing change. The patient is willing to look at the incision during a dressing change. The patient assists in opening the packages of dressing material for the nurse.

A patient with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the patient has a perforated ulcer?

The patient has a rigid, boardlike abdomen that is tender.

A patient underwent an open bowel resection 2 days ago and the nurses most recent assessment of the patients abdominal incision reveals that it is dehiscing. What factor should the nurse suspect may have caused the dehiscence?

The patient has vomited three times in the past 12 hours.

The nurse is preparing to insert a patients ordered NG tube. What factor should the nurse recognize as a risk for incorrect placement?

The patient is agitated.

A patient has recently received a diagnosis of gastric cancer; the nurse is aware of the importance of assessing the patients level of anxiety. Which of the following actions is most likely to accomplish this?

The patient is encouraged to express fears openly.

The nurse is caring for a patient after abdominal surgery in the PACU. The patients blood pressure has increased and the patient is restless. The patients oxygen saturation is 97%. What cause for this change in status should the nurse first suspect?

The patient is in pain.

A nurse is preparing to discharge a patient after recovery from gastric surgery. What is an appropriate discharge outcome for this patient?

The patient maintains or gains weight.

The OR nurse is taking the patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104F temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the patient?

The patient may be at risk for malignant hyperthermia.

A medical patients CA 19-9 levels have become available and they are significantly elevated. How should the nurse best interpret this diagnostic finding?

The patient may have cancer, but other GI disease must be ruled out.

The circulating nurse in an outpatient surgery center is assessing a patient who is scheduled to receive moderate sedation. What principle should guide the care of a patient receiving this form of anesthesia?

The patient must never be left unattended by the nurse.

The perioperative nurse is preparing to discharge a female patient home from day surgery performed under general anesthetic. What instruction should the nurse give the patient prior to the patient leaving the hospital?

The patient should not drive herself home.

In anticipation of a patients scheduled surgery, the nurse is teaching her to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the patient?

The patient should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs.

A patient who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize?

The patient will take immunosuppressive agents as required.

A patient will be undergoing abdominal computed tomography (CT) with contrast. The nurse has administered IV sodium bicarbonate and oral acetylcysteine (Mucomyst) before the study as ordered. What would indicate that these medications have had the desired therapeutic effect?

The patients BUN and creatinine levels are within reference range following the CT.

A patients screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this patients health problem?

The patients polyps constitute a risk factor for cancer.

The PACU nurse is caring for a patient who has been deemed ready to go to the postsurgical floor after her surgery. What would the PACU nurse be responsible for reporting to the nurse on the floor? Select all that apply.

The patients preoperative level of consciousness. The presence of family and/or significant others The patients full name.

The nurse is preparing a patient for surgery prior to her hysterectomy without oophorectomy. The nurse is witnessing the patients signature on a consent form. Which comment by the patient would best indicate informed consent?

The physician is going to remove my uterus and told me about the risk of bleeding.

You are the nurse caring for an unconscious trauma victim who needs emergency surgery. The patient is a 55-year-old man with an adult son. He is legally divorced and is planning to be remarried in a few weeks. His parents are at the hospital with the other family members. The physician has explained the need for surgery, the procedure to be done, and the risks to the children, the parents, and the fianc. Who should be asked to sign the surgery consent form?

The son.

A patient with a recent history of intermittent bleeding is undergoing capsule endoscopy to determine the source of the bleeding. When explaining this diagnostic test to the patient, what advantage should the nurse describe?

The test is noninvasive.

A patient waiting in the presurgical holding area asks the nurse, Why exactly do they have to put a breathing tube into me? My surgery is on my knee. What is the best rationale for intubation during a surgical procedure that the nurse should describe?

The tube provides an airway for ventilation.

You are caring for an 88-year-old woman who is scheduled for a right mastectomy. You know that elderly patients are frequently more anxious prior to surgery than younger patients. What would you increase with this patient to decrease her anxiety?

Therapeutic touch

The nurse in the ED is caring for a man who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the wound. You are aware that the wound will now heal by what means?

Third intention.

A patient with a diagnosis of peptic ulcer disease has just been prescribed omeprazole (Prilosec). How should the nurse best describe this medications therapeutic action?

This medication will reduce the amount of acid secreted in your stomach.

The nurse is providing preoperative teaching to a patient scheduled for surgery. The nurse is instructing the patient on the use of deep breathing, coughing, and the use of incentive spirometry when the patient states, I dont know why youre focusing on my breathing. My surgery is on my hip, not my chest. What rationale for these instructions should the nurse provide?

To promote optimal lung expansion

A nurse caring for a patient with colorectal cancer is preparing the patient for upcoming surgery. The nurse administers cephalexin (Keflex) to the patient and explains what rationale?

To reduce intestinal bacteria levels.

A nurse is caring for a patient who has a gastrointestinal tube in place. Which of the following are indications for gastrointestinal intubation? Select all that apply.

To remove gas from the stomach. To remove toxins from the stomach. To diagnose GI motility disorders.

A patient admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely the best choice for this patient?

Tofu.

An older adult has a diagnosis of Alzheimers disease and has recently been experiencing fecal incontinence. However, the nurse has observed no recent change in the character of the patients stools. What is the nurses most appropriate intervention?

Toilet the patient on a frequent, scheduled basis.

The dressing surrounding a mastectomy patients Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion?

Trace the outline of the drainage on the dressing for future comparison.

The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the nurse observes that the patients skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the patient is not breathing. What is the priority intervention?

Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw.

A patient who underwent a bowel resection to correct diverticula suffered irreparable nerve damage. During the case review, the team is determining if incorrect positioning may have contributed to the patients nerve damage. What surgical position places the patient at highest risk for nerve damage?

Trendelenburg.

In the past stress and anxiety were thought to be the main causes of peptic ulcer disease. With current research the primary cause is pylori. True or False?

True.

An adult patient is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The patients vital signs and level of consciousness stabilized, but the patient then complains of severe nausea and begins to retch. What should the nurse do next?

Turn the patient completely to one side.

A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patients current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?

Two to 3 soft bowel movements daily.

A patient is admitted to the ICU with acute pancreatitis. The patients family asks what causes acute pancreatitis. The critical care nurse knows that a majority of patients with acute pancreatitis have what?

Undiagnosed chronic pancreatitis.

A nurse is caring for a newly admitted patient with a suspected GI bleed. The nurse assesses the patients stool after a bowel movement and notes it to be a tarry-black color. This finding is suggestive of bleeding from what location?

Upper GI tract.

A nurse is creating a care plan for a patient with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube?

Use a combination of at least two accepted methods for confirming placement.

The circulating nurse is admitting a patient prior to surgery and proceeds to greet the patient and discuss what the patient can expect in surgery. What aspect of therapeutic communication should the nurse implement?

Use a tone that decreases the patients anxiety.

The nurse is caring for a patient who is experiencing pain and anxiety following his prostatectomy. Which intervention will likely best assist in decreasing the patients pain and anxiety?

Use of guided imagery along with pain medication.

The nurse is performing a preadmission assessment of a patient scheduled for a bilateral mastectomy. Of what purpose of the preadmission assessment should the nurse be aware?

Verifies completion of preoperative diagnostic testing.

A patient is postoperative day 1 following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate?

Wash the area around the tube with soap and water daily.

A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patients stools will have what characteristics?

Watery with blood and mucus.

A clinic nurse is conducting a preoperative interview with an adult patient who will soon be scheduled to undergo cardiac surgery. What interview question most directly addresses the patients safety?

What prescription and nonprescription medications do you currently take?

A 77-year-old mans coronary artery bypass graft has been successful and discharge planning is underway. When planning the patients subsequent care, the nurse should know that the postoperative phase of perioperative nursing ends at what time?

When a follow-up evaluation in the clinical or home setting is done.

The nurse is caring for a trauma victim in the ED who will require emergency surgery due to injuries. Before the patient leaves the ED for the OR, the patient goes into cardiac arrest. The nurse assists in the successful resuscitation and proceeds to release the patient to the OR staff. When can the ED nurse perform the preoperative assessment?

When assisting with the resuscitation.

A patient is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting coffee-ground like emesis. The patient is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the patient most likely anticipate that the surgery will be scheduled?

Without delay because the bleed is emergent.

The nurse is caring for a patient in the postoperative period following an abdominal hysterectomy. The patient states, I dont want to use my pain meds because theyll make me dependent and I wont get better as fast. Which response is most important when explaining the use of pain medication?

You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is administered for an extended period of time.

One of the things a nurse has taught to a patient during preoperative teaching is to have nothing by mouth for the specified time before surgery. The patient asks the nurse why this is important. What is the most appropriate response for the patient?

You will need to have food and fluid restricted before surgery so you are not at risk for choking.

A nurse is providing preprocedure education for a patient who will undergo a lower GI tract study the following week. What should the nurse teach the patient about bowel preparation?

Youll need to have enemas the day before the test.

A patient has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The patient is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond?

Your appendix doesnt play a major role, so you wont notice any difference after you recovery from surgery.

Surgical gowns are considered sterile from the front of the ________ to the level of the ________.

chest, sterile field

When obtaining an Informed Consent it is the responsibility of the ____________ to inform the patient about a surgical procedure?

surgeon